Search Results (130)

Substantial evidence from previous clinical studies, randomized trials, and patient registries confirms the existence of significant differences in cardiac morphology, pathophysiology, prevalence of specific coronary artery disease (CAD), and clinical course of myocardial infarction (MI) between men and women. The aim of this review is to investigate the impact of sex or gender on the development and clinical course of MI, the mechanisms and features of left ventricular (LV) remodeling, and heart failure (HF). The main sex-related difference in post-MI LV remodeling is adverse LV dilatation in males versus concentric LV remodeling or concentric LV hypertrophy in females. In addition, women have a higher incidence of microvascular dysfunction, which manifests as impaired coronary flow reserve, distal embolism, and a higher prevalence of the no-reflow phenomenon. Consequently, impaired myocardial perfusion after MI is more common in women than in men. Regardless of age or other comorbidities, the incidence of reinfarction, hospitalization for HF, and mortality is significantly higher in females. There is therefore a “sex paradox”: despite the lower prevalence of obstructive CAD and HF with reduced ejection fraction (HFrEF), women have a higher mortality rate after MI. Different characteristics of the coronary network, such as plaque formation, microvascular dysfunction, and endothelial inflammation, as well as the prolonged time to optimal coronary flow restoration, secondary mitral regurgitation, and pulmonary vascular dysfunction, lead to a worse outcome in females. A better understanding of the mechanisms responsible for MI occurrence, LV remodeling, and HF in men and women would contribute to optimized patient therapy that would benefit both sexes. Full article

This paper presents a novel hybrid approach that integrates computational fluid dynamics (CFD), physics-informed neural networks (PINN), and fluid–structure interaction (FSI) methods to simulate fluid flow in stenotic coronary artery trees and predict fractional flow reserve (FFR) in areas of stenosis. The primary objective is to utilize a 1D PINN model to accurately predict outlet flow conditions, effectively addressing the challenges of measuring or estimating these conditions within complex arterial networks. Validation against traditional CFD methods demonstrates strong accuracy while embedding physics-based training to ensure compliance with fundamental fluid dynamics principles. The findings indicate that the hybrid CFD PINN FSI method generates realistic outflow boundary conditions crucial for diagnosing stenosis, requiring minimal input data. By seamlessly integrating initial conditions established by the 1D PINN into FSI simulations, this approach enables precise assessments of blood flow dynamics and FFR values in stenotic regions. This innovative application of 1D PINN not only distinguishes this methodology from conventional data-driven models that rely heavily on extensive datasets but also highlights its potential to enhance our understanding of hemodynamics in pathological states. Ultimately, this research paves the way for significant advancements in non-invasive diagnostic techniques in cardiology, improving clinical decision making and patient outcomes. Full article

Background: Optimal medical therapy (OMT) is increasingly recognized as a cornerstone in managing chronic coronary syndrome (CCS), offering a non-invasive alternative to percutaneous coronary intervention (PCI). Case Presentation: A 38-year-old male with diabetes, dyslipidemia, and hypertension was treated with early and comprehensive OMT, including statins, ezetimibe, sodium-glucose cotransporter 2 inhibitors (SGLT2i), pioglitazone, and renin-angiotensin system inhibitors. Insulin was introduced during the acute phase to stabilize glycemic control. His HbA1c decreased to 6.3% within 4 months. Results: Over 8 months, the patient experienced a reduction in coronary plaque burden and an improvement in fractional flow reserve (FFR) from 0.75 to 0.90, indicating enhanced coronary blood flow. Plaque volume burden decreased from 85% to 52% in key coronary segments. Conclusions: This case highlights the effectiveness of OMT, including statins, ezetimibe, SGLT2i, and pioglitazone, in achieving outcomes comparable to PCI. FFR-computed tomography follow-up is critical in guiding treatment decisions. Continued OMT is recommended if plaque stabilization is observed. If no improvement is observed, OMT should be intensified, and PCI considered as appropriate. Full article

Background: With modern diagnostic tools, incidence ischemia with no obstructive coronary atherosclerosis (INOCA) and heart failure with preserved ejection fraction (HFpEF) are found to be much higher than previously believed, and—as they lead to adverse cardiovascular outcomes—their causes and development are subjects of ongoing research. There is growing evidence that coronary microvascular dysfunction might be the underlying cause of both INOCA and HFpEF. Methods: In 65 patients with effort angina but no obstructive coronary artery disease, the index of microvascular resistance and coronary flow reserve were measured invasively in the LAD. The echocardiographic parameters, including left atrial strain, left ventricular strain, and indices of left ventricular diastolic dysfunction, were compared between two groups of patients: those with normal coronary microcirculation parameters and those with impaired coronary microvascular function. Results: Patients with coronary microvascular dysfunction had higher a E/E′ index than those with normal microvessel reactivity. This finding was further confirmed by ROC analysis. The groups did not differ significantly in values of other echocardiographic parameters, including the left ventricular and left atrial strain. The prevalence of classical cardiovascular risk factors was similar in both groups. Conclusions: The coexistence of impaired coronary microvascular function with moderately elevated left ventricular filling pressures might correspond to the co-development of early stages of coronary microvascular dysfunction and HFpEF. Full article

Background/Objectives: The acute drop in distal coronary pressure (Pd)-to-aortic pressure (Pa) ratio after intracoronary nitroglycerin (NTG-Pd/Pa) administration is an acceptable estimate of fractional flow reserve (FFR). We aimed to compare the diagnostic performance of NTG-Pd/Pa with that of the resting full-cycle ratio (RFR) in predicting the binary results of FFR. Methods: This study included two prospective studies registered under the numbers NCT04700397 and NCT03693157. Altogether, 202 vessels were included. The optimal cutoff of NTG-Pd/Pa for predicting FFR ≤ 0.8 was identified and validated in another prospective registry. We used the McNemar’s test and the DeLong method to compare the diagnostic efficiency of NTG-Pd/Pa vs. RFR in predicting FFR ≤ 0.8 in a pooled cohort. Results: NTG-Pd/Pa was strongly correlated with FFR (r = 0.945, p < 0.001). The NTG-Pd/Pa cutoff for predicting FFR ≤ 0.8 was 0.85 in both the derivation and validation cohorts. The area under the receiver-operating characteristic curve (AUC) and accuracy in predicting FFR ≤ 0.8 were higher for NTG-Pd/Pa than for RFR in the pooled cohort (AUC 0.97 vs. 0.91, p < 0.001; accuracy 91% vs. 84%, p < 0.001). The sensitivity and negative predictive values were also higher for NTG-Pd/Pa than for RFR (all p < 0.05). The specificity and positive predictive value were numerically higher for NTG-Pd/Pa than for RFR (all p > 0.05). Conclusions: The diagnostic performance of NTG-Pd/Pa may surpass that of the RFR in predicting the binary results of the FFR. Full article

Fractional flow reserve (FFR) is regarded as the gold standard for assessing the functional significance of coronary artery lesions. However, its utilization in clinical practice remains limited. This study aims to determine whether FFR results can influence treatment decisions for coronary artery disease compared to visual assessments of angiographic images. We conducted a retrospective study involving 63 patients diagnosed with either chronic coronary syndrome (n = 39, 61.9%) or acute coronary syndrome (n = 24, 38.1%) who underwent an FFR assessment. Three experienced interventional cardiologists (>300 PCI procedures/year) reevaluated 105 ambiguous coronary lesions in these patients, blinded to the FFR results. The objective was to assess lesion significance and determine the treatment strategy based on a visual angiographic evaluation. The three operators reached concordant agreement (≥two operators) to perform PCI in 60 (57.1%) of the evaluated lesions based on the angiographic assessment. Of these, nine lesions (15%) were deemed functionally non-significant by FFR (FFR > 0.80). Conversely, they agreed to defer PCI in 45 (42.9%) lesions, but 4 lesions (8.9%) were found to be functionally significant (FFR ≤ 0.80) and required a re-evaluation for PCI. Visual-guided decision making by interventional cardiologists shows variability and does not always align with the functional significance of coronary lesions as determined by FFR. Incorporating FFR into routine decision making could enhance treatment accuracy and patient outcomes. Full article

Coronary CT angiography (CCTA) is now endorsed by all major cardiology guidelines for the investigation of chest pain and assessment for coronary artery disease (CAD) in appropriately selected patients. CAD is a leading cause of morbidity and mortality. There is extensive literature to support CCTA diagnostic and prognostic value both for stable and acute symptoms. It enables rapid and cost-effective rule-out of CAD, and permits quantification and characterization of coronary plaque and associated significance. In this comprehensive review, we detail the road traveled as CCTA evolved to include quantitative assessment of plaque stenosis and extent, characterization of plaque characteristics including high-risk features, functional assessment including fractional flow reserve-CT (FFR-CT), and CT perfusion techniques. The state of current guideline recommendations and clinical applications are reviewed, as well as future directions in the rapidly advancing field of CT technology, including photon counting and applications of artificial intelligence (AI). Full article

Objectives: CT-derived fractional flow reserve (CT-FFR) can improve the specificity of coronary CT-angiography (cCTA) for ruling out relevant coronary artery disease (CAD) prior to transcatheter aortic valve replacement (TAVR). However, little is known about the reproducibility of CT-FFR and the influence of diffuse coronary artery calcifications or segment location. The objective was to assess the reliability of machine-learning (ML)-based CT-FFR prior to TAVR in patients without obstructive CAD and to assess the influence of image quality, coronary artery calcium score (CAC), and the location of measurement within the coronary tree. Methods: Patients assessed for TAVR, without obstructive CAD on cCTA were evaluated with ML-based CT-FFR by two observers with differing experience. Differences in absolute values and categorization into hemodynamically relevant CAD (CT-FFR ≤ 0.80) were compared. Results in regard to CAD were also compared against invasive coronary angiography. The influence of segment location, image quality, and CAC was evaluated. Results: Of the screened patients, 109/388 patients did not have obstructive CAD on cCTA and were included. The median (interquartile range) difference of CT-FFR values was −0.005 (−0.09 to 0.04) (p = 0.47). Differences were smaller with high values. Recategorizations were more frequent in distal segments. Diagnostic accuracy of CT-FFR between both observers was comparable (proximal: Δ0.2%; distal: Δ0.5%) but was lower in distal segments (proximal: 98.9%/99.1%; distal: 81.1%/81.6%). Image quality and CAC had no clinically relevant influence on CT-FFR. Conclusions: ML-based CT-FFR evaluation of proximal segments was more reliable. Distal segments with CT-FFR values close to the given threshold were prone to recategorization, even if absolute differences between observers were minimal and independent of image quality or CAC. Full article

Background: Before surgical or transcatheter aortic valve implantation (TAVI), coronary status evaluation is required. The role of combined computed coronary tomography angiography (cCTA) and TAVI planning CT in this context is not yet well elucidated. This study assessed whether relevant proximal coronary disease requiring coronary revascularization can be safely detected by combined cCTA and TAVI planning CT, including CT-derived fractional flow reserve (FFR) calculation in patients with severe aortic stenosis. Methods: This study analyzed patients with successful cCTA combined with TAVI planning CT using a 128-slice dual-source scanner. The detection via cCTA of relevant left main stem stenosis (>50%) or proximal coronary artery stenosis (>70%) was compared to invasive coronary angiography (ICA). Results: This study comprised 101 consecutive TAVI patients with a median age of 83 [77–86] years, a median STS score of 3.7 [2.4–6.1] and 54% of whom had known coronary artery disease. Of 15 patients with relevant coronary stenoses, 14 (93.3%) were detected with cCTA, while false positive results were found in 25 patients. Only in patients with previous percutaneous coronary stent implantation (PCI) were false positive rates (11/29) increased. In the subgroup without previous PCI, an improved classification performance of 87.5%, being mainly due to 11.1% false positive classifications, led to a negative predictive value of 98.5%. Conclusions: Combined cCTA and CT-FFR with TAVI planning CT via state-of-the-art scanners and protocols as a one-stop shop can replace routine ICA in patients prior to TAVI due to its safe detection of relevant coronary artery stenosis, although diagnostic performance of cCTA is only reduced in patients with coronary stents. Full article

Background and Objectives: Atherosclerotic disease is a major contributor to heart failure, stroke, and myocardial infarction, significantly lowering the quality of life and life expectancy and placing a significant burden on healthcare. Not all lesions deemed non-significant are benign, and conversely, not all significant lesions are causative of ischemia. Fractional flow reserve (FFR) provides a functional assessment of coronary lesions, while optical coherence tomography (OCT) offers detailed imaging of plaque morphology, aiding in therapeutic decision-making. The objective of this study was to evaluate the utility of OCT and FFR as adjunctive tools in the catheterization laboratory for guiding therapeutic decisions in patients with multivessel disease for non-culprit vessels. Specifically, we aimed to assess how OCT and FFR influence therapeutic decision-making in patients with multivessel coronary artery disease. Materials and Methods: A total of 36 patients with acute coronary syndrome (ACS) and multivessel disease were randomized 1:1 into two groups: one guided by FFR alone and the other by a combination of FFR and OCT. For the FFR group, revascularization decisions for non-culprit lesions were based solely on FFR measurements. If the FFR was >0.8, the procedure was concluded, and the patient received maximal medical treatment. If the FFR was ≤0.8, a stent was placed. For the FFR + OCT group, if the FFR was >0.8, the revascularization decision was based on OCT findings. If there were no vulnerable plaques (VP), the procedure was concluded, and the patient received maximal medical treatment. If OCT imaging indicated VP, then the patient underwent revascularization. If the FFR was ≤0.8, the patient underwent revascularization regardless of OCT findings. Results: OCT imaging altered the therapeutic decision in 11 cases where FFR measurements were above 0.8, but the lesions were characterized as VP. Analyzing the total change in the decision to stent, 4 cases in the FFR group and 15 cases in the FFR and OCT groups (4 based on FFR and 11 on OCT) revealed a statistically significant difference (p = 0.0006; Relative Risk = 0.2556; 95% CI: 0.1013 to 0.5603). When analyzing the change in the total decision both to stent and not to stent, we observed a statistically significant difference, with Group 1 having 7 cases and Group 2 having 15 cases (p = 0.0153; Relative Risk = 0.4050; 95% CI: 0.2004 to 0.7698. Conclusions: Based on the findings of this study, OCT significantly increases the percentage of stenting procedures by identifying vulnerable lesions. The use of intracoronary imaging facilitates the timely identification and treatment of these vulnerable lesions. This underscores the crucial role of OCT in enhancing the precision of coronary interventions by ensuring timely intervention for vulnerable lesions, thereby potentially improving patient outcomes. Full article

Background: Negative CCTA can effectively exclude significant CAD, eliminating the need for further noninvasive or invasive testing. However, in the presence of severe CAD, the accuracy declines, thus necessitating additional testing. The aim of our study was to evaluate the diagnostic performance of noninvasive cFFR derived from CCTA, compared to ICA in detecting hemodynamically significant stenoses in participants with high CAC scores (>400). Methods: This study included 37 participants suspected of having CAD who underwent CCTA and ICA. CAC was calculated and cFFR analyses were performed using an on-site machine learning-based algorithm. Diagnostic accuracy parameters of CCTA and cFFR were calculated on a per-vessel level. Results: The median total CAC score was 870, with an IQR of 642–1370. Regarding CCTA, sensitivity and specificity for RCA were 60% and 67% with an AUC of 0.639; a LAD of 87% and 50% with an AUC of 0.688; an LCX of 33% and 90% with an AUC of 0.617, respectively. Regarding cFFR, sensitivity and specificity for RCA were 60% and 61% with an AUC of 0.606; a LAD of 75% and 54% with an AUC of 0.647; an LCX of 50% and 77% with an AUC of 0.647. No significant differences between AUCs of coronary CTA and cFFR for each vessel were found. Conclusions: Our results showed poor diagnostic accuracy of CCTA and cFFR in determining significant ischemia-related lesions in participants with high CAC scores when compared to ICA. Based on our results and study limitations we cannot exclude cFFR as a method for determining significant stenoses in people with high CAC. A key issue is accurate and detailed lumen segmentation based on good-quality CCTA images. Full article

Despite significant goals achieved in diagnosis and treatment in recent decades, coronary artery disease (CAD) remains a high mortality entity and continues to pose substantial challenges to healthcare systems globally. After the latest guidelines, novel data have emerged and have not been yet considered for routine practice. The scope of this review is to go beyond the guidelines, providing insights into the most recent clinical updates in CAD, focusing on non-invasive diagnostic techniques, risk stratification, medical management and interventional therapies in the acute and stable scenarios. Highlighting and synthesizing the latest developments in these areas, this review aims to contribute to the understanding and management of CAD helping healthcare providers worldwide. Full article

Coronary artery lesions (CALs) after Kawasaki disease present complex coronary hemodynamics. We investigated the relationship between coronary fractional flow reserve (FFR), myocardial flow reserve (MFR), and myocardial blood flow volume fraction (MBF) and their clinical usefulness in CALs after Kawasaki disease. Nineteen patients (18 men, 1 woman) who underwent cardiac catheterization and ¹³N-ammonia positron emission tomography, with 24 coronary artery branches, were included. Five branches had inconsistent FFR and MFR values, two had normal FFR but abnormal MFR, and three had abnormal FFR and normal MFR. The abnormal MFR group had significantly higher MBF at rest than the normal group (0.86 ± 0.13 vs. 1.08 ± 0.09, p = 0.001). The abnormal FFR group had significantly lower MBF at adenosine loading than the normal group (2.23 ± 0.23 vs. 1.88 ± 0.29, p = 0.021). The three branches with abnormal FFR only had stenotic lesions, but the MFR may have been normal because blood was supplied by collateral vessels. Combining FFR, MFR, and MBF will enable a more accurate assessment of peripheral coronary circulation and stenotic lesions in CALs and help determine treatment strategy and timing of intervention. Full article

Background: The literature review shows that female patients are more frequently underdiagnosed or suffer from delayed diagnosis. Recognition of sex-related differences is crucial for implementing strategies to improve cardiovascular outcomes. We aimed to assess sex-related disparities in the frequency of fractional flow reserve (FFR)-guided procedures in patients who underwent angiography and/or percutaneous coronary intervention (PCI). Methods: We have derived the data from the national registry of percutaneous coronary interventions and retrospectively analyzed the data of more than 1.4 million angiography and/or PCI procedures [1,454,121 patients (62.54% men and 37.46% women)] between 2014 and 2022. The logistic regression analysis was conducted to explore whether female sex was associated with FFR utilization. Results: The FFR was performed in 61,305 (4.22%) patients and more frequently in men than women (4.15% vs. 3.45%, p < 0.001). FFR was more frequently assessed in females with acute coronary syndrome than males (27.75% vs. 26.08%, p < 0.001); however, women with chronic coronary syndrome had FFR performed less often than men (72.25% vs. 73.92%, p < 0.001). Females with FFR-guided procedures were older than men (69.07 (±8.87) vs. 65.45 (±9.38) p < 0.001); however. less often had a history of myocardial infarction (MI) (24.79% vs. 36.73%, p < 0.001), CABG (1.62% vs. 2.55%, p < 0.005) or PCI (36.6% vs. 24.79%, p < 0.001) compared to men. Crude comparison has shown that male sex was associated with a higher frequency of FFR assessment (OR = 1.2152–1.2361, p < 0.005). Conclusions: Despite a substantial rise in FFR utilization, adoption in women remains lower than in men. Female sex was found to be an independent negative predictor of FFR use. Full article

The use of invasive physiology methods in patients with renal dysfunction is not well elucidated. Our objective was to evaluate the in-hospital and long-term results of using intracoronary physiology to guide revascularization in patients with chronic kidney disease. In this retrospective study, we evaluated 151 patients from January 2018 to January 2022, divided into 2 groups: CKD (81 patients [114 lesions]) and non-CKD (70 patients [117 lesions]). The mean age was higher (p < 0.001), body mass index was lower (p = 0.007), contrast volume used was lower (p = 0.02) and the number of ischemic lesions/patients was higher (p = 0.005) in the CKD group. The primary outcomes (rate of major adverse cardiac events during follow-up, defined as death, infarction, and need for new revascularization) in the CKD and non-CKD groups were 22.07% and 14.92%, respectively (p = 0.363). There was a significant difference in the target lesion revascularization (TLR) rate (11.68%, CKD group vs. 1.49%, non-CKD group, p = 0.02), this initial statistical difference was not significant after adjusting for variables in the logistic regression model. There was no difference between the rates of death from all causes (6.49%, CKD group vs. 1.49%, non-CKD group, p = 0.15), reinfarction (3.89%, CKD group vs. 1.49%, non-CKD group, p = 0.394), and need for new revascularization (11.68%, CKD group vs. 5.97%, non-CKD group, p = 0.297). As there was no difference in the endpoints between groups with long-term follow-up, this study demonstrated the safety of using intracoronary physiology to guide revascularization in patients with CKD. Full article