AK098656: a new biomarker of coronary stenosis severity in hypertensive and coronary heart disease patients

Background AK098656 may be an adverse factor for coronary heart disease (CHD), especially in patients with hypertension. This study aimed to analyze the effect of AK098656 on CHD and CHD with various complications. Methods A total of 117 CHD patients and 27 healthy control subjects were enrolled in the study. Plasma AK098656 expression was determined using the quantitative real-time polymerase chain reaction. Student’s t-test was used to compare AK098656 expression levels in different groups. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to quantify the discrimination ability between CHD patients and health controls and between CHD and CHD + complications patients. The relationship between AK098656 and coronary stenosis was analyzed using Spearman’s correlation. Results AK098656 expression was remarkably higher in CHD patients than in healthy controls (P = 0.03). The ROC curve revealed an effective predictive AK098656 expression value for CHD risk, with an AUC of 0.656 (95% CI 0.501–0.809). Moreover, AK098656 expression was increased in CHD + complications patients compared to CHD patients alone (P = 0.005), especially in patients with hypertension (CHD + hHTN, P = 0.030). The ROC curve revealed a predictive AK098656 prognostic value for discriminating between CHD and CHD + hHTN patients, with an AUC of 0.666 (95% CI 0.528–0.805). There was no significant difference in AK098656 expression in CHD patients with diabetes mellitus compared to CHD patients alone. In addition, AK098656 expression in CHD patients was positively correlated with stenosis severity (R = 0.261, P = 0.006). Conclusion AK098656 expression was significantly increased in patients with CHD, especially those with hypertension, and its expression level was positively correlated with the degree of coronary stenosis. This implied that AK098656 may be a risk factor for CHD and can potentially be applied in clinical diagnosis or provide a novel target for treatment.

Right axis deviation in the canine electrocardiogram for predicting severity of pulmonic stenosis: a retrospective cohort analysis

OBJECTIVE To investigate the predictive value of right axis deviation of the mean electrical axis (MEA) in assessing the severity of pulmonic stenosis (PS) in dogs. ANIMALS Records for 218 client-owned dogs diagnosed between 2014 and 2020 with PS as determined by Doppler echocardiography. PROCEDURES University of Florida Small Animal Clinic medical records were reviewed, and signalment and clinical risk variables (murmur grade and clinical signs) were extracted. MEA was determined from ECG records by use of leads I and III. Predictive potential of MEA and associated risk factors to diagnose PS severity (mild [< 50 mm Hg], moderate, or severe [> 75 mm Hg]) were assessed by receiver-operating characteristic curve analysis and quantile regression. RESULTS Records for 88 dogs were eligible for analysis. Greater PS severity was associated with smaller breeds presenting with ECG abnormalities, overt clinical signs, and high-category murmur grades (IV and V). Mean MEA increased with stenosis severity category, with an average of 62° for mild, 113° for moderate, and 157° for severe. Each 10° increase in MEA corresponded to an approximately 5–mm Hg increase in PG. Increasing PS severity was associated with MEA right axis deviation > 100° and the more severe cases (PG > 75 mm Hg) with MEA right axis deviation > –180°. CLINICAL RELEVANCE Mean electrical axis right axis deviation may be a useful screening metric for dogs with suspected moderate to severe PS.

Surgical Treatment of Iatrogenic Low Variety Anal Stenosis with Diamond Flap Anoplasty – A Prospective Study

Background: Anal stenosis results from loss of anoderm with subsequent fibrosis and scarring of underlying tissue. The condition represents a technical challenge in terms of surgical management. It is a serious complication of anorectal surgery, most commonly seen after surgical haemorrhoidectomy. However, stenosis can also occur after perianal circumferential burn due to application of herbal medicine by village doctors. Objective: This study was conducted to see the outcome of diamond-flap anoplasty for the treatment of moderate to severe anal stenosis. Patients and interventions: Unilateral diamond flaps anoplasty was performed for moderate to severe anal stenosis. Final anal calibre of 25 to 26 mm was targeted. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis severity, postoperative complications and the time of return to work were recorded. Results: From July 2012 to January 2017, 18 patients (12 males, 67% and 6 female patients, 33%) with a mean age of 34 years (range, 25-52) were treated. 15 of the patients had a history of previous haemorrhoidectomy and 3 had circumferential perianal chemical burn due to application of herbal medicine by village doctors. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24- 26), and 25 ± 1 mm (range, 23-27). The clinical success rate was 98.9%. No severe postoperative complications were observed. Conclusion: Diamond-flap anoplasty is a highly successful method for the treatment of anal stenosis caused by previous haemorrhoidectomy and perianal circumferential chemical burn by herbal medicine. J Shaheed Suhrawardy Med Coll 2020; 12(2): 67-71

Valvulo-Arterial Impedance and Dimensionless Index for Risk Stratifying Patients With Severe Aortic Stenosis

The hemodynamic effects of aortic stenosis (AS) consist of increased left ventricular (LV) afterload, reduced myocardial compliance, and increased myocardial workload. The LV in AS patients faces a double load: valvular and arterial loads. As such, the presence of symptoms and occurrence of adverse events in AS should better correlate with calculating the global burden faced by the LV in addition to the transvalvular gradient and aortic valve area (AVA). The valvulo-arterial impedance (Zva) is a useful parameter providing an estimate of the global LV hemodynamic load that results from the summation of the valvular and vascular loads. In addition to calculating the global LV afterload, it is paramount to estimate the stenosis severity accurately. In clinical practice, the management of low-flow low-gradient (LF-LG) severe AS with preserved LV ejection fraction requires careful confirmation of stenosis severity. In addition to the Zva, the dimensionless index (DI) is a very useful parameter to express the size of the effective valvular area as a proportion of the cross-section area of the left ventricular outlet tract velocity-time integral (LVOT-VTI) to that of the aortic valve jet (dimensionless velocity ratio). The DI is calculated by a ratio of the sub-valvular velocity obtained by pulsed-wave Doppler (LVOT-VTI) divided by the maximum velocity obtained by continuous-wave Doppler across the aortic valve (AV-VTI). In contrast to AVA measurement, the DI does not require the calculation of LVOT cross-sectional area, a major cause of erroneous assessment and underestimation of AVA. Hence, among patients with LG severe AS and preserved LV ejection fraction, calculation of DI in routine echocardiographic practice may be useful to identify a subgroup of patients at higher risk of mortality who may derive benefit from aortic valve replacement. This article aims to elucidate the Zva and DI in different clinical situations, correlate with the standard indexes of AS severity, LV geometry, and function, and thus prove to improve risk stratification and clinical decision making in patients with severe AS.

The Atherosclerotic Profile of a Young Symptomatic Population between 19 and 49 Years: Coronary Computed Tomography Angiography or Coronary Artery Calcium Score?

(1) Background: Whether coronary computed tomography angiography (CTA) or the coronary artery calcium score (CACS) should be used for diagnosis of coronary heart disease, is an open debate. The aim of our study was to compare the atherosclerotic profile by coronary CTA in a young symptomatic high-risk population (age, 19–49 years) in comparison with the coronary artery calcium score (CACS). (2) Methods: 1137 symptomatic high-risk patients between 19–49 years (mean age, 42.4 y) who underwent coronary CTA and CACS were stratified into six age groups. CTA-analysis included stenosis severity and high-risk-plaque criteria (3) Results: Atherosclerosis was more often detected based on CTA than based on CACS (45 vs. 27%; p < 0.001), 50% stenosis in 13.6% and high-risk plaque in 17.7%. Prevalence of atherosclerosis was low and not different between CACS and CTA in the youngest age groups (19–30 y: 5.2 and 6.4% and 30–35 y: 10.6 and 16%). In patients older than >35 years, the rate of atherosclerosis based on CTA increased (p = 0.004, OR: 2.8, 95%CI:1.45–5.89); and was higher by CTA as compared to CACS (34.9 vs. 16.7%; p < 0.001), with a superior performance of CTA. In patients older than 35 years, stenosis severity (p = 0.002) and >50% stenosis increased from 2.6 to 12.5% (p < 0.001). High-risk plaque prevalence increased from 6.4 to 26.5%. The distribution of high-risk plaque between CACS 0 and >0.1 AU was similar among all age groups, with an increasing proportion in CACS > 0.1 AU with age. A total of 24.9% of CACS 0 patients had coronary artery disease based on CTA, 4.4% > 50% stenosis and 11.5% had high-risk plaque. (4) Conclusions: In a symptomatic young high-risk population older than 35 years, CTA performed superior than CACS. In patients aged 19–35 years, the rate of atherosclerosis was similar and low based on both modalities. CACS 0 did not rule out coronary artery disease in a young high-risk population.

Radiation dose reduction with deep-learning image reconstruction for coronary computed tomography angiography

Objectives Deep-learning image reconstruction (DLIR) offers unique opportunities for reducing image noise without degrading image quality or diagnostic accuracy in coronary CT angiography (CCTA). The present study aimed at exploiting the capabilities of DLIR to reduce radiation dose and assess its impact on stenosis severity, plaque composition analysis, and plaque volume quantification. Methods This prospective study includes 50 patients who underwent two sequential CCTA scans at normal-dose (ND) and lower-dose (LD). ND scans were reconstructed with Adaptive Statistical Iterative Reconstruction-Veo (ASiR-V) 100%, and LD scans with DLIR. Image noise (in Hounsfield units, HU) and quantitative plaque volumes (in mm3) were assessed quantitatively. Stenosis severity was visually categorized into no stenosis (0%), stenosis (< 20%, 20–50%, 51–70%, 71–90%, 91–99%), and occlusion (100%). Plaque composition was classified as calcified, non-calcified, or mixed. Results Reduction of radiation dose from ND scans with ASiR-V 100% to LD scans with DLIR at the highest level (DLIR-H; 1.4 mSv vs. 0.8 mSv, p < 0.001) had no impact on image noise (28 vs. 27 HU, p = 0.598). Reliability of stenosis severity and plaque composition was excellent between ND scans with ASiR-V 100% and LD scans with DLIR-H (intraclass correlation coefficients of 0.995 and 0.974, respectively). Comparison of plaque volumes using Bland–Altman analysis revealed a mean difference of − 0.8 mm3 (± 2.5 mm3) and limits of agreement between − 5.8 and + 4.1 mm3. Conclusion DLIR enables a reduction in radiation dose from CCTA by 43% without significant impact on image noise, stenosis severity, plaque composition, and quantitative plaque volume. Key Points •Deep-learning image reconstruction (DLIR) enables radiation dose reduction by over 40% for coronary computed tomography angiography (CCTA). •Image noise remains unchanged between a normal-dose CCTA reconstructed by ASiR-V and a lower-dose CCTA reconstructed by DLIR. •There is no impact on the assessment of stenosis severity, plaque composition, and quantitative plaque volume between the two scans.

Impact of Several Factors on the Diagnostic Interpretability of Coronary Computed Tomographic Angiography Using a 256-Detector Row CT Scanner

Purpose: To explore the impact of patient-related, vessel-related, image quality-related and cardiovascular risk factors on CCTA interpretability using 256-detector row Computed Tomography (CT). Methods: One hundred ten patients who underwent CCTA and Invasive Coronary Angiography (ICA) were consecutively retrospectively enrolled from January 2018 to October 2018. Using ICA as the reference standard, ≥50% diameter stenosis was defined as the cut-off criterion to detect the diagnostic performance of CCTA. Diagnostic reproducibility was investigated by calculating the interrater reproducibility of CCTA. Multiple logistic regression models were performed to evaluate the impact of 14 objective factors. Results: A total of 1019 segments were evaluated. The per-segment sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CCTA were 76.8%, 93.7%, 91.2%, 67.8% and 95.9%, respectively. The per-segment diagnostic reproducibility was 0.44 for CCTA. Regarding accuracy, a negative association was found for stenosis severity, calcium load and hyperlipidaemia. Regarding sensitivity, calcium load and diabetes mellitus (DM) were positively related. Regarding specificity, a negative correlation was observed between stenosis severity and calcium load. Regarding interrater reproducibility, stenosis severity and calcium load were negatively associated, whereas male sex and the signal-to-noise ratio (SNR) were positively related (all p<0.05). Conclusion: Per-segment 256-detector row CCTA performance was optimal in stenosis-free or occluded segments. Heavier calcium load was associated with poorer CCTA interpretability. On the one hand, our findings confirmed the rule-out value of CCTA; on the other hand, they suggested improvements in calcium subtractions and deep learning-based tools to improve CCTA diagnostic interpretability.