BACKGROUND

Myocardial bridging (MB) is a congenital coronary anomaly characterized by an epicardial coronary artery taking an intramuscular course, causing systolic compression of the tunneled segment. In comparison to coronary artery disease (CAD), myocardial bridges have been uncommonly associated with acute coronary syndromes and sudden cardiac death.Evidence of accelerated atherosclerotic plaque formation proximal to the bridged segment may increase the risk for future adverse cardiac events in these patients.

This Single–Center Retrospective Study included 323 adult in-patients who underwent coronary angiography for suspected myocardial ischemia in 2022. Clinical information and in-hospital outcomes were obtained by review of medical records.

Myocardial bridging was observed in 31 out of 323 patients (9.60%), with the majority in the mid-left anterior descending artery (87.10%). MB was more prevalent in females (56.62%), and these patients were younger than patients with obstructive CAD (56.9 versus 63.6 years). Chronic Coronary Syndrome was more prevalent in the MB group (82.62%). The coronary segment proximal to the area with MB showed the concurrent presence of obstructive CAD in 16.12% and non-obstructive CAD in 29.03% of cases. In-hospital mortality occurred in 4.44% of the studied population. However, there were no mortalities in the MB group.

Among patients admitted for suspected myocardial ischemia, 9.6% had MB. These patients were younger and, more often, female. Obstructive and non-obstructive CAD were noted in bridged vessels. Although patients with obstructive CAD have a higher risk of experiencing in-hospital death and cardiac complications, evidence of increased atherosclerotic plaque formation in bridged vessels has important implications for future adverse cardiac events and repeat hospitalizations in the MB population. Aggressive risk factor modification, emphasis on long-term follow-up, and the establishment of clinical practice guidelines are therefore necessary for patients with MB.

INTRODUCTION

While a 600 mg loading dose (LD) of clopidogrel has demonstrated superior inhibition of platelet function compared to 300 mg LD, the clinical evidence supporting this superiority is limited. The debate centers on whether higher clopidogrel LD regimen in percutaneous coronary intervention (PCI) outperforms the standard 300 mg LD, with potential benefits being more pronounced in higher-risk patients. Balancing enhanced platelet inhibition to reduce ischemic events against the associated risk of increased bleeding remains a critical consideration in determining the optimal loading dose of clopidogrel for patients with ischemic heart disease.

A systematic literature search for randomized clinical trials (RCTs) was performed comparing 600 mg with 300 mg LD of clopidogrel using PubMed, MEDLINE, Embase, Cochrane, Clinicaltrials.gov and HerdinPH. Studies included those between 2010 and 2023 involving human subjects. The primary efficacy endpoint was a 1-month rate of major adverse cardiac event (MACE) and the primary safety outcome was bleeding adverse effects.

Nine RCTs involving 29,827 patients were included in the efficacy analysis. Mean duration of follow-up was 30 days. Only eight studies were eligible for safety analysis. Compared with standard LD clopidogrel, high LD significantly reduced the incidence of overall MACE (OR: 0.82, 95% CI: 0.74-0.91, p = 0.0002), nonfatal myocardial infarction (OR: 0.56; 95% CI: 0.32-0.99, p = 0.15) and target vessel revascularization (OR: 0.63; 95% CI: 0.41-0.95, p = 0.03), without significant difference in terms of cardiac death (OR: 0.89; 95% CI: 0.76-1.04, p = 0.15) and stroke (OR: 0.92; 95% CI: 0.67-1.26, p = 0.61). However, major bleeding risk was higher in the 600 mg LD (1.9%; 261/13288) compared with 300 mg LD (2.4%; 328/13242) [OR: 1.27; 95% CI: 1.08-1.49, p = 0.005] without significant difference in minor bleeding (OR: 1.05; 95% CI: 0.94-1.17, p = 0.35).

The administration of 600 mg clopidogrel LD reduces the overall risk of MACE with associated increased risk of major bleeding.

BACKGROUND OF THE STUDY

Coronary artery disease (CAD) poses a significant global health challenge. In the Philippines, despite increased availability of coronary artery bypass grafting (CABG), cost remains a barrier to access. This research evaluates key factors such as all-cause death, cardiovascular death, repeat revascularization and quality of life post-CABG under the Philippine Health Z Benefit Package (PZBP). Its findings provide critical insights for shaping clinical practices, policymaking and advocating for broader implementation of the PZBP to improve healthcare access and quality of life for post-CABG patients.

This retrospective cross-sectional study explores the outcomes of post-coronary artery bypass grafting (CABG) patients enrolled under the PZBP. The study, conducted at Perpetual Succour Hospital in Cebu City from December 2018 to September 2023, included patients diagnosed with CAD based on ACC/AHA 2021 guidelines. Using a complete enumeration strategy, the research employed descriptive statistics for demographic and clinical profiling, and measured quality of life using the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) tool.

The study analyzed 29 patients who underwent CABG through the PZBP, presenting detailed demographic and clinical data. Most patients (41.4%) fell within the 51-60 age range, with males comprising 75.9%. Diabetes mellitus type II was prevalent (58.6%) and 86.2% had three-vessel diseases. The quality of life assessed with WHOQOL-BREF yielded positive scores across physical, mental, social and environmental domains, indicating favorable outcomes. Notably, no cardiovascular deaths, all-cause deaths, or repeat revascularizations were reported during the study, highlighting the effectiveness of CABG under PZBP.

The study on post-CABG patients under the PZBP shows promising outcomes with no all-cause death, cardiovascular death, or repeat revascularization. This indicates the program's effectiveness in delivering accessible, high-quality healthcare, enhancing long-term survival rates and overall well-being. However, addressing underutilization is crucial, highlighting the importance of raising awareness and utilization to further improve post-CABG patients' outcomes and quality of life.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD), now known as Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD), is linked to cardiovascular disease. This renaming emphasizes the role of metabolic problems. Coronary artery calcification (CAC) reflects early coronary artery disease, but data on the MAFLD-CAC link is limited. OBJECTIVE: To demonstrate the association between metabolic dysfunction-associated fatty liver disease (MAFLD) based on its criteria and coronary artery calcification, as measured by CT CAC score. METHODS: This single-center retrospective study involved adult Filipino patients who underwent CT CAC scoring between January 2021 and January 2023. Clinical and laboratory data were obtained via review of electronic records. RESULTS: This study involved 147 patients with an average age of 62 years, primarily females (57.14%), and mostly falling into the Obese-Class I category (31.29%). The most common comorbidities were hypertension (95.24%), dyslipidemia (62.59%), and diabetes mellitus (38.1%). In terms of CAC scores using the CT Agatston method, majority (30.61%) had low calcium buildup (Stage 2 with scores between 1-99). Approximately 26.53% had higher liver fat content with liver HU below 40, while 73.47% had lower liver fat content with HU equal to or greater than 40. Furthermore, 25.17% of patients with fatty livers and other risk factors were diagnosed with MAFLD, while 74.83% were not. The p-value indicated a significant difference in proportions, suggesting a lower proportion of MAFLD among those who had undergone CT CAC scoring. However, the Pearson Chi-Square statistic (4.051) and the p-value (0.256) indicated no statistically significant association between MAFLD and CT CAC. CONCLUSION The study found a notably lower proportion of MAFLD diagnoses in patients who underwent CT CAC scoring. Additionally, there was no statistically significant link between MAFLD and CT CAC.
Cardiovascular Diseases ; Coronary Artery Disease ; Fatty Liver, Alcoholic

Background: Worldwide, coronary artery disease (CAD) is a leading cause of mortality and morbidity and remains to be a top health priority in many countries. A non-invasive imaging modality for diagnosis of CAD such as single photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) is usually requested by cardiologists as it displays radiotracer distribution in the heart reflecting myocardial perfusion. The interpretation of SPECT-MPI is done visually by a nuclear medicine physician and is largely dependent on his clinical experience and showing significant inter-observer variability. Objective: The aim of the study is to apply a deep learning approach in the classification of SPECT-MPI for perfusion abnormalities using convolutional neural networks (CNN). Methods: A publicly available anonymized SPECT-MPI from a machine learning repository (https://www.kaggle.com/ selcankaplan/spect-mpi) was used in this study involving 192 patients who underwent stress-test-rest Tc99m MPI. An exploratory approach of CNN hyperparameter selection to search for optimum neural network model was utilized with particular focus on various dropouts (0.2, 0.5, 0.7), batch sizes (8, 16, 32, 64), and number of dense nodes (32, 64, 128, 256). The base CNN model was also compared with the commonly used pre-trained CNNs in medical images such as VGG16, InceptionV3, DenseNet121 and ResNet50. All simulations experiments were performed in Kaggle using TensorFlow 2.6.0., Keras 2.6.0, and Python language 3.7.10. Results: The best performing base CNN model with parameters consisting of 0.7 dropout, batch size 8, and 32 dense nodes generated the highest normalized Matthews Correlation Coefficient at 0.909 and obtained 93.75% accuracy, 96.00% sensitivity, 96.00% precision, and 96.00% F1-score. It also obtained higher classification performance as compared to the pre-trained architectures. Conclusions The results suggest that deep learning approaches through the use of CNN models can be deployed by nuclear medicine physicians in their clinical practice to further augment their decision skills in the interpretation of SPECT-MPI tests. These CNN models can also be used as a dependable and valid second opinion that can aid physicians as a decision-support tool as well as serve as teaching or learning materials for the less-experienced physicians particularly those still in their training career. These highlights the clinical utility of deep learning approaches through CNN models in the practice of nuclear cardiology.
Coronary Artery Disease ; Deep Learning

BACKGROUND: Cardiac Amyloidosis is a disorder of protein misfolding and metabolism in which insoluble fibrils are deposited in the myocardial extracellular matrix causing organ dysfunction and eventually death. It can exhibit cardiac signs and symptoms, or it can be identified through screening in patients who exhibit extracardiac symptoms of amyloidosis. As there were no clear clinical signs of cardiac amyloidosis and a biopsy is required to show amyloid deposition, the condition has been historically challenging to diagnose. Thus, a high index of suspicion based on the clinical presentation and the outcomes of the preliminary testing arecrucial to determine the approach to diagnosis. CASE SUMMARY: We outline a case of 75-year-old Filipino male who was admitted due to progressive exertional dyspnea. Cardiac Amyloidosis was considered due to evaluation findings of heart failure with preserved ejection fraction with restrictive type of cardiomyopathy. This was subsequently confirmed through extracardiac fat pad biopsy, echocardiographic strain analysis and Technetium (99mTc) Pyrophosphate (PYP) single photon emission computed tomography scan (SPECT). CONCLUSION This case report discussed the red flags of clinical manifestations of cardiac amyloidosis and highlighted the use of non-invasive diagnostic modalities to diagnose the disease. Cardiac amyloidosis remains a rare entity and with emerging therapies that have the potential to improve patient outcomes, early diagnosis is really important. Having high index of suspicion based on signs and symptoms can lead to early detection and an increased number of patients being referred for treatment.
Human ; Male ; Aged: 65-79 yrs old ; Coronary Artery Disease

This 63 year old, heavy drinker, previous smoker man, was physically active, a community leader and with good sleeping habits. His diet: processed foods and drinks, meat, poultry products; minimal fruits and vegetables added about a year earlier. Two weeks prior, after drinking alcohol, he experienced progressive difficulty of breathing on physical exertion, relieved by rest. The night before the incident he had a drinking spree. Early morning, he had severe shortness of breath, difficulty of breathing and chest heaviness. He was rushed to the nearby hospital, was admitted at the ICU with the diagnosis of Ischemic Heart Disease with Myocardial Infarction, and, Type 2 Diabetes. The diagnosis was sustained and the management continued upon transfer to a better-equipped hospital. Strict nutritional prescription was introduced and early ambulation started while still in the hospital. His medications were steeply tapered off while lifestyle modification intensified. His progress was extraordinary. This case exemplified the havoc of heavy alcohol drinking, and, its uneventful cold turkey abstinence; favored early ambulation post myocardial infarction, and showed the independence of each CVD risk factor. Is intensive Lifestyle Modification safe and beneficial even in morbid situations?
Coronary artery disease ; myocardial infarction ; alcohol consumption

BACKGROUND: Limited data are available on the comparison of clinical outcomes of complete vs. incomplete percutaneous coronary intervention (PCI) for patients with chronic total occlusion (CTO) and multi-vessel disease (MVD). The study aimed to compare their clinical outcomes. METHODS: A total of 558 patients with CTO and MVD were divided into the optimal medical treatment (OMT) group ( n = 86), incomplete PCI group ( n = 327), and complete PCI group ( n = 145). Propensity score matching (PSM) was performed between the complete and incomplete PCI groups as sensitivity analysis. The primary outcome was defined as the occurrence of major adverse cardiovascular events (MACEs), and unstable angina was defined as the secondary outcome. RESULTS: At a median follow-up of 21 months, there were statistical differences among the OMT, incomplete PCI, and complete PCI groups in the rates of MACEs (43.0% [37/86] vs. 30.6% [100/327] vs. 20.0% [29/145], respectively, P = 0.016) and unstable angina (24.4% [21/86] vs. 19.3% [63/327] vs. 10.3% [15/145], respectively, P = 0.010). Complete PCI was associated with lower MACE compared with OMT (adjusted hazard ratio [HR] = 2.00; 95% confidence interval [CI] = 1.23-3.27; P = 0.005) or incomplete PCI (adjusted HR = 1.58; 95% CI = 1.04-2.39; P = 0.031). Sensitivity analysis of PSM showed similar results to the above on the rates of MACEs between complete PCI and incomplete PCI groups (20.5% [25/122] vs. 32.6% [62/190], respectively; adjusted HR = 0.55; 95% CI = 0.32-0.96; P = 0.035) and unstable angina (10.7% [13/122] vs. 20.5% [39/190], respectively; adjusted HR = 0.48; 95% CI = 0.24-0.99; P = 0.046). CONCLUSIONS For treatment of CTO and MVD, complete PCI reduced the long-term risk of MACEs and unstable angina, as compared with incomplete PCI and OMT. Complete PCI in both CTO and non-CTO lesions can potentially improve the prognosis of patients with CTO and MVD.
Humans ; Treatment Outcome ; Percutaneous Coronary Intervention/methods* ; Coronary Occlusion/surgery* ; Prognosis ; Angina, Unstable/surgery* ; Chronic Disease ; Risk Factors

BACKGROUND: Right ventricular (RV)-arterial uncoupling is a powerful independent predictor of prognosis in heart failure with preserved ejection fraction (HFpEF). Coronary artery disease (CAD) can contribute to the pathophysiological characteristics of HFpEF. This study aimed to evaluate the prognostic value of RV-arterial uncoupling in acute HFpEF patients with CAD. METHODS: This prospective study included 250 consecutive acute HFpEF patients with CAD. Patients were divided into RV-arterial uncoupling and coupling groups by the optimal cutoff value, based on a receiver operating characteristic curve of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP). The primary endpoint was a composite of all-cause death, recurrent ischemic events, and HF hospitalizations. RESULTS: TAPSE/PASP ≤0.43 provided good accuracy in identifying patients with RV-arterial uncoupling (area under the curve, 0.731; sensitivity, 61.4%; and specificity, 76.6%). Of the 250 patients, 150 and 100 patients could be grouped into the RV-arterial coupling (TAPSE/PASP >0.43) and uncoupling (TAPSE/PASP ≤0.43) groups, respectively. Revascularization strategies were slightly different between groups; the RV-arterial uncoupling group had a lower rate of complete revascularization (37.0% [37/100] vs . 52.7% [79/150], P <0.001) and a higher rate of no revascularization (18.0% [18/100] vs . 4.7% [7/150], P <0.001) compared to the RV-arterial coupling group. The cohort with TAPSE/PASP ≤0.43 had a significantly worse prognosis than the cohort with TAPSE/PASP >0.43. Multivariate Cox analysis showed TAPSE/PASP ≤0.43 as an independent associated factor for the primary endpoint, all-cause death, and recurrent HF hospitalization (hazard ratios [HR]: 2.21, 95% confidence interval [CI]: 1.44-3.39, P <0.001; HR: 3.32, 95% CI: 1.30-8.47, P = 0.012; and HR: 1.93, 95% CI: 1.10-3.37, P = 0.021, respectively), but not for recurrent ischemic events (HR: 1.48, 95% CI: 0.75-2.90, P = 0.257). CONCLUSION RV-arterial uncoupling, based on TAPSE/PASP, is independently associated with adverse outcomes in acute HFpEF patients with CAD.
Humans ; Prognosis ; Prospective Studies ; Stroke Volume/physiology* ; Echocardiography, Doppler/adverse effects* ; Coronary Artery Disease/complications* ; Heart Failure ; Pulmonary Artery/diagnostic imaging* ; Ventricular Function, Right/physiology* ; Ventricular Dysfunction, Right

Humans ; Cardiovascular Diseases ; Risk Factors ; Myocardial Infarction/complications* ; Coronary Disease/etiology* ; Heart Disease Risk Factors