Risultati per: Gestione dei pazienti con angina stabile

Circulation, Volume 148, Issue Suppl_1, Page A15977-A15977, November 6, 2023. Introduction:AKI after invasive coronary angiography (CAG) or PCI is common with an estimated incidence of 7-9%. This complication incurs approximately a $9,500 higher cost of stay, with proportional length of stay increases with absolute elevations in serum creatinine (sCr). While the majority of adverse events occur within 30 days of procedure, there is evidence of increased mortality, stroke, and MACE at 1 year and 5 years following index AKI. This study aimed to identify risk factors for AKI in hospitalized NSTEMI and unstable angina undergoing CAG ± PCI.Methods:Patients who were admitted for NSTEMI or UA who underwent CAG from 2011-2022 in Northeast Ohio Cleveland Clinic hospitals were identified from the EMR. Admission and serial blood work results in addition to demographics, past medical history, and hospital course were compiled and analyzed via multivariable logistic regression using R statistical software. KIDAGO definitions of AKI were utilized to define presence of AKI. All patients declared ESRD prior to admission were excluded from analysis.Results:4,174 cases were included in the analysis with mean age 66.5 years, 63% male, and 81% Caucasian. 7% developed AKI and there was no difference in the proportion of race, gender, or prevalence of ischemic heart disease between those who developed AKI and those who did not. Patients who developed AKI were older (70.9 vs. 66.1 years, p

Circulation, Volume 148, Issue Suppl_1, Page A15772-A15772, November 6, 2023. Introduction:LIMA to PA fistulae are a rare complication after coronary artery bypass graft (CABG) surgery. We present a patient with angina secondary to a steal syndrome from LIMA-PA fistulae, treated with endovascular coiling.Case:The patient is a 49-year-old active male with coronary artery disease, status post CABG at age 46 with a LIMA graft to the left anterior descending artery, radial artery graft to the first obtuse marginal artery, and saphenous venous graft (SVG) to the posterior descending artery. At age 48, he developed angina and underwent stent placement to the distal right coronary artery after the SVG was found to be occluded. Several months later, he reported dyspnea and chest pain on exertion. An exercise nuclear stress test showed abnormal myocardial perfusion in the anteroseptal region, and he was referred for left heart catheterization (LHC). LHC revealed unchanged native coronary disease, patent LIMA, and a network of collateral vessels from the LIMA feeding into the pulmonary vasculature (Figure 1). The collaterals were not seen on LHC 9 months prior. CT coronary angiography confirmed multiple fistulae originating from the superior aspect of the LIMA graft communicating with the PA (Figure 1). After a multidisciplinary, patient-centered, heart team discussion, he underwent successful endovascular coiling of the collateral branches (Figure 2).Discussion:LIMA-PA fistulae is a rare cause of angina and there is a paucity of literature on management. To our knowledge, coil embolization has been described in roughly 10 cases. Here, we present a successful case of endovascular coiling of collateral vessels leading to symptomatic improvement.

Circulation, Volume 148, Issue Suppl_1, Page A15114-A15114, November 6, 2023. Background:Angina and no obstructive coronary artery disease (ANOCA) is associated with poor outcomes and limited treatment options. Enhanced external counterpulsation (EECP) is a non-invasive treatment that involves applying external inflatable cuffs to the lower extremities to increase blood flow during diastole (diastolic augmentation and increased preload), followed by deflation during systole (decreased afterload). Although EECP is indicated in refractory angina patients, its effectiveness in treating refractory angina in ANOCA patients is relatively unknown and limited to small case series.Objective:Assess the efficacy of EECP treatment in ANOCA patients using Canadian Cardiovascular Society (CCS) angina class, 6-minute walk test (6MWT), Duke Activity Status Index (DASI), Seattle Angina Questionnaire (SAQ), and weekly anginal episodes.Methods:We examined ANOCA patients (defined as £50% stenosis in any major epicardial vessels) with CCS class 3 or 4 angina that completed EECP treatment at 2 large centers. CCS class, 6MWT, DASI, SAQ, and weekly anginal episodes were evaluated pre- and post- EECP treatment, as data was available. A paired Student’s t-test, Wilcoxon signed-rank test, and McNemar’s test were utilized as appropriate.Results:65 ANOCA patients (63% female; 60±11 years) that completed 35±2 EECP sessions were included. Patients were on 4±2 cardiac medications pre-EECP (78% statin, 52% ACEI/ARB, 62% BBs, 34% CCBs, 48% nitrates, and 53% ranolazine). Post-EECP, 42 patients (65%) had an improvement of31 CCS angina class with 16 (25%) improving by32 classes. Significant improvements in CCS angina severity, 6MWT, DASI, SAQ, and weekly anginal episodes were evident post-EECP (Table).Conclusion:In ANOCA patients, EECP therapy reduces CCS angina class and improves exercise tolerance. EECP should be considered in ANOCA patients with refractory angina CCS class 3 or 4 as a part of optimal medical therapy.

Circulation, Volume 148, Issue Suppl_1, Page A13412-A13412, November 6, 2023. Introduction:Multi-vessel coronary vasospastic angina (multi-VSA) is life-threatening disease. We tried to predict multi-VSA by machine learning (ML) on 12-lead electrocardiogram (ECG).Hypothesis:Machine learning on 12-lead ECG has powerful diagnostic value for multi-VSA.Methods:We recruited 227 consecutive sinus-rhythm patients (63.6±12.9years, 136men) who underwent acetylcholine-provocation test in coronary angiography (CAG). Multi-VSA was defined as spasm in at least 2 major branches. ECG was recorded before CAG in no chest pain period. ML was performed on table data of ECG parameters using several ensemble learning methods.Results:79 patients (35%) showed multi-VSA, and univariate logistic regression analysis extracted 23 significant but weak predictors, the highest area under receiver operating characteristics curve (AUROC) was 0.673. Conversely, ML demonstrated high diagnostic performance (AUROC of extra trees classifier: 0.817). Shapley additive explanation method showed male, QTc, J wave in lead II, and low amplitude of Q wave in lead I/aVL played essential roles to build the ML model.Conclusion:Several parameters of 12-lead ECG in multi-VSA patients contains potential features of VSA, and their aggregation and ensemble learning can predict VSA with high diagnostic performance.

Circulation, Volume 148, Issue Suppl_1, Page A14643-A14643, November 6, 2023. Background:There is controversy on clinical implication of spotty calcification in the coronary arteries. Optical coherence tomography (OCT) enables detailed plaque characterization including features of plaque vulnerability. Pericoronary adipose tissue (PCAT) attenuation is a recently developed marker for perivascular inflammation.Methods:Patients with stable angina pectoris (SAP) who had both computed tomography angiography (CTA) and OCT prior to coronary intervention were included. They were classified into two groups: spotty calcification group (calcification arc

Circulation, Volume 148, Issue Suppl_1, Page A15654-A15654, November 6, 2023. Backgrounds:Layered plaque, a signature of previous plaque destabilization and healing, is one of the predictors for rapid plaque progression, the mechanism of which is unknown.Aims:To investigate the level of vascular inflammation and plaque vulnerability in layered plaques to elucidate possible mechanisms of rapid plaque progression.Methods:Patients who underwent both coronary computed tomography angiography (CTA) and optical coherence tomography (OCT) were selected. Plaques were defined as any tissue (noncalcified, calcified, or mixed) within or adjacent to the lumen. Pericoronary adipose tissue (PCAT) attenuation was measured at the plaque level on CTA. OCT features of plaque vulnerability were assessed at the corresponding site.Results:A total of 475 plaques from 195 patients presented with stable angina pectoris were included. Layered plaques (n=241), compared to non-layered plaques (n=234), had a higher level of vascular inflammation (-70.94 [-77.86, -64.66] HU vs. -73.52 [-80.83, -67.66] HU, P=0.014, Figure 1). Layered plaques also had a higher prevalence of the features of plaque vulnerability (Figure 2), including lipid-rich plaque (83.8% vs. 66.7%, P

Circulation, Volume 148, Issue Suppl_1, Page A18940-A18940, November 6, 2023. CASE DESCRIPTION:A 73-year-old male with HTN, HLD, CAD/MI status post PCI to the RCA and LAD (2021), and former tobacco use presented with acute, severe, left-sided chest pain with nausea, diaphoresis and dizziness. He started fasting and adjusted his sleep schedule 3 days prior for Ramadan, but did not miss any of his medications including isosorbide and ranolazine. He was chest pain free on arrival, but subsequently developed severe chest pain becoming bradycardic, hypotensive and hypoxic. At that time the EKG (Figure 1) showed ST elevation (STEMI) in leads II, III and aVF with high degree atrioventricular block. He was started on intravenous fluids and a vasopressor but had spontaneous resolution of symptoms within 10 minutes. Emergent coronary angiography revealed stable 70% stenosis of an ostial left circumflex (LCx) artery and non-obstructive CAD of the RCA. Labs revealed normal blood glucose, negative urine toxicology and mild elevation of troponin (trended serially). Echocardiogram was normal with no regional wall motion abnormalities. He was treated as vasospastic angina with addition of a calcium channel blocker without recurrence of his symptoms.DISCUSSION:Vasospastic angina is an important cause of acute coronary syndrome. Our patient had severe vasospastic angina while being treated for CAD for over 10 years. No prior studies have linked fasting to vasospasm. We hypothesize that fasting and a diurnal sleep schedule may contribute to worsened episodes in susceptible individuals due to hormonal changes including glucose shifts and an increase in catecholamines and cortisol. Increased catecholamine levels may induce spasm by stimulation of alpha receptors in the coronary arteries, and cortisol can induce vascular inflammation, potentiating negative effects. We highlight the importance of keeping high clinical suspicion for a diagnosis of vasospasm, as well as the need to further understand the complex pathophysiology to counsel patients in the future.

Circulation, Volume 148, Issue Suppl_1, Page A18268-A18268, November 6, 2023. Introduction:Approximately 75% of women that undergo coronary angiography for angina do not have obstructive disease. However, a significant number have persistent angina, which can reduce their functional capacity and performance, impacting patients’ quality of life. There is a need for further studies that accurately compare angina and functional capacity among women angina with non-obstructive coronary disease (ANOCA).Objective:We examined the association between perceived anginal symptoms and functional capacity in patients with ANOCAMethods:A the Women’s Heart Center at the Christ Hospital, all women completed the Duke Activity Status Index (DASI) and Seattle Angina Questionnaire-7 (SAQ7) at the initial visit. DASI score range from 0 to 58.2 and assess functional capacity using self-assessment and VO2 peak formula with higher scores indicating better functional capacity. SAQ7 assesses angina symptoms, physical limitation, and quality of life; the score is from 0-100, where a lower score indicates a higher frequency of angina, increased physical limitation, and poor quality of life. DASI and SAQ7 scores were correlated. Sperman correlation and Mcnemar chi-square were used to compare DASI and SAQ7 score results.Results:Among 225 women with ANOCA, the mean DASI score was 16.73, and the mean SAQ7 score was 43.79. 63.1% reported a low score of SAQ7, and 79.6% reported a low DASI score. SAQ7 and DASI were moderately correlated (Spearman correlation of +0.42). Further analysis with McNemar chi- square showed that women with lower SAQ7 (score 0-49.4) tends to corresponds with low DASI (score 0-24.5) (Specificity 86.6%), compared to women with higher SAQ7 (score 49.5-100) and high DASI (score 24.6-58.2) (Sensitivity 32.5%) (p

Circulation, Volume 148, Issue Suppl_1, Page A17136-A17136, November 6, 2023. Introduction:Enhanced external counterpulsation (EECP) therapy is a potential treatment for refractory angina, which refers to persistent symptoms despite optimal treatment. However, the immobility, cost, and lack of individualized pressure control limit the accessibility and clinical implications of EECP. To address these limitations, a new Mobile, Motorized Enhanced Counterpulsation (MECP) device has been developed.Hypothesis:To investigate efficacy of MECP in improving in angina functional class and exercise tolerance in patients with refractory angina and to validate the consistency in outcomes observed with conventional EECP treatment.Methods:This prospective study enrolled patients with symptomatic refractory angina between September 2020 and December 2022 at two tertiary centers in Korea. Baseline and post-treatment assessments included measurements of angina scale, 6-minute walking test, cardiopulmonary exercise test, and central arterial pressure.Results:The study included 71 patients (70.4% male, median age 66 years). After the 10-hour MECP treatment session, 57.7% of patients showed improvement in angina scale based on Canadian Cardiovascular Society classification, with a significant distribution change from 76.8% to 49.3% in class II and from 21.7% to 5.7% in class III (p

Circulation, Volume 148, Issue Suppl_1, Page A14202-A14202, November 6, 2023. Introduction:Although evidence-based practice of has progressed, little is known about underlying mechanisms of chest pain symptoms in patients with post-acute sequelae of COVID-19 (PASC) and preferred approaches for their assessment. Several mechanisms underlying COVID-19-related endothelial dysfunction have been proposed. The purpose of this study was to explore the prevalence of vasospastic angina as a cause of chest pain in PASC patients.Methods:We retrospectively reviewed 273 consecutive patients who presented to an outpatient unit for cardiovascular PASC between June 2021 and March 2023. After the initial evaluation with electro- and echocardiography, coronary computed tomography angiography or cardiac magnetic resonance imaging were performed to rule out obstructive coronary artery disease and myopericarditis if patients had intermittent chest pain and had no contraindications to these tests. When the patients’ chest pain mainly occurred at night and in the morning or was resolved by nitrates, invasive coronary angiography and acetylcholine provocation testing were performed to diagnose vasospastic angina.Results:Eight of 273 patients with PASC underwent acetylcholine provocation testing. The median time from the diagnosis of SARS-CoV2 infection to acetylcholine provocation testing was 197 (interquartile range, 120-542) days. The mean age of the patients was 37.1 years; two required oxygen support during acute COVID-19; and none had previous history of cardiovascular disease (Figure). Five of the 8 patients showed acetylcholine-induced multivessel coronary vasospasm and were diagnosed as vasospastic angina. Their chest pain improved with calcium channel blockers and nitrates, whereas nonfatal myocardial infarction occurred in one patient after the diagnosis of vasospastic angina.Conclusions:Our observational case series suggest that vasospastic angina should be considered as a potential cause of PASC.

Circulation, Volume 148, Issue Suppl_1, Page A13787-A13787, November 6, 2023. Background:The myocardial blood flow (MBF) mechanism in mental stress-induced myocardial ischemia (MSIMI) in angina with no obstructive coronary artery disease (ANOCA) population is unknown.Methods:13-NH3cardiac PET-CT was utilized to assess MBF and perfusion changes under mental stress (ms) and adenosine stress (as) in ANOCA subjects and gender- and age-matched healthy controls. MSIMI was defined as an increase in perfusion defect score of ≥3 points.Results:Among the 126 participants enrolled, ANOCA women showed a significantly higher prevalence of MSIMI compared to the healthy controls (36/84 vs. 1/42,p

Circulation, Volume 148, Issue Suppl_1, Page A12409-A12409, November 6, 2023. Background:Short-term increases (days to weeks) in fine particulate matter (PM2.5) air pollution are associated with hospitalization for acute coronary syndromes (ACS). A changing climate is shifting sources of PM2.5toward summer wildfires in the western US. This study evaluated if short-term increases in PM2.5and ozone were associated with ACS risks in wildfire (June-October) and winter inversion (Nov.-March) seasons.Methods:Case-crossover analyses examined N=21,414 subjects with emergency or inpatient hospitalization at 11 Intermountain hospitals for ACS, including the primary diagnosis of myocardial infarction (AMI, n=20,287) or unstable angina (USA, n=1,127). PM2.5data were collected in January 1, 1999 to March 31, 2022 (ozone: 2006-2022) from community monitors on Utah’s Wasatch Front. Odds ratios (OR) and 95% confidence intervals (CI) were computed by Poisson regression with adjustment for weather data.Results:Subjects averaged 66±14 years of age and 31.0% were female. Overall PM2.5increases were associated with concurrent day (lag 0 days) ACS hospitalizations (OR=1.024 per +10 μg/m3, CI: 1.004, 1.043, p=0.019), driven by AMI (OR=1.025 per +10 μg/m3, CI: 1.004, 1.045, p=0.017). USA admissions were delayed to the second week [lag moving average (mAvg) days 7-13] after PM2.5increases (OR=1.090 per +10 μg/m3, CI: 1.024, 1.159, p=0.007) and PM2.5associations with USA were strengthened by adjustment for ozone. Analyzed by wildfire and inversion seasons, PM2.5associations differed for AMI and USA (Figure). Short-term increases in ozone in wildfire season were associated with lower USA risk at lag 1, lag 2, 3-day mAvg 0-2, and 1-week mAvg 0-6 and lower AMI risk at mAvg 7-13, but not with inversion season risks.Conclusions:Short-term increases in PM2.5air pollution were associated with ACS hospitalizations for AMI and USA, with patterns of risk differing between wildfire and inversion seasons. Ozone increases were not associated with greater risk.

Circulation, Volume 148, Issue Suppl_1, Page A16624-A16624, November 6, 2023. Introduction:PACT-ANGINA is a quality improvement initiative aimed to improve the understanding of challenges in the management of angina and chronic coronary syndromes.Hypothesis:An international patient survey is conducted to assess how angina and its management affect patients’ lives and what patients want in terms of the management of their angina.Methods:A working group that included 9 cardiologists and 7 patient representatives developed an online, anonymous questionnaire. Patients with angina were invited to take part in the survey by patient organizations and treating physicians.Results:Between January and June 2023, the survey was completed by 891 patients in 21 countries. The proportion of female patients was 46%. Among participants, 57% had been diagnosed with angina for 2 years or less, and 54% had never undergone a percutaneous coronary intervention. The proportion of patients with no history of smoking was 65% and the most common self-reported concomitant diseases were hypertension (49%), diabetes (38%) and dyslipidemia (23%). Pain, tightness, pressure or discomfort in the chest (89%), shortness of breath (44%), and fatigue (39%) were the most frequently reported symptoms, and 34% of participants felt that their physical activities were very or extremely limited by angina symptoms. The proportion of respondents who felt that angina was having a great or extreme impact on their quality of life was 37%. When asked to rate the relative importance of 9 treatment objectives, respondents assigned the highest priority to 1) reducing angina attacks and symptoms, 2) avoiding hospitalizations, and 3) prolonging their life as much as possible. Among different aspects of care, those considered the most important by respondents to improve the management of their angina were 1) a better follow-up of their symptoms, 2) practical and easy-to-understand information, and 3) lifestyle changes counseling.Conclusions:This study demonstrates that patients with angina are often limited by their symptoms, which impact their quality of life. Patient-centered management of angina is necessary to improve clinical care of such a common cardiac condition.

Anmar, serve un percorso diagnostico terapeutico per gestirle

Carolyn Smith, ‘dal ballo può arrivare un aiuto importante contro i tumori’