Canadian Journal of Cardiology最新文献

As discussed in the preceding companion papers, there are complicated theoretical and practical issues that hinder progress in the evaluation and treatment of patients with coronary microvascular and vasomotor dysfunction. Solving this problem will require intellectual flexibility, but the invasive assessment requires a practical standardized protocol to minimize variations among participating sites. In this third companion paper, we review the indications and develop a standardized protocol for the invasive assessment of coronary vascular function that will be used in the Canadian Coronary Physiology Registry. It reflects the heterogeneous nature of the disease(s), is flexible enough to interrogate multiple distinct pathways, but is sufficiently structured to allow sites to combine and compare data. With comprehensive clinical assessment and mechanistic substudies, this protocol will facilitate the design and conduct of future clinical trials.

Background: Coronary microvascular dysfunction (CMD) is associated with poor prognosis in patients with dilated cardiomyopathy with reduced ejection fraction (DCMrEF). However, its assessment remains challenging in routine clinical practice. This study aimed to explore the potential value of angiography-derived microcirculatory resistance (AMR) in predicting clinical outcomes in DCMrEF patients.

Methods: This multicentre retrospective study included DCMrEF patients (2019-2024) with a 5-year major adverse cardiovascular events (MACE) end point. AMR was calculated for all major arteries. Its prognostic value was assessed by means of Kaplan-Meier analysis and multivariate Cox regression. A subgroup analysis was conducted to evaluate the impact of vericiguat treatment on clinical outcomes according to patients' baseline AMR levels.

Results: A total of 531 eligible patients with DCMrEF were enrolled in the study, 204 of whom had end point events. The optimal AMR cutoffs were > 2.295 for the left anterior descending coronary artery (LAD; area under the receiver operating characteristic curve 0.776) and left circumflex artery (AUC 0.761), and > 2.5 for the right coronary artery (AUC 0.745), all with P < 0.001. Patients were then classified into the higher AMR group and the lower AMR group. Kaplan-Meier and multivariate Cox analyses confirmed that higher AMR was independently associated with increased MACE risk. LAD-AMR significantly improved risk reclassification over traditional factors (net reclassification improvement 0.015, integrated discrimination improvement 0.051, both P < 0.001). Subgroup analysis revealed vericiguat benefitted only patients with elevated AMR.

Conclusions: AMR may be a powerful independent predictor of poor prognosis in DCMrEF patients, with LAD-AMR showing potential for greater predictive value. Vericiguat may represent a potential precision-targeted agent for the high risk of heart failure mediated by microcirculatory dysfunction.

Background: Indications for pre-emptive aortic surgery are based on ascending aortic diameter. In this study we assessed the diagnostic test properties of novel unadjusted, adjusted, and combined measures of aortic geometry.

Methods: This study comprised an international multicentre analysis of patients undergoing contrast-enhanced computed tomography angiography (CTA) before acute type A aortic dissection (ATAAD). An historical cohort of nonaneurysmal patients and patients with known aneurysmal disease (TAA) were included as a control group. Receiver operating characteristic (ROC) curves were applied to evaluate the aortic measures' diagnostic accuracy (for [un]adjusted aortic diameter, length, and volume), with sensitivity analyses performed in a matched sample. Clinically intuitive measures, such as the number needed to reclassify (NNR) to identify an additional patient at risk of ATAAD, were calculated.

Results: Eighty patients underwent CTA before ATAAD occurred, in 5 centres in The Netherlands and Germany. The control group encompassed 333 patients. The specificity of all measures was 98.8%, 97.0%, and 94.9% at contemporary diameter thresholds of 55 mm, 52 mm, and 50 mm. The sensitivity of diameter, length, or volume was 4.1%, 6.8%, and 14.9% at the 98.8% specificity threshold (NNR volume vs diameter: 9.3, P = 0.008). The combination of diameter, length, and volume as a new criterion resulted in an increased sensitivity at the 55-mm and 52-mm thresholds (18.9%, NNR = 6.8, P = 0.001; 23.0%, NNR = 9.3, P = 0.008). Results were consistent in matched samples.

Conclusions: These newly introduced aortic measures seem promising to identify patients at risk of ATAAD, but their net benefit needs to be validated in real-world cohorts.