Abstract 12258: Ceramides Predict the Development of Type 2 Diabetes

Chronic medical conditions such as type 2 diabetes (T2DM) or coronary artery disease (CAD) and their treatment have a crucial impact on patients’ daily life. The EQ-5D-5L questionnaire is a validated and widely used tool to measure the health-related quality of life (HRQL). We investigated and compared the HRQL in patients with or without T2DM and CAD. We included 481 consecutive patients undergoing coronary angiography for the evaluation of established or suspected stable CAD in a tertiary care setting in Central Europe. Patients’ HRQL was measured using the EQ-5D-5L, comprising the EQ index calculated from the domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A response rate of 88.1% was achieved. From our patients, 166 (34.5%) had T2DM according to ADA criteria, and 254 (52.8%) had significant CAD with stenoses ≥50% at angiography. Patients with T2DM showed significantly lower EQ index values than patients without T2DM (0.891 [IQR=0.783-0.970]) vs. 0.943, [IQR=0.861-1.0], p=0.002)). Regarding the different dimensions of the questionnaire, patients with T2DM reported to have significantly more problems with anxiety and depression (p=0.002) and mobility (p<0.001) than nondiabetic patients. EQ index values in contrast did not differ significantly between patients with vs. those without significant CAD. Accordingly, in analysis of covariance T2DM (F=7.38, p=0.007) but not significant CAD (F=1.74, p=0.183) predicted EQ index values after adjustment for age, sex and body-mass-index. We conclude that T2DM rather than the presence of significant CAD is associated with quality of life in angiographied coronary patients. Disclosure M. Ratz: None. J. Vogel: None. P. Elsner: None. T. Plattner: None. A. Vonbank: None. A. Mader: None. B. Larcher: None. A. Leiherer: None. A. Muendlein: None. M. Frick: None. H. Drexel: None. C.H. Saely: None.

Comparison of the presence of fragmented QRS complexes in the inferior versus the anterior leads for predicting coronary artery disease severity

Guidelines for the interpretation of the exercise radionuclide ventriculogram for diagnosing coronary artery disease

Objectives: Dobutamine stress echocardiography (DSE) and contrast-enhanced electron beam tomography (EBCT) both have the potential to noninvasively detect coronary artery disease (CAD). We compared the accuracy of both methods to detect significant CAD in a direct comparison. Methods: 79 patients (32 women, 47 men, mean age 62 years) who were admitted for coronary angiography due to suspected CAD were studied. By EBCT coronary calcification (CAC) as well as angiography (CTA) was assessed. Presence of significant CAD was assumed if the calcium score exceeded 400 or the contrast-enhanced images displayed significant lumen reduction. DSE was performed using a standard protocol (5–40 µg/kg/min dobutamine plus 0.25–1.0 mg atropine if necessary). DSE and EBCT were independently evaluated concerning the presence of signficant CAD. Results were compared to invasive, quantitative coronary angiography. Results: 6 patients (8%) in DSE and 2 patients (3%) in EBCT were unevaluable for various reasons and therefore excluded from further analysis. In the remaining 71 patients, 33 patients (46%) showed significant CAD. DSE demonstrated a sensitivity of 70% (23/33) and a specificity of 84% (32/38). EBCT showed a sensitivity of 91% (30/33) and a specificity of 74% (28/38). By combining DSE and EBCT sensitivity increased to 97% with a specificity of 63%. Conclusions: In a blinded comparison, DSE demonstrated lower sensitivity but higher specificity than EBCT for the detection of significant CAD. Sensitivity was improved by combining both modalities.

Background Assessing clinically for significant coronary artery disease (CAD) in stable angina patients presents a formidable task. Routinely performed echocardiography is limited in diagnosing CAD with provision for the regional wall motion abnormality (RWMA) for left ventricle (LV) systolic dysfunction and altered mitral inflow velocities for LV diastolic dysfunction. However, the advent of two-dimensional (2D) speckle-tracking technique has established the era of strain imaging, opening new possibilities in echocardiography. It is now possible to have a detailed functional assessment of left atrium (LA). We utilised speckle tracking imaging to obtain strain parameters for LA function. Combining these strain parameters with the doppler myocardial velocities and mitral inflow velocities, may prove useful mode of imaging to diagnose significant CAD in stable angina patients. Purpose To study the parameters of left atrial functions utilising echocardiographic strain imaging and evaluate their correlation with the syntax score-II in patients with symptoms of stable angina. Methods 103 patients with symptoms of stable angina undergoing coronary angiography for suspected coronary artery disease(CAD), were considered for LA function assessment and compared with their syntax-II score. Results The LA reservoir function parameters, peak atrial longitudinal strain (PALS) and peak global systolic strain rate (LAsSR), decreased with increasing syntax-II score (p values 0.011 and 0.001 respectively) and the parameter of LA conduit function, peak global early diastolic strain rate (LAeSR) increased (p value <0.001). The LA filling pressures reflected by E/e`, also increased with more severe syntax-II score (p value <0.001). We, further, configured cut off values of < 23.56 for PALS, < 1.15 for LAsSR, > -1.09 for LAeSR, and E/e` ratio > 10.39 as predictors of significant CAD, with good sensitivity and specificity. Therefore, stable angina patients who had significant CAD on coronary angiogram represented by severe syntax score-II, had higher LA filling pressures and deranged LA function with transition from more of reservoir chamber to merely a conduit. Conclusion Our study shows a significant association between LA strain parameters (PALS, LAsSR, and LAeSR) and LA filling pressures (E/e`), with the presence of significant CAD in these patients. The stable angina patients with more severe CAD as quantified by their severe syntax score-II, have an impaired LA reservoir and LA functions more as a conduit, with elevated filling pressures. This study establishes a significant association between LA deformation strain variables and severity of CAD and hence LA strain imaging can be a useful tool to diagnose significant CAD in stable angina patients.

Risk Stratification and Prognostic Implication of Plasma Biomarkers in Nondiabetic Patients With Stable Coronary Artery Disease: The Role of High-Sensitivity C-Reactive Protein

Chest pain (CP) is the major presenting symptom of coronary artery disease (CAD) wherein history remains to be a fundamental and challenging diagnostic step. Despite the clarity of ‘typical’ CP characteristics in guidelines; interpretation and description of CP by patients are open to wide variations. The aim of this study was to define the components of CP that most closely associate to presence of obstructive CAD and determine the influence of gender on CP features. Herein, consecutive patients with suspected stable CAD who were scheduled for a coronary angiography(CAG) were prospectively enrolled. The data on demographic and pain characteristics were collected by a questionnaire. Patients were categorized into ‘CAD’ and ‘Normal’ groups with respect to presence of obstructive CAD in CAG. Among 402 patients, 86 had chest discomfort or equivalent symptoms but denied ‘CP’. Patients with CAD were more commonly male; with older age, lower BMI, more frequent prior revascularization, clopidogrel use, higher creatinine and lower HDL levels. When classical features of CP such as quality; location, duration, relationship to exertion were compared; stabbing/sharp pain, CP related to cold or emotional stress and CP that radiates to back were significant factors against CAD; while absence of precipitating factors was related to CAD. Yet, none of the features of typical angina pectoris were significantly related to presence of CAD. Determinants of CAD were; prior revascularization (OR= 22.7, p=0.021), body mass index (OR=1.4, p=0.007), clopidogrel use(OR=55.5, p=0.018) and blood glucose (OR=1.02, p=0.046) in women; and age (OR=1.2, p=0.029) was the single predictor of CAD in men. This study demonstrated no association between classical features of typical CP and presence of CAD in patients with stable angina pectoris. Clinical factors that influenced presence of CAD in different genders were also different.

The number of young women suffering acute myocardial infarction (AMI) is increasing. There are conflicting results on the prognostic impact of gender in young patients with AMI. The aim of the present study was to assess in-hospital and 5-year outcomes in men and women ≤50 years old admitted for AMI and participating in the FAST-MI programme. Methods FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years since 2005. We used the 2005, 2010 and 2015 data with up to 5-year follow-up, to describe baseline characteristics and outcomes according to gender in young patients. Of 13,130 patients included, 1,912 were ≤50 years old (335 women, 17.5%). Results Men and women had a similar age (44±5 years), BMI, current smoking (72% vs 75%), diabetes, family history, prior history of CVD, GRACE score (104±22 vs 106±23), and LVEF (54±10%). LDL at admission was lower in women (127±46 vs 138±46 mg/dl). Women had a higher admission heart rate (81±19 vs 78±17 BPM) and lower systolic blood pressure (133±26 vs 136±25 mm Hg). Presenting AMI was STEMI in 63% in women vs 68% in men (P=0.08). All in-hospital complications except reinfarction (1.8 vs 0.6%, p<0.03) were similar in women and men; in-hospital death was 1.5% vs 0.8%, P=0.20. Coronary angiography was performed slightly less often (97.6% vs 99.0%, P=0.047) and more women had non-significant coronary artery disease (CAD) (13% vs 6%, P<0.001); PCI was less often used (74% vs 85.5%, P<0.001). At discharge, ESC guidelines-recommended medical treatment was less often prescribed in women (41% vs 53%, P<0.001), even in patients with significant CAD (46% vs 55%, P=0.004). Kaplan-Meier 5-year survival did not differ in women (94.7%) and men (95.2%), P=0.56 (Figure). The respective figures for hospital survivors were 96.1% and 96.0% (HR 1.00, 95% CI 0.52–1.91; HR adjusted on age, type of MI, previous history of CAD, presence of significant CAD, LVEF, Killip class and appropriate medications at discharge: 0.99, 95% CI 0.51–0.92). Similar results were found for the combined end-point of death, AMI or stroke. Conclusion There were more similarities than differences between women and men who sustained an AMI at age ≤50 years. Women had lower LDL-c, lower haemoglobin, higher heart rate and lower blood pressure on admission. Non-significant CAD was more frequently found in women, who were less often treated with PCI and recommended medications at discharge. Five-year outcomes, however, did not differ according to gender. Five-year mortality Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer, MSD, AstraZeneca

Prevalence and Clinical Characteristics of Symptomatic Patients with Obstructive Coronary Artery Disease in the Absence of Coronary Calcifications

Background: Sepsis survivors are at risk of developing myocardial infarction and heart failure. It remains unclear whether coronary artery disease (CAD) is a major contributor to the development of these complications. This study sought to characterize the burden and distribution of significant CAD in sepsis survivors. Methods: Sepsis survivors who underwent computed tomography coronary angiography (CTCA) or invasive coronary angiography (ICA) in a UK tertiary cardiac center for suspected ischemic heart disease were retrospectively studied. Results: Of the 30 sepsis survivors (age 57 ± 12 years; 50% males), 21 patients underwent CTCA and 9 patients underwent ICA a median 39 days [IQR 12-152] from the sepsis episode. Eight patients (~27%) had angiographically significant CAD (n = 6 severe [>70%] stenosis; n = 2 moderate [50-70%] stenosis). The CT coronary calcium score was higher in patients with significant CAD compared to patients without significant CAD (638 [368-1015] vs. 4 [1-72]; p < 0.001). Of the 8 patients with significant CAD, 3 patients had LV systolic dysfunction (38%) on echocardiography and 8/21 (38%) patients without significant CAD had LV systolic dysfunction (p = 1.00). Long-term adverse complications (all-cause mortality and/or heart failure hospitalization) occurred 3/8 (38%) patients with significant CAD and 4/22 (18%) patients without significant CAD (p = 0.345). Conclusions: A minority of sepsis survivors have significant CAD. The presence of significant CAD cannot fully explain the occurrence of post-sepsis LV systolic dysfunction and adverse outcomes. The ischemic and non-ischemic mechanisms underlying post-sepsis cardiovascular disease require further investigation.

Background: In stable patients without known coronary artery disease (CAD), clinical practice guidelines recommend documentation of ischemia prior to evaluation by invasive angiography. We sought to determine how often non-invasive stress testing is performed in this population and the association between stress test results and obstructive CAD. Methods: Patients undergoing cardiac catheterization for exclusion of CAD who were without prior history of myocardial infarction, PCI, or CABG were identified from 601 hospitals using the American College of Cardiology National Cardiovascular Data Registry between 2005 – 2007. Significant obstructive CAD was defined as the presence of any stenosis ≥ 50% left main or ≥ 70% major epicardial vessel. Patient demographics, risk factors, symptoms, stress test status and CAD presence were determined. Results: A total of 376,430 patients without known CAD were identified. The median age was 61 years, 53% were male, 26% had diabetes, and 69% had hypertension. At angiography, 142,912 (38%) of patients were found to have significant obstructive CAD. Symptom status was associated with the presence of CAD (stable angina 50%, atypical 25%, asymptomatic 40%; p&lt;0.001). Stress testing was performed in 316,248 (84%) of patients prior to angiography, and results were associated with the presence of CAD (p&lt;0.001) see Table . Although a positive stress test was noted in 255,617 (68% of patients undergoing cath), obstructive CAD was noted in only 105,435, yielding a positive predictive value of 41%. Conclusions: In a large national registry of stable patients without known CAD undergoing invasive angiography, only 38% were found to have significant obstructive disease. Although performed in 84% of patients prior to cath, the low positive predictive value of current stress tests may have contributed to the high rate of patients without obstructive CAD. Table p value for stress test results and presence of obstructive CAD p&lt;0.001

<h3>Introduction</h3> Patients undergoing surgical aortic valve replacement (sAVR) routinely undergo simultaneous coronary artery bypass grafting (CABG) for significant coronary artery disease (CAD) due to adverse prognostic impact. While manufacturers advise percutaneous intervention (PCI) of significant CAD prior to transcatheter aortic valve implantation (TAVI) there is considerable variation among operators. <h3>Methods</h3> We performed a retrospective analysis of 168 patients who underwent TAVI using the Edwards bioprosthesis from March 2008 to October 2010 at St. Thomas Hospital, London. They were divided into two groups according to the results of the pre-TAVI coronary angiogram: (Group 1) patients with ≥1 coronary stenosis of ≥70% severity and those without (Group 2). The end-point was all-cause mortality. <h3>Results</h3> In total, 70 patients (41.7%) had significant CAD prior to TAVI, with 10 (6.0%) undergoing PCI prior to their procedure. There were no significant differences in either the baseline characteristics or access approach between the two groups (Abstract 26 tables 1 and 2). At a mean follow-up of 335±277 days (mean±SD), the overall mortality was 22.6%; Group 1 mortality was 30% and in group 2 was 17.3% (p=0.124) (see Abstract 26 figure 1) There was no difference seen in the length of stay in the intensive care unit (2.7±6.2 vs 4.1±14.9 days, p=0.462) nor in the number of days to discharge (12.6±10.1 vs 12.8±13, p=0.928). Among those patients who underwent PCI in Group 1, 8 had single vessel intervention and 2 had PCI to 2 vessels. The target vessels were left main stem (LMS) (n=2), proximal left anterior descending artery (LAD) (n=5), circumflex (n=1), right coronary artery (RCA) (n=2), saphenous vein graft (SVG) to LAD (n=1) and SVG to circumflex (n=1). Mortality in this sub-group was not significantly different from the CAD patients who did not receive PCI (50% vs 26.7%, p=0.272). <h3>Conclusion</h3> The presence of significant CAD had no significant impact upon the all-cause mortality of patients after TAVI in our study. As yet, the impact of PCI to significant CAD upon outcome after TAVI is not known and will be assessed in a prospective, randomised controlled trial currently underway.

Does serum ferritin correlate with coronary angiography findings?

Coronary artery disease (CAD) screening is required before transcatheter aortic valve implantation (TAVR). Although invasive coronary angiography (CA) remains the gold standard for CAD assessment, computed tomographic CA (CTCA) could be a safe and effective noninvasive alternative for CAD screening in patients undergoing TAVR. From November 2007 to May 2013, all patients undergoing TAVR at our institution were included in the study cohort. CTCA was used as first-line imaging tool for CAD screening. Invasive CA was performed when any of the following were present: coronary anatomy at CTCA was not evaluable and presence of significant CAD at CTCA. The primary objective was to compare major adverse cardiovascular and cerebrovascular events at 30 days and 1 year between patients who performed CTCA as only screening test and those who performed CTCA and invasive CA. Of 491 patients treated with TAVR, 375 (76.3%) performed only CTCA, whereas 116 (21.7%) underwent also CA. No differences were present in crude major adverse cardiovascular and cerebrovascular event rates at 30 days and 1 year between the 2 groups. After multivariable adjustment, CTCA performed alone was not associated with higher risk of MACE at 1 year of follow-up (hazard ratio, 0.89; 95% confidence interval, 0.49-1.60; P=0.69). CTCA performed as a routine noninvasive imaging tool in patients undergoing TAVR seems safe and effective allowing, with a single test, acquisition of information on aortic annulus anatomy, peripheral access sites, and evaluation of coronary anatomy.

Endothelial dysfunction (ED) is frequently present in patients presenting with acute or stable coronary artery disease (CAD), but it is also found in patients presenting with chest pain without angiographic coronary lesions. We hypothesized that even in patients without CAD, the presence of cardiovascular (CV) risk factors will correlate with the presence of ED. Our study included a total of 341 consecutive patients referred for coronary angiography. We used pulse wave analysis with a finger plethysmograph (peripheral arterial tonometry) to determine endothelial function. Hyperemia ratio was calculated as the ratio of the postischemic hyperemia response relative to baseline measurement. The hyperemia ratio was significantly higher in patients without CAD (2.02 ± 0.52) compared with patients with chronic CAD (1.81 ± 0.44, P = 0.001) or acute CAD (1.74 ± 0.49, P < 0.001). Prevalence of ED was 33%, 46%, and 58%, respectively. In multivariate analysis, the presence of CAD, diabetes, and cigarette smoking, and the total number of CV risk factors, were strong predictors of ED. In 67% of the patients without CAD but with ≥3 CV risk factors, ED was present. Prevalence of ED in patients with chest pain depends on the presence of CAD and CV risk factors. Patients without CAD but with ≥3 risk factors frequently presented with ED. Such patients may be at increased risk for future CV events and may profit from intensified therapy to control CV risk factors.