Role of Ayurveda based non-invasive intervention in management of ischemic heart disease patient of diabetes

Background: The aim of the study was to determine the effectiveness of IRP therapy in patients of myocardial ischemia attending Madhavbaug clinics in Vidarbha region, Maharashtra.Methods: This was a retrospective study conducted from June 2019 to December 2019, wherein we identified the data of patients suffering from IHD (positive for inducible ischemia from stress test) of either gender or any age, and who had attended the Out-patient departments (OPDs) of Madhavbaug clinics across India. The data of patients who had been administered IRP with minimum 7 sittings over a span of 12 weeks were considered for the study.Results: In the present study, medical records of 50 patients of IHD were analyzed. At the end of IRP therapy there was statistically significant reduction in weight, BMI, SBP, and DBP. VO2 peak was improved at the end of therapy i.e. 26.51±5.93 ml/kg/min as compared to baseline i.e.; 15.62±5.36 ml/kg/min and the difference was highly statistically significant (p<0.001). DTS improved from -2.93±5.88 at baseline to 3.21±6.03 at week 12 of IRP therapy and the difference was highly statistically significant (p<0.0001).Conclusions: Findings of present study suggest that IRP can serve as effective therapeutic option for the management of myocardial ischemia.

Reduced Sympathetic Reserve Detectable by Heart Rate Response after Dipyridamole in Anginal Patients with Normal Coronary Arteries

Background. Patients with ischemia and normal coronary arteries (INOCA) may show abnormal cardiac sympathetic function, which could be unmasked as a reduced heart rate reserve (HRR) during dipyridamole stress echocardiography (SE). Objectives. To assess whether HRR during dipyridamole SE predicts outcome. Methods. Dipyridamole SE was performed in 292 patients with INOCA. HRR was measured as peak/rest heart rate and considered abnormal when ≤1.22 (≤1.17 in presence of permanent atrial fibrillation). All-cause death was the only endpoint. Results. HRR during SE was normal in 183 (63%) and abnormal in 109 patients (37%). During a follow-up of 10.4 ± 5.5 years, 89 patients (30%) died. The 15-year mortality rate was 27% in patients with normal and 54% in those with abnormal HRR (p < 0.0001). In a multivariable analysis, a blunted HRR during SE was an independent predictor of outcome (hazard ratio 1.86, 95% confidence intervals 1.20–2.88; p = 0.006) outperforming inducible ischemia. Conclusions. A blunted HRR during dipyridamole SE predicts a worse survival in INOCA patients, independent of inducible ischemia.

Phenotypic Clustering of Patients With Newly Diagnosed Coronary Artery Disease Using Cardiovascular Magnetic Resonance and Coronary Computed Tomography Angiography

Background: Epidemiological characteristics and prognostic profiles of patients with newly diagnosed coronary artery disease (CAD) are heterogeneous. Therefore, providing individualized cardiovascular (CV) risk stratification and tailored prevention is crucial.Objective: Phenotypic unsupervised clustering integrating clinical, coronary computed tomography angiography (CCTA), and cardiac magnetic resonance (CMR) data were used to unveil pathophysiological differences between subgroups of patients with newly diagnosed CAD.Materials and Methods: Between 2008 and 2020, consecutive patients with newly diagnosed obstructive CAD on CCTA and further referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or non-fatal myocardial infarction. For this exploratory work, a cluster analysis was performed on clinical, CCTA, and CMR variables, and associations between phenogroups and outcomes were assessed.Results: Among 2,210 patients who underwent both CCTA and CMR, 2,015 (46% men, mean 70 ± 12 years) completed follow-up [median 6.8 (IQR 5.9–9.2) years], in which 277 experienced a MACE (13.7%). Three mutually exclusive and clinically distinct phenogroups (PG) were identified based upon unsupervised hierarchical clustering of principal components: (PG1) CAD in elderly patients with few traditional risk factors; (PG2) women with metabolic syndrome, calcified plaques on CCTA, and preserved left ventricular ejection fraction (LVEF); (PG3) younger men smokers with proximal non-calcified plaques on CCTA, myocardial scar, and reduced LVEF. Using survival analysis, the occurrence of MACE, cardiovascular mortality, and all-cause mortality (all p &lt; 0.001) differed among the three PG, in which PG3 had the worse prognosis. In each PG, inducible ischemia was associated with MACE [PG1, Hazards Ratio (HR) = 3.09, 95% CI, 1.70–5.62; PG2, HR = 3.62, 95% CI, 2.31–5.7; PG3, HR = 3.55, 95% CI, 2.3–5.49; all p &lt; 0.001]. The study presented some key limitations that may impact generalizability.Conclusions: Cluster analysis of clinical, CCTA, and CMR variables identified three phenogroups of patients with newly diagnosed CAD that were associated with distinct clinical and prognostic profiles. Inducible ischemia assessed by stress CMR remained associated with the occurrence of MACE within each phenogroup. Whether automated unsupervised phenogrouping of CAD patients may improve clinical decision-making should be further explored in prospective studies.

Long-Term Prognostic Value of Stress Cardiovascular Magnetic Resonance–Related Coronary Revascularization to Predict Death: A Large Registry With >200 000 Patient-Years of Follow-Up

Background: Although the benefit of coronary revascularization in patients with stable coronary disease is debated, data assessing the potential interest of stress cardiovascular magnetic resonance (CMR) to guide coronary revascularization are limited. We aimed to assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry. Methods: Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range, 5.0–8.0) included all consecutive patients referred for stress CMR. CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR. The primary outcome was all-cause death based on the National Death Registry. Results: Among the 31 762 consecutive patients (mean age 63.7±12.1 years and 65.7% males), 2679 (8.4%) died at 206 453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement by CMR were associated with death (both P <0.001). In multivariable Cox regression, inducible ischemia and late gadolinium enhancement were independent predictors of death (hazard ratio, 1.61 [99.5% CI, 1.41–1.84]; hazard ratio, 1.62 [99.5% CI, 1.41–1.86], respectively; P <0.001). In the overall population, CMR-related coronary revascularization was an independent predictor of greater survival (hazard ratio, 0.58 [99.5% CI, 0.46–0.74]; P <0.001). In 1680, 1:1 matched patients using a limited number of variables (840 revascularized, 840 nonrevascularized), CMR-related revascularization was associated with a lower incidence of death in patients with severe inducible ischemia (≥6 segments, P <0.001) but showed no benefit in patients with mild or moderate ischemia (<6 segments, P =0.109). Using multivariable analysis in the propensity-matched population, CMR-related revascularization remained an independent predictor of a lower incidence of all-cause mortality (hazard ratio, 0.66 [99.5% CI, 0.54–0.80], P <0.001). Conclusions: In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors. CMR-related revascularization was associated with a lower incidence of death in patients with severe ischemia.

Prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance after inconclusive stress testing

Background While current guidelines recommend noninvasive testing to detect coronary artery disease, stress tests are deemed inconclusive in a quarter of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized. To assess the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing. Methods Between 2008 and 2020, consecutive patients with a first non-CMR inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. Results Of 1563 patients who completed the CMR protocol, 1402 patients (66.7% male, 69.5 ± 11.0 years) completed the follow-up (median [interquartile range], 6.5 [5.6–7.5] years); 197 experienced a MACE (14.1%). Vasodilator stress CMR was well tolerated without severe adverse events. Using Kaplan–Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.88 [95% CI 2.18–3.81]; and HR: 1.46 [95% CI 1.16–1.89], both p < 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95% CI 1.89–3.40]; and HR: 1.58 [95% CI 1.47–1.71]; both p < 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95% CI 0.69–0.81] with C-statistic improvement: 0.12). The study suggested no benefit of CMR-related coronary revascularization in reducing MACE. Conclusions In patients with a first non-CMR inconclusive stress test, vasodilator stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.

Cardiovascular Magnetic Resonance in Ischemic Heart Disease

Ischemic heart disease is one of the leading causes of death and disability, limiting individual’s quality of life. Cardiac magnetic resonance is radiation-free tool to image IHD patients and can depict inducible ischemia, extent and distribution of scar burden, associated complications like mitral regurgitation, thrombus, aneurysm formation, myocardial rupture, and any other incidental pathology. With increasing availability of the CMR there is an ever increasing need to interpret these images by non-imaging clinicians in order to manage patients more effectively. In this article, image interpretation for detection of ischemia, infarct and thrombus are discussed in simple easy to understand manner leaving behind intricate technical details which are of less important to the referring physicians.

Prognostic interest of vasodilator stress perfusion cardiovascular magnetic resonance after a first inconclusive stress testing

Funding Acknowledgements Type of funding sources: None. BACKGROUND While current guidelines recommend to perform a noninvasive test to detect coronary artery disease, stress tests are deemed inconclusive in almost a third of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized. PURPOSE To assess the prognostic value of stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing. METHODS Between 2008 and 2020, consecutive patients with a first inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. RESULTS Of 1,563 patients who completed the CMR protocol, 1,402 patients (66.7% male, mean age 69.5 ± 11.0 years) completed the follow-up (median[interquartile range], 6.5 [5.6-7.5] years); 197 experienced a MACE (14.1%). Stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.88 [95%CI, 2.18-3.81]; and HR: 1.46 [95%CI, 1.16-1.89], both p &lt; 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95%CI, 1.89-3.40]; and HR: 1.58 [95%CI, 1.47-1.71]; both p &lt; 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95%CI: 0.69-0.81] with C-statistic improvement: 0.12). The study showed no benefit of CMR-related coronary revascularization in reducing MACE. CONCLUSION In patients with a first inconclusive stress test, stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.

Long-term prognostic value of stress CMR in patients with history of percutaneous coronary intervention

Funding Acknowledgements Type of funding sources: None. BACKGROUND Recurrence of cardiovascular (CV) events remains a substantial cause of mortality and morbidity among patients with previous coronary revascularization. PURPOSE The aim was to assess the prognostic value of stress cardiovascular magnetic resonance (CMR) parameters and CMR-based revascularization in patients with history of percutaneous coronary intervention (PCI). METHODS Between 2011 and 2014, consecutive patients with history of PCI referred for stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Patients with prior coronary artery bypass graft were excluded. CMR-related coronary revascularization was defined as any revascularization occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. RESULTS Of 1,762 patients who completed the CMR protocol, 1,624 patients (81.7% male, mean age 67.9 ± 10.4 years) completed the follow-up (median [interquartile range], 6.7 [5.6–7.3] years); 251 experienced a MACE (15.5%). Stress CMR was well tolerated. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.70 [95%CI, 2.11–3.46], p &lt; 0.001; and HR: 1.52 [95%CI, 1.16–1.99], p = 0.002; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 2.83 [95%CI, 2.20–3.64]; p &lt; 0.001; and HR: 1.42 [95%CI, 1.06–1.91]; p = 0.012; respectively). CMR-related coronary revascularization was associated with a lower incidence of MACE, even after adjustment. CONCLUSIONS Stress CMR and CMR-related revascularization were independently associated with MACE in patients with history of PCI.

Prognostic value of pre-hospitalization stress perfusion CMR to predict death in patients hospitalized for COVID-19

Funding Acknowledgements Type of funding sources: None. BACKGROUND Inducible ischemia is a strong marker of vascular vulnerability that may be a key pathogenetic determinant of COVID-19 severity. PURPOSE This study investigated the prognostic value of prior inducible ischemia on stress perfusion CMR to predict death in patients hospitalized for COVID-19. METHODS In an observational study, we retrospectively analyzed consecutive patients referred for stress perfusion CMR within last two years prior to hospitalization for COVID-19. The primary outcome was all-cause death, including in-hospital and post-hospitalisation deaths, based on the electronic national death registry. RESULTS Among the patients referred for stress perfusion CMR, 481 were hospitalized for COVID-19 (mean age =68.4 ± 9.6 years, 61.3% males) and completed the follow-up (median 73[36-101] days). There were 93 (19.3%) all-cause deaths, of which 13.7% were in-hospital and 5.6% post-hospitalisation deaths. Using Kaplan-Meier analysis, age, male gender, hypertension, diabetes, known CAD, the presence of prior inducible ischemia, the number of ischemic segments, the presence of LGE, and LVEF were significantly associated with all-cause death. In multivariable stepwise Cox regression analysis, age (HR: 1.04; 95%CI:1.01-1.07, p = 0.023), hypertension (HR: 2.77; 95%CI:1.71-4.51, p &lt; 0.001), diabetes (HR: 1.72; 95%CI:1.08-2.74, p = 0.022), known CAD (HR: 1.78; 95%CI:1.07-2.94, p = 0.025) and the presence of prior inducible ischaemia (HR: 2.05; 95%CI:1.27-3.33, p = 0.004) were independent predictors of all-cause death. CONCLUSIONS In COVID-19 patients, prior inducible myocardial ischemia by stress CMR over the last two years preceding the COVID-19 pandemic was independently associated with all-cause in-hospital and post-hospitalisation deaths, suggesting involvement of vasculature and endothelial dysfunction in the severity of COVID-19.