580 Percutaneous coronary intervention or medical therapy as initial management strategy of patients with spontaneous coronary artery dissections: insight from the multicentre, international dissezioni spontanee coronariche (disco) registry

Aims Whether patients with spontaneous coronary artery dissection (SCAD) should undergo an initial conservative management or immediate revascularization through percutaneous coronary intervention (PCI) remains debated. To investigate the frequency and predictors of choosing a strategy of immediate PCI for SCAD, and to compare the clinical outcomes of immediate PCI patients with those undergoing an initial strategy of medical management. Methods and results 369 patients enrolled in the multicentre international DIssezioni Spontanee COronariche (DISCO) registry between January 2009 and December 2020 were included. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction (MI) and any PCI. 240 (65%) patients underwent initial medical management, whereas 129 (35%) had immediate PCI. PCI patients presented more frequently with ST segment-elevation myocardial infarction (STEMI) (68.2% vs. 35%, P < 0.001) and had higher frequency of proximal coronary segment SCAD (31.8% vs. 6.7%, P < 0.001), Thrombolysis in Myocardial infarction (TIMI) flow grade 0–1 (54.3% vs. 20.4%, P < 0.001) and multivessel SCAD (18.6% vs. 9.2%, P = 0.015), as well as a more severe diameter stenosis [99% (100–90) vs. 90% (99–75), P < 0.001]. At multivariate logistic regression, STEMI at presentation (vs. NSTE-ACS, OR: 3.30 95% CI: 1.56–7.12, P = 0.002), proximal coronary segment involvement (OR: 5.43, 95% CI: 1.98–16.45, P = 0.002), TIMI flow grade 0–1 and 2 (respectively, vs. grade 3: OR: 3.22 95% CI: 1.08–9.96, P = 0.038; and OR: 3.98; 95% CI: 1.38–11.80, P = 0.009) and diameter stenosis (per 5% increase, OR: 1.13; 95% CI: 1.01–1.28, P = 0.037) were predictors of immediate PCI, whereas the angiographic subtype 2B predicted a conservative approach (OR: 0.25; 95% CI: 0.07–0.83, P = 0.026). The frequency of in-hospital major adverse cardiac events did not differ between medically and PCI-treated patients. At 2-year follow-up, there were no differences with respect to the composite of MACE (11.7% vs. 13.9%, P = 0.47) and the individual components of cardiovascular death (0.4% vs. 0.7%, P = 0.65), non-fatal MI (8.3% vs. 9.3%, P = 0.92), and any PCI (8.7% vs. 12.4%, P = 0.23). Conclusions The choice between an immediate medical or PCI management of SCAD is mostly driven by clinical presentation and procedural aspects. In the DISCO cohort, the primary treatment approach was not associated with the risk of short-to-midterm adverse events.

686 Coronary lesion distribution in young patient presenting with acute coronary syndrome

Aims The distribution of coronary lesions in young patients presenting with acute coronary syndrome (ACS) is not known. Methods and results We included 82 consecutive young patients (≤45 years at presentation) with ACS and obstructive coronary artery disease referred from October 2013 until March 2021 to our clinic. Significant coronary lesions (>50%) at each segment during coronary angiography were evaluated. A total of 158 lesions have been evaluated. Multivessel disease was observed in 37% of patients. Lesions at proximal and mid left anterior descending (LAD) coronary artery were the most common observation (Figure A). Roughly one in three lesions affected a proximal coronary segment (i.e. segment 1, 5, 6, or 11), and 45.1% of patients presented at least one lesion in these segments. Within each segment, lesions affected the ostium in 15.8%, proximal third in 26.8%, mid-third in 32.9%, and distal-third in 15.9% of cases. Among those presenting with ST-segment elevated myocardial infarction, culprit lesion distribution is presented in Figure B. Proximal segments were affected in 33.9%, while culprit lesion of the LAD, left circumflex, and right coronary artery was observed in 51.8%, 16.1%, and 32.1% respectively. Conclusions In conclusion, coronary artery disease in patients presenting with ACS occur more often in the LAD and in proximal coronary segments. A significant lesion in a proximal coronary segment affected roughly half of young patients presenting with ACS.

Effect of 26 Weeks of Liraglutide Treatment on Coronary Artery Inflammation in Type 2 Diabetes Quantified by [64Cu]Cu-DOTATATE PET/CT: Results from the LIRAFLAME Trial

BackgroundQuantification of coronary artery inflammation and atherosclerosis remains a challenge in high-risk individuals. In this study we sought to investigate if the glucagon like peptide-1 receptor agonist liraglutide has a direct anti-inflammatory effect in the coronary arteries using positron emission tomography (PET) with a radioactive tracer targeting activated macrophages in the vessel-wall.MethodsThirty randomly selected participants with type 2 diabetes from the placebo-controlled trial LIRAFLAME were enrolled in this sub-study. Participants were, prior to enrollment in this sub-study, randomized to either treatment with daily liraglutide (n=15) or placebo (n=15). Both groups underwent a combined [64Cu]Cu-DOTATATE positron emission tomography and computed tomography scan of the heart at baseline and after 26 weeks of treatment. Coronary artery uptake of [64Cu]Cu-DOTATATE were measured as maximum standardized uptake values (SUVmax); and means of the maximum values (mSUVmax), both values were calculated at the level of each participant and each individual coronary-segment.ResultsSUVmax and mSUVmax values decreased significantly in the liraglutide group both at the participant level (SUVmax: p=0.013; mSUVmax: p=0.004) and at the coronary-segment level (SUVmax: p=0.001; mSUVmax: p<0.0001). No change was observed in the placebo group neither at the participant level (SUVmax: p=0.69; mSUVmax: p=0.67) or at the coronary-segment level (SUVmax: p=0.49; mSUVmax: p=0.30). When comparing the mean change in uptake values between the two groups at both the participant level (SUVmax: p=0.076; mSUVmax: p=0.077) and the coronary segment level (SUVmax: p=0.13; mSUVmax: p=0.11) a borderline significant difference was observed. Baseline SUVmax [64Cu]Cu-DOTATATE uptake values showed a weak positive correlation with the inflammatory biomarker high-sensitivity c-reactive protein (τ =0.26, p=0.045).ConclusionLiraglutide treatment for 26-weeks caused a significant reduction in [64Cu]Cu-DOTATATE uptake in the coronary arteries whereas this was not seen in the placebo treated group. In addition, [64Cu]Cu-DOTATATE PET/CT as a marker of coronary inflammation correlated with the systemic inflammation marker hs-CRP.

Cardiac care of Non-COVID-19 patients during the SARS-CoV-2 pandemic: The pivotal role of CCTA

Funding Acknowledgements Type of funding sources: None. Aims To describe the role of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic test for symptomatic patients with suspected CAD in a hub center for cardiovascular emergencies in the presence of limited access to hospital facilities during the COVID-19 pandemic. Methods and Results From March 9th to April 30th, during the peak of the COVID-19 pandemic, a consecutive cohort of symptomatic patients with high clinical suspicion of CAD and clinical indication to CCTA were enrolled in a hub hospital in Milan, Italy. When obstructive coronary artery disease was detected (>70% diameter stenosis in a proximal coronary segment or >90% stenosis in any coronary segment) patients were referred to invasive coronary angiography (ICA). Clinical follow-up was assessed in patients in whom ICA was considered deferrable. Overall, 58 consecutive patients were included. Ten (17.2%) symptomatic patients underwent ICA according to CCTA findings, while in 48 (82.8%) patients ICA was deferred. No clinical events were recorded after a mean follow-up of 49.7 ± 16.8 days. In nine out of ten patients referred to ICA, severe coronary artery disease was confirmed and treated accordingly. Changes in medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA. Conclusion We report a potential pivotal role for CCTA in the triage of non-COVID-19 patients with suspected CAD during the SARS-CoV-2 pandemic. CCTA may be helpful for identifying patients who necessitate ICA, ensuring adequate resource utilization during the pandemic.

Longitudinal Progression of Subclinical Coronary Atherosclerosis in Swiss HIV-Positive Compared With HIV-Negative Persons Undergoing Coronary Calcium Score Scan and CT Angiography

Background People with HIV (HIV+) may have increased cardiovascular event rates compared with HIV-negative (HIV-) persons. Cross-sectional data from the United States and Switzerland, based on coronary artery calcium scan (CAC) and coronary computed tomography angiography (CCTA), suggest, respectively, increased and similar prevalence of subclinical atherosclerosis in HIV+ vs HIV- persons. Methods We repeated CAC/CCTA in 340 HIV+ and 90 HIV- study participants >2 years after baseline CAC/CCTA. We assessed the association of HIV infection, Framingham risk score (FRS), and HIV-related factors with the progression of subclinical atherosclerosis. Results HIV+ were younger than HIV- participants (median age, 52 vs 56 years; P < .01) but had similar median 10-year FRS (8.9% vs 9.0%; P = .82); 94% had suppressed HIV viral load. In univariable and multivariable analyses, FRS was associated with the incidence rate ratio (IRR) of new subclinical atherosclerosis at the follow-up CAC/CCTA, but HIV infection was not: any plaque (adjusted IRR for HIV+ vs HIV- participants, 1.21; 95% CI, 0.62–2.35), calcified plaque (adjusted IRR for HIV+ vs HIV- participants, 1.06; 95% CI, 0.56–2), noncalcified/mixed plaque (adjusted IRR for HIV+ vs HIV- participants, 1.24; 95% CI, 0.69–2.21), and high-risk plaque (adjusted IRR for HIV+ vs HIV- participants, 1.46; 95% CI, 0.66–3.20). Progression of CAC score between baseline and follow-up CAC/CCTA was similar in HIV+ (median annualized change [interquartile range {IQR}], 0.41 [0–10.19]) and HIV- participants (median annualized change [IQR], 2.38 [0–16.29]; P = .11), as was progression of coronary segment severity score (HIV+: median annualized change [IQR], 0 [0–0.47]; HIV-: median annualized change [IQR], 0 [0–0.52]; P = .10) and coronary segment involvement score (HIV+: median annualized change [IQR], 0 [0–0.45]; HIV-: median annualized change [IQR], 0 [0–0.41]; P = .25). Conclusions In this longitudinal CAC/CCTA study from Switzerland, Framingham risk score was associated with progression of subclinical atherosclerosis, but HIV infection was not.