An analysis of risk factors and diagnostic methods for patients with an intermediate probability of ischemic heart disease

Aim: To evaluate the differences of the risk factors, laboratory tests results, the results of visual, functional diagnostic methods between the obstructive and non-obstructive ischemic heart disease groups and the clinical angina pectoris (AP) manifestation groups of patients with an intermediate pre-test probability (PTT). Objectives: To evaluate the proliferation of atherosclerotic lesions in the coronary arteries (CA) by invasive angiography or cardiac computed tomography angiography (CTA) and to identify the relationship with manifestation of AP symptoms. To evaluate patients with intermediate PTT, socio-demographic data, cardiovascular risk factors, co-morbidities, medication, routine laboratory tests, and to identify their association with AP symptoms and CA atherosclerotic lesions. To evaluate the results of 2D echocardiography, non-invasive tests and their association with symptoms and CA atherosclerotic lesions. Methods: This retrospective observational study, performed in 2017-2019, included 116 subjects with intermediate PTT referred for testing during the period of 2013-2018. These patients underwent interventional coronary angiography or CTA for the first time. According to the results, the patients were divided into two groups: non-obstructive CAD (stenosis <50%) and obstructive CAD (≥50%). Patients were also divided into groups depending on experienced symptoms (non-anginal pain, atypical AP, typical AP). Cardiovascular risk factors, comorbidities, used medication, echocardiographic and non-invasive functional testing results were assessed. Results: Non-obstructive CAD was detected in 87 (74.36%) patients. These patients were more likely to have atypical chest pain (p = 0.041), be younger than obstructive CAD group patients (57 (min. 40 - max. 83) vs. 65.5 (min. 47 - max. 79) (p = 0.024)). More autoimmune diseases were observed in the non-anginal pain group (p = 0.024). In the typical AP group, a more frequent left anterior fascicular block was observed (p = 0.026). Patients with non-obstructive CAD had a higher incidence of smoking (p = 0.035). Bronchial asthma (BA) (p = 0.035), left anterior fascicular block (p = 0.023), atrial fibrillation (p = 0.023), usage of statins (p = 0.012) and aspirin (p = 0.036) were more common in obstructive CAD group. Lower left ventricular mass (p = 0.021), mass index (p = 0.01)), TAPSE (p=0,002) and more frequent normal diastolic function were observed in the non-obstructive CAD group. In patients with obstructive CAD, 2nd degree diastolic dysfunction is more common (p = 0.03). In a typical AP patient group, T-wave inversion (p = 0.028) was more frequent after non-invasive testing. Contraction disorders are more frequent in obstructive CAD patients (p = 0.038). Non-invasive testing results were frequently found to be limiting (threshold) in the non-obstructive CAD group and the pathological result is more frequent in patients with significant obstruction (p = 0.018). Conclusions: Patients with intermediate PTT are more likely to experience non-obstructive CAD characterized by atypical AP pain. Non-obstructive CAD group patients were younger, more likely to smoke while obstructive CAD was more common in patients with BA and rhythm disorders. Patients of the non-anginal pain group were more likely to have autoimmune diseases. In a typical AP group, left anterior fascicular block was more common. Patients with obstructive CAD more frequently used statins and aspirin. Lower echocardiographic values (left ventricular mass, mass index, TAPSE) and normal diastolic function were observed in the non-obstructive CAD group. In patients with obstructive CAD, 2nd degree diastolic dysfunction was more frequent. Patients with typical AP symptoms were more likely to experience T-inversion on non-invasive testing. Contraction disorders are more frequent in obstructive CAD patients. Non-invasive testing results were frequently found to be limiting (threshold) in the non-obstructive CAD group and the pathological result is more frequent in patients with significant obstruction

Coronary CT Value in Quantitative Assessment of Intermediate Stenosis

Background and Objectives: Cardiac computed tomography angiography (CCTA) is an excellent non-invasive imaging tool to evaluate coronary arteries and exclude coronary artery disease (CAD). Managing intermediate coronary artery stenosis with negative or inconclusive functional tests is still a challenge. A regular stenosis evaluation together with high-risk plaque features, using semi-automated programs, are becoming promising tools. This case&ndash;control study was designed to evaluate the intermediate lesion features&rsquo; impact on CAD outcomes, using a semi-automated CCTA atherosclerotic plaque analysis program. Materials and Methods: We performed a single-center, prospective cohort study. A total of 133 patients with low to intermediate risk of CAD, older than 18 years with no previous history of CAD and good quality CCTA images were included in the study, and 194 intermediate stenosis (CAD-RADS 3) were analyzed. For more detailed morphological analysis, we used semi-automated CCTA-dedicated software. Enrolled patients were prospectively followed-up for 2 years. Results: Agatston score was significantly higher in the major adverse cardiovascular events (MACE) group (p = 0.025). Obstruction site analysis showed a significantly lower coronary artery remodeling index (RI) among patients with MACE (p = 0.037); nonetheless RI was negative in both groups. Plaque consistency analysis showed significantly bigger necrotic core area in the MACE group (p = 0.049). In addition, unadjusted multivariate analysis confirmed Agatston score and RI as significant MACE predictors. Conclusions: The Agatston score showes the total area of calcium deposits and higher values are linked to MACE. Higher plaque content of necrotic component is also associated with MACE. Additionally, negatively remodeled plaques are linked to MACE and could be a sign of advanced CAD. The Agatston score and RI are significant in risk stratification for the development of MACE

CT or Invasive Coronary Angiography in Stable Chest Pain.

Background: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. Methods: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. Results: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). Conclusions: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.)