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Jan201118

5

Identification of ADAMTS7 As a Novel Locus for Coronary Atherosclerosis and Association of ABO With myocardial Infarction in the Presence of Coronary Atherosclerosis: Two Genome-Wide Association Studies

Lancet. . 2011; 377(9761):200-203

Reilly MP, Li M, He J, Ferguson JF, Stylianou IM, Mehta NN, Burnett MS, Devaney JM, Knouff CW, Thompson JR, Horne BD, Stewart AF, Assimes TL, Wild PS, Allayee H, Nitschke PL, Patel RS; Myocardial Infarction Genetics Consortium; Wellcome Trust Case Control Consortium, Martinelli N, Girelli D, Quyyumi AA, Anderson JL, Erdmann J, Hall AS, Schunkert H, Quertermous T, Blankenberg S, Hazen SL, Roberts R, Kathiresan S, Samani NJ, Epstein SE, Rader DJ

OBJECTIVES: We tested whether genetic factors distinctly contribute to either development of coronary atherosclerosis or, specifically, to myocardial infarction in existing coronary atherosclerosis.

METHODS: We did two genome-wide association studies (GWAS) with coronary angiographic phenotyping in participants of European ancestry. To identify loci that predispose to angiographic coronary artery disease (CAD), we compared individuals who had this disorder (n=12 393) with those who did not (controls, n=7383). To identify loci that predispose to myocardial infarction, we compared patients who had angiographic CAD and myocardial infarction (n=5783) with those who had angiographic CAD but no myocardial infarction (n=3644).

RESULTS: In the comparison of patients with angiographic CAD versus controls, we identified a novel locus, ADAMTS7 (p=4·98×10(-13)). In the comparison of patients with angiographic CAD who had myocardial infarction versus those with angiographic CAD but no myocardial infarction, we identified a novel association at the ABO locus (p=7·62×10(-9)). The ABO association was attributable to the glycotransferase-deficient enzyme that encodes the ABO blood group O phenotype previously proposed to protect against myocardial infarction.

CONCLUSIONS: Our findings indicate that specific genetic predispositions promote the development of coronary atherosclerosis whereas others lead to myocardial infarction in the presence of coronary atherosclerosis. The relation to specific CAD phenotypes might modify how novel loci are applied in personalised risk assessment and used in the development of novel therapies for CAD.

PMID: 21239051

Dec201014

18

Left Main Trunk Coronary Artery Dissection as a Consequence of Inaccurate Coronary Computed Tomographic Angiography

Arch Intern Med. 2010; 170(22):1067-1070

Matthew C. Becker, John M. Galla, Steven E. Nissen

A 52-year-old woman presented to a community hospital with atypical chest pain. Her low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels were not elevated. She underwent cardiac computed tomography angiography, which showed both calcified and noncalcified coronary plaques in several locations. Her physicians subsequently performed coronary angiography, which was complicated by dissection of the left main coronary artery, requiring emergency coronary artery bypass graft surgery. Her subsequent clinical course was complicated, but eventually she required orthotropic heart transplantation for refractory heart failure. This case illustrates the hazards of the inappropriate use of cardiac computed tomography angiography in low-risk patients and emphasizes the need for restraint in applying this new technology to the evaluation of patients with atypical chest pain.  
 
 

 

PMID:

Nov201025

22

A Heart With 67 Stents

J Am Coll Cardiol. 2010; 56(19):1605

Rami N. Khouzam, Rajvir Dahiya, Richard Schwartz

A 56-year-old male with coronary artery disease presented with angina, nonspecific electrocardiographic changes, and elevated troponins. Coronary angiography revealed total occlusion of a stent in the circumflex artery, where another was deployed—his 67th stent. The patient had 28 catheterizations over 10 years, with stents placed in his native coronary arteries as well as in 3 bypass grafts. All stents were placed to relieve his angina, refractory to maximal medical treatment and transmyocardial laser revascularization. Stents can be a great tool to help revascularization and relieve symptoms; unfortunately, they are prone to thrombosis and restenosis. If they fail while medical management is maximized unsuccessfully, alternative tools are lacking. This case raises many questions: “How much is too much?” “Are there guidelines?” and “What else can be offered for symptom relief?” More studies are needed to evaluate impact on quality of life versus risks in this multistent population.

PMID: 21029877

Nov201023

9

The Ability of Optical Coherence Tomography to Monitor Percutaneous Coronary Intervention: Detailed Comparison With Intravascular Ultrasound

J Invasive Cardiol. 2010; 22(11):541-545

Kawamori H, Shite J, Shinke T, Otake H, Sawada T, Kato H, Miyoshi N, Yoshino N, Kozuki A, Hariki H, Inoue T, Hirata K

OBJECTIVES: We investigated the usefulness of optical coherence tomography (OCT) to evaluate vessel response after stent implantation by comparing with that of intravascular ultrasound (IVUS).

METHODS: Eighteen cases undergoing percutaneous coronary intervention (PCI) who provided consent for both IVUS and OCT usage pre- and post-PCI procedure were enrolled.

RESULTS: The lumen area at the distal site of the culprit lesion was smaller on OCT images than on IVUS images due to proximal vessel occlusion, whereas the lumen area at the proximal site of the lesion did not differ between OCT and IVUS images (distal site: 4.6 ± 2.0 vs. 5.0 ± 1.8 mm²; p = 0.0004; proximal site: 5.5 ± 2.3 vs. 5.6 ± 2.3 mm²; p = 0.8160). Stent malapposition was more frequently observed by OCT (30%) than by IVUS (5%, p = 0.0381). Stent edge dissection was not detected by IVUS, but was detected in 10% by OCT. Tissue prolapse was identified in all stents by OCT and in 5% by IVUS. Thrombus was observed in 15% by OCT and in 5% by IVUS.

CONCLUSIONS: Proximal coronary occlusion during OCT imaging was possibly related to underestimation of vessel sizing at distal reference. Our data suggested that OCT might provide more detailed information on the presence of tissue prolapse, thrombus formation and edge dissection than IVUS. Further study is warranted to assess its clinical utility.

PMID: 21041851

Nov201010

4

Cardiac Magnetic Resonance Imaging Characteristics of Isolated Left Ventricular Noncompaction in a Chinese Adult Han Population

Int J Cardiovasc Imaging. 2010 ; 26(7):1011-1013

Cheng H, Zhao S, Jiang S, Yu J, Lu M, Ling J, Zhang Y, Yan C, Liu Q, Li S, Jin L, Jerecic R, He Z

OBJECTIVES: To analyze cardiac magnetic resonance imaging (CMR) characteristics in patients with isolated left ventricular noncompaction (IVNC) and assess its value in the diagnosis of IVNC in a Chinese adult Han population.

METHODS: We collected a consecutive series of 30 patients with IVNC from January 1, 2007, to December 31, 2008. During the same period, we prospectively included patients drawn from groups given a potential differential diagnosis for IVNC. All magnetic resonance images were analyzed using 17-segment model.

RESULTS: Left ventricular ejection fraction was significantly lower for patients with DCM (16.2 ± 5.2%, P < 0.001) and higher in AR (47.6 ± 16.2%, P = 0.009), AS (54.6 ± 21.1%, P = 0.001) and HHD (62.4 ± 6.8%, P < 0.001) compared with IVNC (33.0 ± 14.1%). The two-layered structure was most frequently seen at the apical segments, followed by the mid-cavity and basal segments in patients with INVC. The anterior and lateral walls were more commonly involved in patients with IVNC. The number of noncompacted segments and end-diastolic ratio of non-compacted to compacted myocardium (NC/C ratio) was greater in patients with IVNC than in other five groups. The end-diastolic NC/C ratio of >2.5 had 96.4% sensitivity and 97.4% specificity for identifying patients with IVNC.

CONCLUSIONS: CMR provides an accurate and reliable evaluation of the localization and extent of noncompacted myocardium at end-diastole. The end-diastolic NC/C ratio of >2.5 had high diagnostic accuracy for IVNC in a Chinese adult Han population.

PMID: 21046254

Nov201001

3

An Intravascular Ultrasound Analysis in Women Experiencing Chest Pain in the Absence of Obstructive Coronary Artery Disease: A Substudy from the National Heart, Lung and Blood Institute-Sponsored Women’s Ischemia Syndrome Evaluation (WISE)

J Interv Cardiol . 2010; 23(5):867-869

Khuddus MA, Pepine CJ, Handberg EM, Bairey Merz CN, Sopko G, Bavry AA, Denardo SJ, McGorray SP, Smith KM, Sharaf BL, Nicholls SJ, Nissen SE, Anderson RD

OBJECTIVES:  Using intravascular ultrasound (IVUS), we sought to characterize coronary morphology in women with chest pain without major epicardial obstructive coronary artery disease (CAD). We have previously observed an unexpectedly high rate of adverse outcomes among women with chest pain and normal or insignificant obstructive CAD. Information about the presence and characteristics of coronary atherosclerosis in these women could provide insight into the mechanisms related to increased risk, as well as improved diagnosis, prevention, and treatment.

Methods:  Women (n = 100) with suspected ischemia without obstructive CAD (>50% stenosis) underwent IVUS of a left coronary segment with measurements by a core lab masked to clinical and angiographic findings.

Results:  Angiograhic core lab analysis found 69.6% of patients had no (≤20%) and 30.4% had minimal (20-<50%) CAD. IVUS segmental images were interpretable by the core lab in 92 women, with 19 (21%) having no atherosclerosis (intimal-medial thickness <0.5 mm). In the remaining 73 women (79%), percent atheroma volume was 27 ± 8% and mean maximum plaque thickness was 0.53 ± 0.22 mm. Thirty-eight women with atherosclerosis (53%) had ≥30% of interrogated vessel involved. The average vessel involvement was 40%, and the maximum plaque thickness was 1.27 mm. The number of risk factors strongly correlated with percent atheroma volume (r = 0.53, P < 0.0001) and percent vessel involvement (r = 0.51, P < 0.0001), with the strongest independent predictor of both being age. Remodeling was assessed in 59/73 women (81%), and 73% had evidence of positive remodeling.

CONCLUSIONS:  In symptomatic women without significant luminal obstructive CAD, we observed a high prevalence of atherosclerosis with positive remodeling and preserved lumen size. These findings may help explain increased risk and emphasize need for improved diagnostic and treatment options for women with concealed CAD.

PMID: 21029178

Oct201021

2

Assessment of Coronary Plaque Characteristics by Optical Coherence Tomography in Patients With Diabetes Mellitus Complicated With Unstable Angina Pectoris

Atherosclerosis. 2010; 212(2):1342-1345

Feng T, Yundai C, Lian C, Zhijun S, Changfu L, Jun G, Hongbin L

OBJECTIVES: Diabetic patients are characterised by poorer prognosis and more cardiovascular complications compared with non-diabetic patients, which may be due to metabolic abnormalities and atherosclerotic plaque characteristics.

METHODS: Patients with unstable angina pectoris were enrolled in the study and divided into diabetes mellitus (DM) (patients, n=25; plaques, n=42) and non-DM (patients, n=53; plaques, n=65) groups according to their DM history. Optical coherence tomography (OCT) examinations were performed on all patients, and images were analysed by two independent investigators. Fibrous cap thickness was measured at the thinnest point of each plaque. The presence of plaque disruption, dissection, erosion, thrombosis and calcification were also noted.

RESULTS: Calcified plaques in the DM group were significantly greater than those in the non-DM group (42.9% vs. 23.1%; p=0.03). Thin-cap fibroatheroma (TCFA) were detected, and no significant difference was found in the frequencies (42.9% vs. 52.3%; p=0.34) and fibrous cap thickness (57.08±6.20μm vs. 56.11±9.23μm, p=0.74) between the DM and non-DM groups. Thrombus and plaque erosion were similar in the two groups, but the frequency of dissection in the DM group was greater than that in the non-DM group (21.4% vs. 7.7%, p=0.04). The high sensitivity C-reactive protein between the two groups was similar (0.44±0.20mg/dl vs. 0.46±0.15mg/dl, p=0.83).

CONCLUSIONS: Higher calcification and dissection were detected in diabetic patients with unstable angina pectoris, and the difference in coronary plaque characteristics can explain the difference in clinical prognoses between DM and non-DM patients.

PMID: 20951380

Oct201009

2

Ultrasound-Guided Catheterization of the Radial Artery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Chest. 2010; 138(4):767-775

Shiloh AL, Savel RH, Paulin LM, Eisen LA

OBJECTIVES: Ultrasound-guidance is commonly used for the placement of central venous catheters (CVC). The Agency for Healthcare Research and Quality (AHRQ) recommends the use of ultrasound for CVC placement as 1 of their 11 practices to improve patient care. Despite increased access to portable ultrasound machines and comfort with ultrasound-guided CVC access, fewer clinicians are familiar with ultrasound-guided techniques of arterial catheterization. The goal of this systematic review and meta-analysis was to determine the utility of real-time two-dimensional (2-D) ultrasound-guidance for radial artery catheterization.

METHODS: A comprehensive literature search of Medline, Embase, and the Cochrane Central Register of Controlled Trials by two independent reviewers identified prospective, randomized controlled trials (RCT) comparing ultrasound-guidance with traditional palpation techniques of radial artery catheterization. Data were extracted on study design, study size, operator and patient characteristics, and the rate of first-attempt success. A meta-analysis was constructed to analyze the data.

RESULTS: Four trials with a total of 311 subjects were included in the review, with 152 subjects included in the palpation group and 159 subjects in the ultrasound-guided group. Compared with the palpation method, ultrasound-guidance for arterial catheterization was associated with a 71% improvement in the likelihood of first-attempt success (relative risk 1.71, 95% confidence interval 1.25-2.32).

CONCLUSIONS: The use of real-time 2-D ultrasound-guidance for radial artery catheterization improved first pass success rate.

PMID: 20724734

Sep201016

3

Transcatheter Device Closure of Perimembranous Ventricular Septal Defects: Mid-Term Outcomes

Eur Heart J. 2010; 31(18):2238-2245

Yang J, Yang L, Wan Y, Zuo J, Zhang J, Chen W, Li J, Sun L, Yu S, Liu J, Chen T, Duan W, Xiong L, Yi D

OBJECTIVES: The aim of this study was to evaluate the safety and efficacy of transcatheter closure for perimembranous ventricular septal defect (pmVSD) and its long-term results. The most common congenital heart condition is pmVSD. Transcatheter closure of pmVSD is a recently described technique with limited results for mid- to long-term follow-up.

METHODS: Between June 2002 and June 2008, 848 patients with pmVSD were enrolled in our study and treated percutaneously with pmVSD occluders. All patients were followed up until December 2008, an average of 37 months.

RESULTS: According to colour Doppler transthoracic echocardiography before the intervention and ventriculography, the average end-diastolic pmVSD size was 5.1 and 5.4 mm, respectively. Placement of the device was successful in 832 patients (98.1%) and the median device size was 8.6 mm. During follow-up, 103 adverse events (12.4%) were reported. Most adverse events were categorized as minor and there were nine major adverse events (8.7%), including two complete atrioventricular block requiring pacemaker implantation. Kaplan-Meier estimates showed >85% freedom from major or minor adverse events during a maximal follow-up of 79 months.

CONCLUSIONS: In experienced hands, transcatheter pmVSD closure can be performed safely and successfully with low morbidity and mortality. Long-term prognostic results are favourable, and the transcatheter approach provides a less-invasive alternative that may become the first choice in selected pmVSD patients.

PMID: 20801925

Aug201021

3

Angiographic Versus Functional Severity of Coronary Artery Stenoses in the FAME Study Fractional Flow Reserve Versus Angiography in Multivessel Evaluation

J Am Coll Cardiol. 2010; 55(25):2816-2821

Tonino PA, Fearon WF, De Bruyne B, Oldroyd KG, Leesar MA, Ver Lee PN, Maccarthy PA, Van't Veer M, Pijls NH

OBJECTIVES: The purpose of this study was to investigate the relationship between angiographic and functional severity of coronary artery stenoses in the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study. It can be difficult to determine on the coronary angiogram which lesions cause ischemia. Revascularization of coronary stenoses that induce ischemia improves a patient’s functional status and outcome. For stenoses that do not induce ischemia, however, the benefit of revascularization is less clear.

METHODS: In the FAME study, routine measurement of the fractional flow reserve (FFR) was compared with angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease. The use of the FFR in addition to angiography significantly reduced the rate of all major adverse cardiac events at 1 year. Of the 1,414 lesions (509 patients) in the FFR-guided arm of the FAME study, 1,329 were successfully assessed by the FFR and are included in this analysis.

RESULTS: Before FFR measurement, these lesions were categorized into 50% to 70% (47% of all lesions), 71% to 90% (39% of all lesions), and 91% to 99% (15% of all lesions) diameter stenosis by visual assessment. In the category 50% to 70% stenosis, 35% were functionally significant (FFR <0.80) and 65% were not (FFR >0.80). In the category 71% to 90% stenosis, 80% were functionally significant and 20% were not. In the category of subtotal stenoses, 96% were functionally significant. Of all 509 patients with angiographically defined multivessel disease, only 235 (46%) had functional multivessel disease (> coronary arteries with an FFR <0.80).

CONCLUSIONS: Angiography is inaccurate in assessing the functional significance of a coronary stenosis when compared with the FFR, not only in the 50% to 70% category but also in the 70% to 90% angiographic severity category.

PMID: 20579537

Aug201009

2

Analysis of Saphenous Vein Graft Lesion Composition Using Near-Infrared Spectroscopy and Intravascular Ultrasonography With Virtual Histology

Atherosclerosis. 2010; 211(2):432-436

Wood FO, Badhey N, Garcia B, Abdel-Karim AR, Maini B, Banerjee S, Brilakis ES

OBJECTIVES: To examine the composition of saphenous vein graft (SVG) lesions using two novel modalities, near-infrared spectroscopy (NIRS) and intravascular ultrasonography with virtual histology (IVUS-VH).

METHODS: We performed NIRS and IVUS-VH imaging of 23 SVGs in 21 patients undergoing clinically-indicated angiography.

RESULTS: Mean patient and SVG age was 66+/-7 and 10+/-7 years, respectively. SVG lesion location was aorto-ostial in 8 (35%), body in 13 (57%) and distal anastomotic in 2 (9%). Compared to anastomotic lesions, body lesions had larger mean lumen area (6.4+/-1.8mm(2) vs. 4.2+/-6.4mm(2), P=0.02) but similar mean plaque burden (73+/-5% vs. 70+/-10%, P=0.66). A NIRS lipid core plaque was identified in 9 of 13 body lesions vs. 1 of 10 anastomotic lesions (69% vs. 10%, P=0.005). SVG body lesions had higher lipid core burden index (LCBI) compared to anastomotic lesions (184+/-76 vs. 49+/-54, P<0.001). By IVUS-VH, SVG lesions had high % necrotic core (28+/-10%) and % dense calcium (13+/-10%), without any significant difference between body and anastomotic sites. Older SVG age was associated with higher lesion and vessel LCBI (r=0.76 and r=0.64, respectively, P<0.001), but was not associated with IVUS-VH determined plaque composition. Higher HDL-cholesterol was associated with lower lesion LCBI (r=-0.43, P=0.04).

CONCLUSIONS: NIRS-measured lipid core plaque in SVGs increases with increasing SVG age and is infrequent in anastomotic lesions. No association was found between IVUS-VH plaque composition measurements and SVG lesion location or age.

PMID: 20673899

Jul201030

1

Relation of Microchannel Structure Identified By Optical Coherence Tomography to Plaque Vulnerability in Patients With Coronary Artery Disease

Am J Cardiol . 2010; 105(12):1673-1678

Kitabata H, Tanaka A, Kubo T, Takarada S, Kashiwagi M, Tsujioka H, Ikejima H, Kuroi A, Kataiwa H, Ishibashi K, Komukai K, Tanimoto T, Ino Y, Hirata K, Nakamura N, Mizukoshi M, Imanishi T, Akasaka T

OBJECTIVES: Increased neovascularization in atherosclerotic plaques is associated with plaque vulnerability. The high resolution of optical coherence tomography (OCT) might provide a chance to directly visualize plaque neovascularization in vivo. The aim of the present study was to investigate the relation between microchannels in culprit plaques identified by OCT and plaque vulnerability in patients with coronary artery disease.

METHODS: A total of 63 consecutive patients with coronary artery disease who had undergone both OCT and intravascular ultrasound before any interventions to examine culprit lesion morphologies were enrolled. Microchannel was defined as a no-signal tubuloluminal structure on the cross-sectional optical coherence tomographic image.

RESULTS: Microchannels were found in 24 (38%) of the 63 patients. The patients were divided into 2 groups according to the presence or absence of microchannels. The frequency of plaque rupture tended to be greater in the microchannel group (50% vs 28%, p = 0.11). The thickness of the fibrous cap (median 60 vs 100 microm, p = 0.001) was significantly less in the patients with microchannels, and significant differences were found in the frequency of thin-cap fibroatheroma (54% vs 21%, p = 0.012) and positive remodeling (67% vs 36%, p = 0.02) between the 2 groups. The high-sensitivity C-reactive protein levels in the microchannel group was significantly greater than those in the no-microchannel group (median 0.27 vs 0.13 mg/dl, p = 0.015). Moreover, increased microchannel counts were associated with greater high-sensitivity C-reactive protein levels (p = 0.01).

CONCLUSIONS: In conclusion, a significant relation was found between the presence of microchannels in plaques identified by OCT and plaque vulnerability in patients with coronary artery disease.

PMID: 20538113

Jul201030

1

Development of Lipid-Rich Plaque Inside Bare Metal Stent: Possible Mechanism of Late Stent Thrombosis? An Optical Coherence Tomography Study

Heart . 2010; 96(15):1187-1190

Jingbo Hou, Hai Qi, Maomao Zhang, Lijia Ma, Huimin Liu, Zhigang Han, Lingbo Meng, Shuang Yang, Shaosong Zhang, Bo Yu, Ik-Kyung Jang

OBJECTIVES: To study in-stent tissue characteristics by optical coherence tomography (OCT) at long-term follow-up in patients with previous bare metal stent implantation.

METHODS: Among 1636 patients who underwent bare metal stent (BMS) implantation between 1999 and 2006, 39 patients with 60 BMS who developed recurrent ischaemia underwent repeat catheterisation and OCT imaging between June 2008 and August 2009.

RESULTS: The average time interval between initial BMS implantation and OCT imaging was 6.5±1.3 years. A lesion that had features of lipid-rich plaque was found in 20 stents (33.3%) in 16 patients (41%). Fibrous intima was observed in the remaining 40 stents. In the group with lipid-rich plaque, average fibrous cap thickness was 56.7±5.8 μm and lipid arc was 173±58. Six patients had evidence of recent plaque disruption and another six patients had mural thrombus. Hypertension and smoking were more common in these patients than in those with fibrous intima.

CONCLUSIONS: Lipid-rich plaque with a thin fibrous cap was seen in patients with previous BMS implantation and recurrent ischaemia at late follow-up. This may be one possible mechanism for late stent thrombosis.

PMID: 20639235

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