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Circulation, Volume 150, Issue Suppl_1, Page A4147765-A4147765, November 12, 2024. Case Description:A 74-year-old male with hypertension, hyperlipidemia, coronary artery disease status post PCI, paroxysmal atrial fibrillation, and coronary vasospasm presented with recurrent episodes of chest pain at rest described as substernal, pressure like, 10/10 lasting for a few minutes. The patient was hemodynamically stable upon presentation but had an event of pulseless ventricular tachycardia (VT) requiring shock x 2 (Image 1). The patient was stabilized, and an emergent left heart catheterization showed stable obstructive CAD with diffuse coronary vasospasm responsive to intracoronary nitrates (Image 2). The patient was transferred to the intensive care unit for further management. He had multiple prior presentations for chest pain, with one complicated by a transient hemodynamically unstable high grade AV block (Image 1). Prior work up was also consistent with coronary vasospasm despite being optimally managed on nitrates and calcium channel blockers. Despite medical management the patient had a refractory course with recurrent symptoms.Clinical Decision Making:As it was believed that symptoms were likely driven by high sympathetic tone, the patient was intubated and sedated for sympathetic drive suppression. After a multidisciplinary meeting with cardiothoracic surgery and electrophysiology, a decision was made to go for video assisted thoracoscopic surgery (VATS) which was performed successfully. The patient was extubated, had no recurrence of symptoms after, and was offered an implantable-cardioverter defibrillator at discharge for secondary prevention.Discussion:Coronary vasospasm can be life threatening due to transient and acute ischemia driven myocardial injury or arrhythmias. This case highlights the role of VATS sympathectomy in managing severe cases of vasospastic angina that are unresponsive to conventional treatments. Further studies are required to establish the efficacy and safety of this procedure in broader patient populations.

Circulation, Volume 150, Issue Suppl_1, Page A4147752-A4147752, November 12, 2024. Background:Angina with no obstructive coronary arteries (ANOCA) is clinically challenging to diagnose and manage. The agreement between Doppler-derived coronary flow reserve (CFRDoppl) and PET-derived CFR (CFRPET) in patients with ANOCA remains unclear.Aims:To evaluate the correlation between Doppler- and PET-derived CFR in patients with ANOCA.Methods:We conducted a single-center, retrospective study of adult patients (age ≥18 years) with ANOCA who were referred for evaluation of possible microvascular ischemia with Doppler- and PET-derived CFR at the Mayo Clinic (Rochester, MN) between January 1, 2018, and May 1, 2024. Pearson correlation was used to quantify the association between Doppler- and PET-derived CFR. Agreement between Doppler- and PET-derived CFR was assessed by Bland-Altman analysis using a 2-way mixed effects model with measures of absolute agreement.Results:A total of 66 patients were initially identified, of which 40 were included in the final analysis (66.7% female, median age 58 years [Q1-Q3: 45-66 years]). Median time between PET- and Doppler-derived CFR was 8 days (Q1-Q3: 1-31 days). Median CFRDopplwas 2.75 (IQR: 2.23-3.28) and median CFRPETwas 2.50 (IQR: 2.10-3.10). Doppler-derived CFR displayed a wider range than PET-derived CFR (0.8-5.2 vs 1.2-4.0). A strong correlation was found between Doppler- and PET-derived CFR (r=0.81; p

Circulation, Volume 150, Issue Suppl_1, Page A4143127-A4143127, November 12, 2024. Background:Cross-sectional Seattle Angina Questionnaire (SAQ) scores not only measure patients’ symptoms, function and quality of life, but are also associated with prognosis in chronic coronary disease (CCD). Yet, the prognostic significance of serial SAQ scores in the modern era is unknown, particularly after revascularization.Hypothesis:Serial collection of SAQ scores can provide updatable estimates of clinical risk in patients with CCD.Aims:To describe the association of serial SAQ Summary Scores (SAQ-SS) with the primary endpoint of the ISCHEMIA trial (CV death, MI, or hospitalization for heart failure, unstable angina, or resuscitated cardiac arrest), stratified by medical management and recent revascularization.Methods:Analyses were framed from the perspective of a clinician reviewing the SAQ-SS in clinic and seeking to understand whether the prior score, the current score, or the change was most prognostic of subsequent clinical events. Cox models were created using the 3-month, 6-month, and change between the 3- and 6-month SAQ-SS scores, individually, as well as those scores in combination to find the most prognostic permutation. Each model was adjusted for 17 potentially confounding covariates. We performed separate analyses for the conservative and invasive management cohorts. In the conservative group, we excluded those who underwent revascularization prior to their 6-month assessment. In the invasive group, we included only patients who were revascularized within the first three months. In both groups, we excluded patients with events prior to 6 months.Results:In both the conservatively managed (n=1965) and recent revascularization (n=1447) cohorts, unadjusted analyses estimated a 6-9% lower risk of clinical events over a median of 3.2 years for each 5-point increase in SAQ-SS score. The current SAQ-SS score was most strongly associated with clinical events, even after including the prior SAQ-SS score and all other covariates (Table).Conclusions:Routine clinical use of the SAQ provides an updatable measure of risk in patients with CCD—managed either medically or with revascularization—with the current SAQ-SS score demonstrating the strongest association with clinical events.

Circulation, Volume 150, Issue Suppl_1, Page A4140212-A4140212, November 12, 2024. INTRODUCTION:Nicorandil, a dual mechanism anti-anginal used in Europe, Asia, and Australia for >20 years acts as NO donor and K+ATP channel opener, providing balanced pre- and afterload vasodilation. Antianginal efficacy matches beta and calcium channel blockers, and long-acting nitrates but without tolerance build-up. Immediate release nicorandil (IR NIC) taken 2-3 times daily with 80% dose release in 45 min, requires high patient adherence. While EU labeling and trials highlight no proarrhythmogenicity lack of recent data remains along with prior reports of potential impact of IR NIC on EKG patterns. Once-daily extended-release nicorandil (ER-NIC) AUX-001 is being developed to improve compliance, symptom control, and QoL for chronic stable angina patients.ONJECTIVE:Examine ER NIC impact on EKG patterns before and after 2 sequential 24h single-dose exposures during fed and fasting status.METHODS:12-lead EKG was recorded in 16 adult healthy volunteers at baseline. Peak systemic exposure of ER NIC was predicted at 6h post dose. Consequently, postdose EKG was scheduled at 6h after AUX-001 administration, with 24h monitoring. Variables included PR, ST, QT, and TP interval and P, QRS and T wave duration. QT interval was corrected using Bazett’s and Fridericia’s formula.Results:12-lead EKGs were available on 16 fasting and 15 fed patients. None discontinued due to safety or tolerability. 13 EKGs at baseline on day 1, and 14 on day 8 showed non-clinically relevant abnormalities. No clinically relevant abnormalities were found at baseline or 6h postdose. Mean HR was 58±5.8 and 59±6.2 at baseline and 68±8.2 and 67±6.7 at 6h for fasting and fed. Mean QTc (Bazett) was 395±19 ms pre- and 400±18 ms 6h postdose under fasting and 395±14 and 399±16 ms under fed status. Mean PR interval was 170±22 ms pre- and 160±21 ms 6h post-dose fasting and 169±17 and 158±18 under fed status.CONCLUSION:Single dose AUX-001 caused near no QTc changes in healthy volunteers compared to baseline. 6h postdose PR intervals physiologically adjusted to changing HR, and stayed within normal range. Similar to IR NIC, AUX-001 had no discernable effect on EKG patterns during fasting or fed conditions. Findings highlight no relevant AUX-001 effect on electrophysiological safety providing additional safety information supporting development of ER NIC. Findings also confirm previous healthy volunteer trials with IR NIC highlighting no tendency promoting arrhythmia in normal, non-ischemic myocardium.

Circulation, Volume 150, Issue Suppl_1, Page A4140903-A4140903, November 12, 2024. Background:Patients with multivessel coronary spasm showed relatively poor outcomes in vasospastic angina. Recent report also revealed that Ergovonine response definite group showed poor clinical outcomes compared to the Ergovonine response intermediate group. The purpose of this study is to evaluate the clinical impact of Ergovonine provocation definite or intermediate response in multivessel vasospastic angina patients.Methods:A total of 428 patients between May 2010 to November 2013, diagnosed as multivessel vasospastic angina who were registered in the Vasospastic Angina Korea (VA-KOREA) were enrolled. Patients were divided into Ergovonine provocation response definite group (n=111) and intermediate group (n=317). The primary endpoint was cumulative incidece of cardiac death, new onset arrhythmia, acute coronary syndrome, re-admission due to chest pain during 3 years follow-up.Results:In the baseline clinical chracteristics, Ergovonine response definite group had less proportion of male patients (32.4% vs. 49.8%, p=0.002). Other conventional cardiovascular risk factors were similar between two groups. In the angiographic characteristics, electrocardiogram changes during Ergovonine provocation was higher in the deinite group including ST change (18% vs 10.7%; p=0.046), ST elevation (16.2% vs 2.8%; p

Circulation, Volume 150, Issue Suppl_1, Page A4146729-A4146729, November 12, 2024. Background:Although residual angina after revascularization for chronic coronary disease (CCD) is common, it is unclear if the cause is incomplete revascularization of epicardial coronary disease or other ischemic mechanisms such as microvascular dysfunction or vasospastic angina.Methods:Among invasively managed ISCHEMIA trial participants with angina at baseline and anatomic complete revascularization (ACR) determined by core lab analysis, the frequency of and characteristics associated with residual angina and its association with health status, medication use at 6 months, and 5-year all-cause and cardiovascular (CV) mortality were assessed. The Seattle Angina Questionnaire Angina Frequency (SAQ AF) was used in a binary fashion to define residual angina as a score

Circulation, Volume 150, Issue Suppl_1, Page A4142676-A4142676, November 12, 2024. Background:Interview techniques for angina pectoris in patients with chest pain have demonstrated a low positive probability of 35.7% (PROMISE study) when using the Diamond-Forrester approach, which evaluates pre-test probability (PTP) based on classic chest symptoms, age, and gender. Therefore, it is beneficial to use artificial intelligence (AI) to create a more precise medical interview system by combining patient clinical data. Our objective is to create such a system.Methods:A medical interview is taken from patients presenting with chest pain as a chief complaint. Then, coronary artery examinations (CAG, contrast-enhanced CT, stress tests) will be conducted to definitively diagnose angina. The results of these definitive diagnoses will be combined with the patients’ baseline data to develop an AI algorithm. The input attributes used for the interview are listed in Table 1. A multilayer perceptron (MLP) was applied to predict patients diagnosed with angina pectoris, and these models were validated using 10-fold cross-validation.Results:There were a total of 315 patients, of whom 135 were diagnosed with angina pectoris. Additionally, patient information including atherosclerosis risk factors such as diabetes (102 cases), dyslipidemia (216 cases), hypertension (225 cases), and smoking status (never: 141 cases, past: 124 cases, current: 23 cases) were added as attributes and analyzed. Using only medical interviews and setting the threshold at 80% (where the AI determined the probability of angina to be 80% or higher), the prediction accuracy was 62.6%, with a sensitivity of 30.8% and a specificity of 87.7%. The precision was 66.6%. Additionally, when the four atherosclerosis risk factors were included, the prediction accuracy increased to 69.9%. Notably, the precision reached 79.9%. (Figure1)Conclusion:Our AI system based on interview data demonstrated high accuracy for diagnosis of angina while it was improved by adding the attribute of the four atherosclerosis risk factors. Further investigation is needed to complete a highly accurate AI-based application by increasing the number of samples.

Circulation, Volume 150, Issue Suppl_1, Page A4120805-A4120805, November 12, 2024. Introduction:Patients with angina but unobstructed coronaries (ANOCA) represent a diagnostic and therapeutic challenge. Current Guidelines recommend invasive testing using acetylcholine and adenosine for evaluation of coronary vasomotor disorders. However, there is a broad variability among the different measurement techniques.Purpose:To assess the differences of bolus thermodilution versus Doppler flow velocity derived indexes of coronary physiology using intracoronary adenosine in patients with ANOCA.Methods:A total of 162 patients (61.1% women, mean age 63±28 years) with ANOCA (no epicardial stenosis >50%, FFR >0.80) were enrolled between 2018 and 2023. All patients underwent wire-based assessment of coronary flow reserve (CFR) and microvascular resistance (MR) using adenosine in the left anterior descending artery. The bolus thermodilution technique was applied in 46 patients (CFR/IMR, CFRThermo) and the Doppler technique in another 116 patients (CFR/HMR, CFRDoppler). All measurements were performed according to a standardised protocol. The commonly applied cut-offs for CFR (2.5) and IMR ( >25) were used.Results:The study population was characterized by the following risk factors: arterial hypertension (63%), hypercholesterolemia (62%), positive family history for cardiovascular disease (36%), diabetes (16%) and smoking (10%). The frequency of an abnormal CFR 2.5 in 12.1%, median 1.7 [IQR 0.7], p

Circulation, Volume 150, Issue Suppl_1, Page A4144819-A4144819, November 12, 2024. Background:Refractory angina severely affects patients’ quality of life around the world. Among the new treatment methods, the coronary sinus reducer (CSR) is one of the most thoroughly researched.Purpose:We aim to investigate the efficacy and safety of CSR for refractory angina.Methods:We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Web of Science, Scopus, Embase, and Cochrane searches until May 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3).Results:With the inclusion of three RCTs, our cohort comprised a total of 180 patients. Compared to the control group, after six months, CSR was significantly associated with decreased mean change of Canadian cardiovascular society (CCS) class (MD: -0.54 with 95% CI [-0.80, -0.27], P< 0.01), an increased number of patients in the CCS class I (RR: 2.29 with 95% CI [1.14, 4.61], P= 0.02), a decreased number of patients in the CCS class III (RR: 0.53 with 95% CI [0.32, 0.87], P= 0.01), and increased exercise time (MD: 50.46 with 95% CI [9.47, 91.45], P= 0.02). However, there was no significant difference between CSR and the control group in CCS class II, class IV, across all Seattle Angina Questionnaire (SAQ) domains, the incidence of any serious adverse events (RR: 3.44 with 95% CI [0.82, 14.42], P= 0.09), stroke (RR: 2.13 with 95% CI [0.20, 22.88], P= 0.53), and all-cause mortality (RR: 1.06 with 95% CI [0.07, 16.59], P= 0.97).Conclusion:CSR has been shown to reduce angina severity by lowering CCS class scores and increasing exercise time. Large-scale RCTs are needed to confirm its effectiveness in patients with refractory angina.

Circulation, Volume 150, Issue Suppl_1, Page A4122256-A4122256, November 12, 2024. Background:Coronary artery disease (CAD) exerts a considerable impact on mortality from cardiovascular disease. Approximately half of patients with CAD initially present with angina pectoris. The GREAT study is designed to establish a large cohort of Chinese patients with angina pectoris and compare the effectiveness of different anti-angina regimens, using the Seattle Angina Questionnaire.Method:The GREAT (reGistRy study of medical thErapy in patients with Angina pecToris) Registry is a multicenter, prospective, observational, cohort study that enrolled 1556 adult CAD patients with angina pectoris from nine hospitals in China. The study included patients currently receiving or eligible to receive oral anti-anginal regimens. The cohort was classified into nicorandil and non-nicorandil groups based on the treatment therapies. The primary outcome was the Seattle Angina Questionnaire summary score (SAQ-SS) changes from baseline to 12 months. The SAQ-SS averages the domains of physical limitation, angina frequency, and quality-of-life scores.Results:From September 2021 to May 2022, a total of 1575 patients were screened, of whom 1556 met the inclusion criteria and were included (Figure 1). Among the patients at the full analysis set (FAS, N=1528), 28.5% were women, and the median age was 61 years. Baseline variables were well balanced after propensity score matching, with both groups containing 450 patients. In the nicorandil group, patients showed a significantly greater increase in mean SAQ-SS score at Month 12 compared to the non-nicorandil group (17.6±14.0 vs 15.1±13.0; difference: 0.19; 95% CI, 0.05-0.32; p=0.003). In addition, patients in the nicorandil versus the non-nicorandil group reported a significantly greater mean improvement in the SAQ-QoL domain (18.9±21.4 vs 16.3±20.4; p=0.042) and SAQ-PL domain (11.7±16.9 vs 10.0±17.0; p=0.001). Over 12 months, a higher proportion of patients in the nicorandil group, compared to the non-nicorandil group, reported substantial improvements in SAQ-SS, with 24.1% experiencing large improvements (20-29 points) and 18.2% reporting very large improvements (≥30 points) versus 20.7% and 12.0%, respectively (p=0.005 across all categories) (Figure 2).Conclusion:This real-world data indicates that nicorandil-based anti-angina regimens are associated with a greater health status outcome improvement compared to those not using nicorandil in CAD patients.

Circulation, Volume 150, Issue Suppl_1, Page A4144202-A4144202, November 12, 2024. [Background]:Evidence on the long-term prognosis of stent-less percutaneous coronary intervention (PCI) using paclitaxel-coated balloons (PBCs) is becoming established, however some prognostic indicators remain unexplored. Recently, elevated blood lipoprotein(a) levels are gaining attention as an independent risk factor for the development of atherosclerosis. We hypothesized that elevated lipoprotein(a) levels would also adversely affect the outcome of stent-less PCI.[Object]:The aim of this study is to investigate the association between lipoprotein(a) levels and outcomes after stent-less PCI.[Methods]:In this single-center retrospective study, patients with stable angina undergoing stent-less PCI with PCBs in de novo lesions at our institution were included between October 2016 and September 2022. We classified all patients into three groups according to lipoprotein(a) tertiles and performed a Cox proportional hazards analysis. The primary endpoint was a composite outcome of cardiovascular death, major bleeding, myocardial infarction, and target lesion revascularization.[Results]:A total of 207 patients were included, including a mean age of 70±11 years and 75% male. The median lipoprotein(a) level was 12.4 nmol/L (IQR 4.8-21.4 nmol/L). During a median follow-up of 18 months, the composite outcome was observed in 37 patients (17.9%). Patients with the highest lipoprotein(a) group (≧18.4 nmol/L) had a 4-fold higher risk than those with the lowest group (