Impact of fractional flow reserve on decision-making in daily clinical practice: A single center experience in Egypt.

BACKGROUND: Fractional flow reserve (FFR) is the reference standard for the assessment of the functional significance of coronary artery stenoses, but remains underutilized. Our aims were to study whether FFR changed the decision for treatment of intermediate coronary lesions and to assess the clinical outcome in the deferred and intervention groups. METHODS: In this retrospective study, coronary angiograms of patients with moderately stenotic lesions (40-70%) for which FFR was performed were re-analyzed by three experienced interventional cardiologists (blinded to FFR results) to determine its angiographic significance and whether to defer or perform an intervention. RESULTS: We revised 156 equivocal lesions of 151 patients. The clinical presentation were stable angina (65.6%) and acute coronary syndrome in (34.4%). All reviewers had concordant agreement to do PCI in 59 (37.8%) lesions based on angiographic assessment. Interestingly 23 (39%) of these lesions were functionally non-significant by FFR. The reviewers agreed to defer 97 (62.2%) lesions, however, 32 (33%) of these lesions were functionally significant by FFR and necessitated PCI. MACE were similar in both groups (1.5% vs 2.4%, p = 1.0). CONCLUSION: Mismatches between visually- and FFR- estimated significance of intermediate coronary stenosis are frequently encountered across a wide spectrum of clinical presentations. FFR leads to a change in decision for coronary intervention. The clinical and cost implications of such changes-in areas with limited resources- needs further evaluation.

Difference in plaque characteristics of coronary culprit lesions in a cohort of Egyptian patients presented with acute coronary syndrome and stable coronary artery disease: An optical coherence tomography study.

AIMS: This study was designed to utilize frequency-domain optical coherence tomography (FD-OCT) for assessment of plaque characteristics and vulnerability in patients with acute coronary syndrome (ACS) compared to stable coronary artery disease (SCAD). METHODS AND RESULTS: We enrolled 48 patients; divided into an ACS-group (27 patients) and SCAD-group (21 patients) according to their clinical presentation. Hypertension and diabetes mellitus were more prevalent in SCAD group. Patients with ACS showed higher frequency of lipid-rich plaques (96.3% vs. 66.7%, P = .015), lower frequency of calcium plaques (7.4% vs. 57.1%, P < .001), and fibrous plaques (14.8% vs. 81%, P < .001) when compared with SCAD patients. The TCFA (defined as lipid-rich plaque with cap thickness <65 µm) identified more frequently (33.3% vs. 14.3%, P = .185), with a trend towards thinner median fibrous cap thickness (70 (50-180) µm vs. 100 (50-220) µm, P = .064) in ACS group. Rupture plaque (52% vs. 14.3%, P = .014), plaque erosion (18.5% vs. 0%, P = .059) and intracoronary thrombus (92.6% vs. 14.3%, P < .001) were observed more frequently in ACS group, while cholesterol crystals were identified frequently in patients with SCAD (0.0% vs. 33.3%, P = .002). CONCLUSION: The current FD-OCT study demonstrated the differences of plaque morphology and identified distinct lesion characteristics between patients with ACS and those with SCAD. These findings could explain the clinical presentation of patients in both groups.

The degree of hair graying as an independent risk marker for coronary artery disease, a CT coronary angiography study.

BACKGROUND: Cardiovascular disease is a leading cause of death worldwide. Aging is an unavoidable coronary risk factor and is associated with dermatological signs that could be a marker for increased coronary risk. We tested the hypothesis that hair graying as a visible marker of aging is associated with risk of coronary artery disease (CAD) independent of chronological age. METHODS: This cross-sectional study included 545 males who underwent a computed tomography coronary angiography (CTCA) for suspicious of CAD, patients were divided into subgroups according to the percentage of gray/white hairs (Hair Whitening Score, HWS: 1-5) and to the absence or presence of CAD. RESULTS: CAD was prevalent in 80% of our studied population, 255 (46.8%) had 3 vessels disease with mean age of 53.2 ± 10.7 yrs. Hypertension, diabetes and dyslipidemia were more prevalent in CAD group (P = 0.001, P = 0.001, and P = 0.003, respectively). Patients with CAD had statistically significant higher HWS (32.1% vs 60.1%, p < 0.001) and significant coronary artery calcification (<0.001). Multivariate regression analysis showed that age (odds ratio (OR): 2.40, 95% confidence interval (CI): [1.31-4.39], p = 0.004), HWS (OR: 1.31, 95% CI: [1.09-1.57], p = 0.004), hypertension (OR: 1.63, 95% CI: [1.03-2.58], p = 0.036), and dyslipidemia (OR: 1.61, 95% CI: [1.02-2.54], p = 0.038) were independent predictors of the presence of atherosclerotic CAD, and only age (p < 0.001) was significantly associated with HWS. CONCLUSIONS: Higher HWS was associated with increased coronary artery calcification and risk of CAD independent of chronological age and other established cardiovascular risk factors.

Validation of Noninvasive Measurement of Cardiac Output Using Inert Gas Rebreathing in a Cohort of Patients With Heart Failure and Reduced Ejection Fraction.

BACKGROUND: Cardiac output (CO) is a key indicator of cardiac function in patients with heart failure. No completely accurate method is available for measuring CO in all patients. The objective of this study was to validate CO measurement using the inert gas rebreathing (IGR) method against other noninvasive and invasive methods of CO quantification in a cohort of patients with heart failure and reduced ejection fraction. METHODS AND RESULTS: The study included 97 patients with heart failure and reduced ejection fraction (age 42±15.5 years; 64 patients (65.9%) had idiopathic dilated cardiomyopathy and 21 patients (21.6%) had ischemic heart disease). Median left ventricle ejection fraction was 24% (10%-36%). Patients with atrial fibrillation were excluded. CO was measured using 4 methods (IGR, cardiac magnetic resonance imaging, cardiac catheterization, and echocardiography) and indexed to body surface area (cardiac index [CI]). All studies were performed within 48 hours. Median CI measured by IGR was 1.75, by cardiac magnetic resonance imaging was 1.82, by cardiac catheterization was 1.65, and by echo was 1.7 L·min-1·m-2. There were significant modest linear correlations between IGR-derived CI and cardiac magnetic resonance imaging-derived CI (r=0.7; P<0.001), as well as cardiac catheterization-derived CI (r=0.6; P<0.001). Using Bland-Altman analysis, the agreement between the IGR method and the other methods was as good as the agreement between any 2 other methods with each other. CONCLUSIONS: The IGR method is a simple, accurate, and reproducible noninvasive method for quantification of CO in patients with advanced heart failure. The prognostic value of this simple measurement needs to be studied prospectively.

Comparison of Safety and Effectiveness Between Right Versus Left Radial Arterial Access in Primary Percutaneous Coronary Intervention for Acute ST Segment Elevation Myocardial Infarction.

BACKGROUND: Transradial approach (TRA) is now considered the standard of care in many centres for elective and primary percutaneous intervention (PCI). The use of the radial approach in ST segment elevation myocardial infarction (STEMI) patients has been associated with a significant reduction in major adverse cardiac events. However, it is still unclear if the side of radial access (right vs. left) has impact on safety and effectiveness of TRA in primary PCI. So this study was conducted to compare the safety, feasibility, and outcomes of right radial access (RRA) vs. left radial access (LRA) in the setting of primary PCI. METHODS: We retrospectively analysed the data of 400 consecutive patients presenting to our institution with STEMI for whom primary PCIs were performed via RRA and LRA. RESULTS: Mean age of the whole studied population was 57±12.8 years, with male predominance (77.2%). There were 202 cases in the RRA group and 198 in the LRA group, with no significant difference in demographics and clinical characteristics for patients included in both groups. There was no significant difference in procedure success rate (97.5% for RRA vs. 98.4% for LRA; P=0.77). In addition, no significant difference between both approaches was observed in the contrast volume, number of catheters, fluoroscopy time (FT), needle-to-balloon time, post-procedure vascular complications, in hospital reinfarction, stroke/transient ischaemic attack (TIA) or death. CONCLUSION: Right radial access and LRA are equally safe and effective in the setting of primary PCI. Both approaches have a high success rate and comparable needle-to-balloon time.

Prevalence and prognostic value of echocardiographic screening for rheumatic heart disease.

Objective: Rheumatic heart disease (RHD) remains a major health problem in many low-income and middle-income countries. The use of echocardiographic imaging suggests that subclinical disease is far more widespread than previously appreciated, but little is known as to how these mild forms of RHD progress. We have determined the prevalence of subclinical RHD in a large group of schoolchildren in Aswan, Egypt and have evaluated its subsequent progression. Methods: Echocardiographic screening was performed on 3062 randomly selected schoolchildren, aged 5-15 years, in Aswan, Egypt. Follow-up of children with a definite or borderline diagnosis of RHD was carried out 48-60 months later to determine how the valvular abnormalities altered and to evaluate the factors influencing progression. Results: Sixty children were initially diagnosed with definite RHD (19.6 per 1000 children) and 35 with borderline disease (11.4 per 1000); most had mitral valve disease. Of the 72 children followed up progression was documented in 14 children (19.4%) and regression in 30 (41.7%) children. Boys had lower rates of progression while older children had lower rates of regression. Functional defects of the valve even in the presence of structural features were associated with lower rates of progression and higher rates of regression than structural changes. Conclusions: RHD has a high prevalence in Egypt. Although a high proportion of the abnormalities originally detected persisted at follow-up, both progression and regression of valve lesions were demonstrated.