Five-Year Follow-Up of Coronary Microvascular Dysfunction and Coronary Artery Disease in Systemic Lupus Erythematosus: Results From a Community-Based Lupus Cohort.

OBJECTIVE: The present study was undertaken to investigate prospective change in the prevalence of coronary microvascular dysfunction (CMD) and obstructive coronary artery disease (CAD) in a cohort of subjects with systemic lupus erythematosus (SLE) initially evaluated for anginal chest pain (CP). Prior work documented a relatively high prevalence of CMD in the absence of obstructive CAD in subjects with SLE. METHODS: Twenty female SLE subjects with CP who underwent stress cardiac magnetic resonance imaging (CMRI) and coronary computed tomography angiography at baseline were reevaluated at 5 years. RESULTS: Seventeen subjects (85%) were available and reenrolled, of which 11 (65%) had persistent CP at follow-up. Fourteen subjects had complete follow-up CMRI, of which 36% (n = 5) demonstrated CMD at follow-up. Further, 25% (1 of 4) of the originally abnormal myocardial perfusion reserve index (MPRI) findings at baseline were lower at follow-up, while 2 additional abnormal MPRI findings at follow-up were noted in previously normal MPRI results. The prevalence of CMD and nonobstructive/obstructive CAD both was unchanged between baseline and follow-up, respectively (both P values not significant). During follow-up, 33% of subjects (5 of 15) had adverse cardiac outcomes, including pericarditis, unstable angina, or intracranial aneurysm clipping procedure. CONCLUSION: At the 5-year follow-up of SLE subjects with CP who were evaluated at baseline and follow-up, a majority had persistent CP, and nearly one-half had similar or worse myocardial perfusion consistent with CMD without obstructive CAD. These findings propose an alternative explanation for CP in SLE subjects compared to the more common SLE-related accelerated obstructive CAD accounting for CP and adverse outcomes. These findings support further studies of CMD as an etiology for cardiac morbidity and mortality in SLE.

Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.

The American College of Cardiology/American Heart Association recently updated recommendations for percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) disease from class III to II(b) according to the results of the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) trial. The SYNTAX score is an angiographic tool using solely the coronary anatomy. We studied the effect of co-morbidities (Parsonnet's score) on the ability of the SYNTAX score to predict long-term outcomes in patients with ULMCA disease treated by revascularization. A total of 328 patients underwent revascularization of ULMCA from April 2003 to February 2007. Of the 328 patients, 120 underwent PCI (median follow-up 973 days) and 208 underwent coronary artery bypass grafting (CABG) (median follow-up 1,298 days). The ability of the SYNTAX score to predict outcomes was assessed using the Cox proportional hazards model. The outcomes between the PCI and CABG groups were compared by propensity analysis. The median SYNTAX score was 26 in the PCI and 28 in the CABG group (p = 0.5). In the PCI group, greater quartiles were associated with worse survival (62.1% at SYNTAX score of ≥36 vs 82.4% at SYNTAX score of <36, p = 0.03) and all-cause mortality, myocardial infarction, cerebrovascular events, and target vessel revascularization-free (MACCE) survival (47.7%, SYNTAX score ≥20 vs 76.6%, SYNTAX score <20, p = 0.02). Using the Parsonnet score as a covariate, the SYNTAX score continued to be an independent predictor of MACCE and demonstrated a trend toward predicting mortality in the PCI group. In contrast, the SYNTAX score did not predict the outcomes for the CABG group. No difference was found in mortality between the PCI and CABG groups for ULMCA disease, regardless of coronary complexity; although greater SYNTAX scores were associated with increased MACCE rates with PCI compared to CABG. Both the coronary anatomy (SYNTAX score) and co-morbidities (Parsonnet's score) predicted long-term outcomes for PCI of ULMCA disease. In contrast, the SYNTAX score did not predict the outcomes after CABG. In conclusion, the ideal scoring system to guide an appropriate revascularization decision for ULMCA disease should take into account both the coronary anatomy and the co-morbidities.

Myocardial ischemia in the absence of obstructive coronary artery disease in systemic lupus erythematosus.

OBJECTIVES: the purpose of this study was to evaluate the presence of myocardial ischemia measured by adenosine stress cardiac magnetic resonance (CMR) using visual myocardial perfusion and a quantitative myocardial perfusion reserve index (MPRI) in the absence of obstructive coronary artery disease (CAD) in women with systemic lupus erythematosus (SLE) with anginal chest pain (CP). BACKGROUND: ischemic heart disease is a leading cause of morbidity and mortality in SLE. Previous studies demonstrated the presence of perfusion defects using adenosine stress CMR in patients with CP and no obstructive CAD, consistent with microvascular coronary dysfunction in patients without SLE. METHOD: Twenty female SLE patients with typical and atypical anginal CP were prospectively enrolled. Patients with established cardiovascular disease were excluded. CMR was performed with 0.05 mmol/kg gadolinium adenosine stress first-pass perfusion in SLE patients and in 10 asymptomatic reference control women. SLE patients also underwent 64-slice coronary computed tomography angiography. CMR was scored visually and quantitatively (MPRI). RESULTS: among 18 patients with complete data, no patient had obstructive CAD; however, 8 of 18 (44%) displayed visual perfusion defects on stress CMR compared with 0 in 10 control subjects (p = 0.014). The mean MPRI in patients versus controls was 2.0 ± 0.4 versus 2.4 ± 0.4 (p = 0.031) in the subepicardium and 1.8 ± 0.3 versus 2.1 ± 0.4 (p = 0.24) in the subendocardium. Multivariate linear regression revealed that SLE was the only predictor of subepicardial (p < 0.0025; ß = -1.059) and subendocardial (p < 0.05; ß = -0.529) MPRIs. CONCLUSIONS: we observed a 44% prevalence of abnormal stress myocardial perfusion by CMR in the absence of obstructive CAD in SLE patients with anginal CP. Compared with controls, reduced MPRI was observed in SLE patients, and SLE presence was a significant predictor of an abnormal MPRI. These findings are consistent with the hypothesis that anginal CP in SLE patients without obstructive CAD is due to myocardial ischemia potentially caused by microvascular coronary dysfunction. Further research in a larger SLE population is warranted.

Meta-analysis of incidence, clinical characteristics and implications of stent fracture.

A meta-analysis of published studies was conducted to evaluate the incidence, predictors, and clinical outcomes of stent fractures. Eight studies with 108 stent fractures in 5,321 patients were analyzed using the Bayesian method. Study end points included in-stent restenosis (ISR) and target lesion revascularization (TLR). The mean incidence of stent fracture per patient was 4.0% (95% confidence interval 0.4% to 16.3%). All cases, except 1, were reported with sirolimus-eluting stents. The incidence of stent fracture was 30.4% in the left anterior descending coronary artery, 10.9% in the left circumflex coronary artery, 56.4% in the right coronary artery, < 0.01% in the left main coronary artery, and 1.7% in saphenous vein grafts. The probability of stent fracture was significantly higher in the right coronary artery than in the left anterior descending and left circumflex lesions (p < 0.01). Left main stents were less likely to fracture compared to those in all other vessels (p < 0.01). The probability of stent fracture was significantly increased in overlapping stents (7.5% vs 2.1%, p = 0.01) and long stents (46 vs 32.5 mm, p < 0.01). Lesions with stent fractures had higher rates of ISR (38% vs 8.2%, p < 0.01) and TLR (17% vs 5.6%, p < 0.01). Conversely, the probability of stent fractures was higher in patients with ISR (12.8% vs 2.1%, p < 0.01) and TLR (8.8% vs 2.7%, p < 0.01). In conclusion, although not always associated with clinical sequelae, the probability of ISR and TLR is increased with stent fracture. Conversely, the probability of stent fractures is increased in lesions with ISR or TLR, thus raising the need for surveillance and management guidelines for at-risk patients.

Management of atrial fibrillation: focus on catheter-based ablation.

Atrial fibrillation (AF) contributes to considerable morbidity, with increasing risk of stroke, complications from anticoagulation, and exacerbation of heart failure. AF ablation has become a commonly performed procedure in many hospitals as the procedural techniques evolve rapidly with improved success. Here we discuss the interventional options of catheter-based AF ablation for rhythm control, which offers the benefit of mortality reduction associated with normal sinus rhythm but without medication complications.

Management of atrial fibrillation: focus on rate versus rhythm control.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and accounts for approximately one-third of all arrhythmias requiring admission to the hospital. Treatment strategies are determined by the classification of AF, whether paroxysmal or persistent, as well as numerous patient-specific cardiac and medical considerations (eg, pre-existing congestive heart failure or previous myocardial infarction). Thromboembolic risk also influences whether patients are treated with antiplatelet or anticoagulant medications. Several large clinical trials have deemed both rate and rhythm control acceptable treatment strategies for AF. Additionally, nonpharmacologic approaches such as surgical and electroablative options also exist. The clinician must exercise sound clinical judgment when deciding which treatment approach is best suited for a particular patient.

Characterization of complex coronary artery stenosis morphology by coronary computed tomographic angiography.

OBJECTIVES: This study sought to assess the ability of coronary computed tomography angiography (CTA) in identifying complex coronary stenosis morphology before invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). BACKGROUND: Complexity of stenosis morphology affects PCI success. Whether CTA can detect the entire spectrum of recognized complex stenosis morphologies has not been investigated. METHODS: All nonbypassed, nonstented, >or=2-mm-diameter native coronary arterial segments in 85 consecutive patients who underwent ICA or=70% stenotic by visual inspection and characterized each as type C or nontype C, according to the modified American College of Cardiology morphology criteria for estimating PCI risk. Results were compared with ICA data similarly analyzed by 2 blinded interventional cardiologists. The PCI procedure duration and contrast use were compared between type C and nontype C lesions identified on both ICA and CTA. RESULTS: CTA detected 84 of 93 lesions (90%) causing >or=70% stenosis on ICA and correctly characterized 42 of 53 lesions (79%) found to concurrently show type C morphology on ICA. Type C features most frequently missed by CTA were ostial involvement (5 cases) and lesion length >20 mm (7 cases). Major branch involvement was the most frequent false-positive type C feature (12 cases). Mean PCI duration in patients with and without type C lesions on CTA were 42.4 +/- 24.7 min and 21.5 +/- 13.3 min (p = 0.009), respectively; mean total contrast used were 263 +/- 150 ml and 140 +/- 47 ml (p = 0.007), respectively. CONCLUSIONS: In vessels segments >or=2 mm in diameter, CTA can predict lesions likely to reach >or=70% stenosis on ICA and provide added value in discerning complex morphologies associated with these lesions. Presence of complex, severely obstructive lesions on CTA is associated with higher contrast use and greater procedure length during PCI.