Gregory A. Sgueglia

Relation between stress-induced myocardial perfusion defects on cardiovascular magnetic resonance and coronary microvascular dysfunction in patients with cardiac syndrome X.

OBJECTIVES The purpose of this study was to investigate whether a direct relation can be demonstrated between myocardial perfusion defects detected during dobutamine stress test (DST) by cardiovascular magnetic resonance (CMR) and impairment of coronary microvascular dilatory function in patients with cardiac syndrome X (CSX). BACKGROUND Despite the fact that coronary microvascular dysfunction has been shown in most patients with CSX, the ischemic origin of CSX remains debated. No previous study assessed whether a strict relation exists between abnormalities in myocardial perfusion and coronary microvascular dysfunction in CSX patients. METHODS Eighteen CSX patients (mean age 58 +/- 7 years, 7 men) and 10 healthy control subjects (mean age 54 +/- 8 years, 4 men) underwent myocardial perfusion study by gadolinium-enhanced CMR at rest and at peak DST (maximal dose 40 microg/kg/min). Coronary flow response (CFR) to adenosine (140 microg/kg/min in 90 s) in the left anterior descending (LAD) coronary artery was assessed by high-resolution transthoracic echo-Doppler and expressed as the ratio between coronary flow velocity at peak adenosine and at rest. RESULTS At peak DST, reversible perfusion defects on CMR were found in 10 CSX patients (56%) but in none of the control subjects (p = 0.004). The CFR to adenosine in the LAD coronary artery was lower in CSX patients than in control subjects (2.03 +/- 0.63 vs. 3.29 +/- 1.0, p = 0.0004). The CSX patients with DST-induced myocardial perfusion defects in the LAD territory on CMR had a lower CFR to adenosine compared with those without perfusion defects in the LAD territory (1.69 +/- 0.5 vs. 2.31 +/- 0.6, p = 0.01). A significant correlation was found in CSX patients between CFR to adenosine and a DST perfusion defect score on CMR in the LAD territory (r = -0.45, p = 0.019). CONCLUSIONS Our data concurrently show DST-induced myocardial perfusion defects on CMR and reduced CFR in the LAD coronary artery territory in CSX patients, thus giving strong evidence that a dysfunction of coronary microcirculation resulting in myocardial perfusion abnormalities is present in these patients.

A Randomized Multicenter Study Comparing a Paclitaxel Drug-Eluting Balloon With a Paclitaxel-Eluting Stent in Small Coronary Vessels: The BELLO (Balloon Elution and Late Loss Optimization) Study

OBJECTIVES The aim of this study was to evaluate the efficacy of drug-eluting balloons (DEB) compared with paclitaxel-eluting stents (PES) for the reduction of restenosis in small vessels. BACKGROUND DEB have been shown to be effective in the treatment of coronary in-stent restenosis, but data are limited regarding their efficacy in de novo disease. METHODS BELLO (Balloon Elution and Late Loss Optimization) is a prospective, multicenter trial that randomized 182 patients with lesions located in small vessels (reference diameter <2.8 mm) to treatment with paclitaxel DEB and provisional bare-metal stenting (n = 90) or PES implantation (n = 92). The primary endpoint was noninferiority of angiographic in-stent (in-balloon) late loss with a delta of 0.25 mm. Secondary endpoints were angiographic restenosis, target lesion revascularization, and major adverse cardiac events (MACE; death, myocardial infarction, target vessel revascularization) at 6 months. RESULTS Baseline characteristics were well matched, except for a smaller vessel size in the DEB group (2.15 ± 0.27 mm vs. 2.25 ± 0.24 mm; p = 0.003). The majority (89%) of lesions involved vessels with a diameter <2.5 mm. Bailout stenting was required in 20% of lesions in the DEB group. The primary endpoint of in-stent (in-balloon) late loss was significantly less with DEB compared with PES (0.08 ± 0.38 mm vs. 0.29 ± 0.44 mm; difference -0.21; 95% CI: -0.34 to -0.09; p(noninferiority) < 0.001; p(superiority) = 0.001). At 6 months, DEB and PES were associated with similar rates of angiographic restenosis (10% vs. 14.6%; p = 0.35), [corrected] target lesion revascularization (4.4% vs. 7.6%; p = 0.37), and MACE (10% vs. 16.3%; p = 0.21). [corrected]. CONCLUSIONS Treatment of small-vessel disease with a paclitaxel DEB was associated with less angiographic late loss and similar rates of restenosis and revascularization as a PES. (Balloon Elution and Late Loss Optimization [BELLO]; Study NCT01086579).

Long-term prognosis of patients with cardiac syndrome X

BACKGROUND Previous follow-up studies of patients with cardiac syndrome X (CSX) reported good prognosis. However, some recent reports challenged this finding by showing appreciable mortality rates in patients with angina and normal coronary arteries admitted for acute coronary syndromes. METHODS We performed clinical follow-up of 155 patients (mean age 58.9+/-10 years, 40 men) with typical CSX. The occurrence of major cardiac events (cardiac death, acute myocardial infarction), readmission for chest pain, revascularization procedures, angina status, and non cardiac events during follow-up were collected for each patient. RESULTS At a mean follow-up time of 137+/-78 months (range 24-372) from the onset of symptoms, 4 patients died, 3 for cancers and 1 for acute pancreatitis. No patient died from cardiovascular causes or had any major cardiovascular event. Hospital readmission for recurrent chest pain was reported by 89 patients (58%), and 33 (22%) underwent at least one more coronary angiography. During follow-up, chest pain had remained unchanged in 33% of patients and had worsened in 14% of patients. CONCLUSION Our data show that patients with CSX have excellent long-term clinical prognosis. A significant number of patients, however, shows persistence or worsening of symptoms, as well as further recurrence to medical evaluation.

Kissing Balloon Inflation in Percutaneous Coronary Interventions

Bifurcation lesions are the most frequently approached complex coronary lesions in everyday interventional practice. Bifurcations complexity relies essentially on their very specific anatomy that is imperfectly handled by current coronary devices and, despite dedicated techniques and drug-eluting stents, percutaneous coronary interventions directed toward the treatment of bifurcations are technically demanding and require proper execution. Kissing balloon (KB) inflation was the first specific bifurcation technique to have been developed for percutaneous bifurcation interventions and continues to currently play an important role. Indeed, KB has been proposed to optimize stent apposition, improve side branch access while correcting stent deformation or distortion. Over the years, the KB technique has been deeply investigated by many different methods, from bench testing and computer simulations to in vivo intravascular imaging and clinical studies, producing a large amount of data pointing out the benefits and limitations of the technique. We sought to provide here a comprehensive overview of all those aspects.

Long‐term follow‐up of patients with cardiac syndrome X treated by spinal cord stimulation

Objective: To assess the long-term effect of spinal cord stimulation (SCS) in patients with refractory cardiac syndrome X (CSX). Methods: A prospective, controlled, long-term follow-up was performed of 19 patients with CSX with refractory angina who underwent SCS (SCS group, 5 men, mean (SD) age 60.9 (8.5) years); 9 comparable patients with CSX who refused SCS treatment (3 men, mean (SD) age 60.9 (8.8) years) constituted the control group. Clinical and functional status were assessed at the time of screening for SCS indication (basal evaluation) and at a median (range) follow-up of 36 (15–82) months. Results: The two groups at baseline did not show any difference in clinical characteristics and angina status. All indicators of angina status (angina episode frequency, duration and short-acting nitrate use) improved significantly at follow-up in the SCS group (p<0.001) but not in controls. Functional status, as assessed by the Seattle Angina Questionnaire and a visual analogue scale for quality of life, improved at follow-up in the SCS group (p<0.001 for all scales) but not in controls. Exercise tolerance, exercise-induced angina and ST segment changes also significantly improved in the SCS group but not in controls. Conclusions: Data show that SCS can be a valid form of treatment for long-term control of angina episodes in patients with refractory CSX.

Drug-coated balloon treatment of coronary artery disease: A position paper of the Italian Society of Interventional Cardiology

Drug‐coated balloons are a new tool for the treatment of patients with coronary artery disease. The main feature of this technology is a rapid and homogenous transfer of an antiproliferative drug (paclitaxel) to the vessel wall just at the time of balloon inflation, when neointimal proliferation, in response to angioplasty, is the highest. Moreover, drug‐coated balloons share adjuntive advantages over stents: the absence of permanent scaffold and polymer, the respect of the original coronary anatomy, and limited inflammatory stimuli, thereby allowing for short‐term dual antiplatelet therapy. To this day, a lot of devices are available in the market, with limited scientific data for the vast majority of them. Thus, the Italian scientific society of interventional cardiologists GISE decided to coordinate the efforts of a group of reknown experts on the field, in order to obtain a Position Paper on the correct use of drug‐coated balloons in all the settings of coronary artery disease, giving a class of indication to each one, based on the clinical evidence. This Position Paper represents a quick reference for operators, investigators, and manufactures to promote the understanding and the correct use of the drug‐coated balloon technology in everyday clinical practice.

Diagnostic and prognostic value of ST segment depression limited to the recovery phase of exercise stress test

Objectives: To investigate the diagnostic and prognostic value of ST segment depression limited to the recovery phase of an exercise stress test, as compared with that of ST segment depression appearing during exercise. Setting: Exercise stress test laboratory of a university hospital. Patients and design: Clinical and angiographic data were compared for 574 consecutive patients who developed ST segment depression during the active phase of an exercise test (group 1) and for 79 patients who developed ST segment depression only during the recovery phase of the exercise test (group 2). Results: There were no differences between the two groups in major clinical features. Significant coronary artery stenoses were found in 488 group 1 patients (85%) and in 62 group 2 patients (78%, p  =  0.14). Three vessel or left main disease was found in 166 (29%) group 1 and in 14 (18%) group 2 patients (p  =  0.045). At a median follow up of 55.3 months of 321 group 1 and 54 group 2 patients, there were no significant differences in major cardiac events between the groups (univariate relative risk 0.81, 95% confidence interval 0.25 to 2.68, p  =  0.72). Conclusion: The diagnostic and prognostic power of ST segment depression limited to the recovery phase of an exercise test is largely similar to that of ST segment depression induced during effort; thus, assessing ST segment depression during recovery can significantly improve the clinical information derived from exercise stress tests.

Ventricular late potentials: a critical overview and current applications

BACKGROUND More than 450 000 Americans die suddenly each year from sustained ventricular tachycardia (VT) or fibrillation. Overall, event rates in Europe are similar to those in the United States. A correct risk stratification is essential to reduce the incidence of sudden cardiac death. Ventricular late potentials (VLPs) represent delayed conduction through a diseased myocardium and consist of the presence of electrical activity after the end of the standard QRS. The VLPs are potential substrates for reentry VT. CLINICAL APPLICATIONS The VLPs were found highly predictive of cardiac events, in particular, arrhythmic events, in patients with acute myocardial infarction. The weakness of VLPs is the low positive predictive value, especially as a single technique. However, their negative predictive value for arrhythmic events is very high. The VLPs are observed in more than 50% of patients with arrhythmogenic right ventricular cardiomyopathy, and are actually considered a helpful diagnostic tool in this setting. In patients with syncope of unknown cause, VLP analysis, combined with patient history and other diagnostic tests, can help identify or exclude a mechanism of VT as a cause of the syncope. CONCLUSIONS The VLP assessment offers a practical and low-cost tool to the clinical cardiologist to recognize the possible electrophysiologic substrate underlying life-threatening ventricular arrhythmias. The strength of VLPs is their high negative predictive value. When positive, VLPs still help better stratify the arrhythmic risk of patients in several clinical settings.

Coronary artery spasm induced by capecitabine.

Capecitabine is a new chemotherapeutic agent considered highly specific for sensitive tumour cells, which convert the drug to 5-fluorouracil. Capecitabine is administered on an ambulatory basis for the treatment of metastatic breast and colorectal cancer, and both general practitioners and specialists are likely to deal with patients treated with this drug. We describe the case of a 44-year-old woman, with no cardiovascular risk factors, who started therapy with capecitabine for relapsing of breast carcinoma. She subsequently developed effort angina. Standard electrocardiogram and echocardiography were normal, whereas ST-segment elevation and angina were induced during exercise stress test. Capecitabine was withdrawn and therapy with diltiazem and transdermal nitroglycerine was started. The patient became asymptomatic and repeated symptom-limited exercise stress test did not induce any ST-segment changes or angina, even after withdrawal of anti-ischaemic therapy, thus confirming the hypothesis of capecitabine-induced coronary artery spasm as the cause of patients symptoms.

Inflammation‐related effects of adjuvant influenza A vaccination on platelet activation and cardiac autonomic function

Abstract.  Lanza GA, Barone L, Scalone G, Pitocco D, Sgueglia GA, Mollo R, Nerla R, Zaccardi F, Ghirlanda G, Crea F (Istituto di Cardiologia; and Università Cattolica del Sacro Cuore, Roma; Italy). Inflammation‐related effects of adjuvant influenza A vaccination on platelet activation and cardiac autonomic function. J Intern Med 2010; 269: 118–125.