Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.

BACKGROUND: The incidence of sudden cardiac arrest (SCA) during acute coronary syndrome is somewhat unclear, since often subjects dying before the first healthcare contact are not included in the estimates. We aimed to investigate the complete incidence of SCA during ACS.
METHODS: The study population consists of two cohorts. The first cohort includes 472 ACS patients from Northern Ostrobothnia, Finland from year 2016 and the second cohort 162 autopsy-verified SCD subjects (extrapolated) from the same region and year, whose death was attributable to coronary artery disease (CAD) and ACS. An extrapolation of SCA incidence during ACS was done by utilizing autopsy data and data from prior autopsy study on this sample.
RESULTS: The overall incidence of SCA in the setting of ACS was 17.5%. The incidence of SCA was 20.6% in all ACS subjects without prior CAD diagnosis, and 25.4% in STEMI subjects without prior CAD diagnosis. In subjects with previously diagnosed CAD, the incidence of SCA was 10.9% in all ACS subjects and 16.1% in STEMI subjects. There was a statistically significant difference in the incidence of SCA between subjects with and without prior CAD diagnoses (p=0.0052).
CONCLUSIONS: The inclusion of ACS-SCA subjects dying before the first emergency medical service (EMS) contact results in a higher and likely more accurate estimation of SCA during ACS. The incidence of SCA was higher among subjects without prior CAD diagnosis. The high mortality rate highlights the importance of early ACS detection to reduce the burden of CAD-related premature deaths.

This retrospective study aims to explore the sex disparity in dual antiplatelet therapy (DAPT) noncompliance among left main stem percutaneous coronary intervention (PCI) patients with drug-eluting stent (DES) and identify predictors associated with non-adherence. Data were collected from the medical records of 1585 patients, including 1104 males and 481 females, who underwent left main stem PCI with DES. Baseline characteristics, angiographic features, and DAPT compliance rates at 1 month and 12 months were analyzed. Univariate logistic regression was used to identify predictors of DAPT noncompliance. The overall DAPT noncompliance rate at 1 month was 8.5%, increasing to 15.5% at 12 months. Females exhibited slightly higher noncompliance rates than males at both 1 month (15.6% vs 14.5%) and 12 months (28.1% vs 19.0%), although the difference was not statistically significant. Smoking status showed a modest impact on non-adherence, with current smokers exhibiting a lower noncompliance rate (14.9% at 1 month). Prior coronary artery disease history was associated with increased noncompliance at 12 months (18.9%). Angiographic characteristics, including lesion location and Syntax score, had no consistent association with DAPT noncompliance. This study highlights sex disparity in DAPT noncompliance among patients undergoing left main stem PCI with DES. Comorbidities, socioeconomic status, smoking status, and prior coronary artery disease history were identified as predictors of non-adherence.

Coronary artery disease (CAD) is a prevalent cause of left ventricular dysfunction. Nevertheless, effective elective revascularization, particularly surgical revascularization, can enhance long-term outcomes and, in selected cases, global left ventricular contractility. The assessment of myocardial viability and scars is still relevant in guiding treatment decisions and selecting patients who are likely to benefit most from blood flow restoration. Although the most recent randomized studies challenge the notion of \"hibernating myocardium\" and the clinical usefulness of assessing myocardial viability, the advancement of imaging techniques still renders this assessment valuable in specific situations. According to the guidelines of the European Society of Cardiology, non-invasive stress imaging may be employed to define myocardial ischemia and viability in patients with CAD and heart failure before revascularization. Currently, several non-invasive imaging techniques are available to evaluate the presence and extent of viable myocardium. The selection of the most suitable technique should be based on the patient, clinical context, and resource availability. This narrative review evaluates the characteristics of available imaging modalities for assessing myocardial viability to determine the most appropriate therapeutic strategy.

UNASSIGNED: Low-density lipoprotein cholesterol (LDL-C) is used to guide lipid-lowering therapy after a myocardial infarction (MI). Lack of LDL-C testing represents a missed opportunity for optimizing therapy and reducing cardiovascular risk.
UNASSIGNED: The purpose of this study was to estimate the proportion of Medicare beneficiaries who had their LDL-C measured within 90 days following MI hospital discharge.
UNASSIGNED: We conducted a retrospective cohort study of Medicare beneficiaries ≥66 years of age with an MI hospitalization between 2016 and 2020. The primary analysis used data from all beneficiaries with fee-for-service coverage and pharmacy benefits (532,767 MI hospitalizations). In secondary analyses, we used data from a 5% random sample of beneficiaries with fee-for-service coverage without pharmacy benefits (10,394 MI hospitalizations), and from beneficiaries with Medicare Advantage (176,268 MI hospitalizations). The proportion of beneficiaries who had their LDL-C measured following MI hospital discharge was estimated accounting for the competing risk of death.
UNASSIGNED: In the primary analysis (mean age 76.9 years, 84.4% non-Hispanic White), 29.9% of beneficiaries had their LDL-C measured within 90 days following MI hospital discharge. Among Hispanic, Asian, non-Hispanic White, and non-Hispanic Black beneficiaries, the 90-day postdischarge LDL-C testing was 33.8%, 32.5%, 30.0%, and 26.0%, respectively. Postdischarge LDL-C testing within 90 days was highest in the Middle Atlantic (36.4%) and lowest in the West North Central (23.4%) U.S. regions. In secondary analyses, the 90-day postdischarge LDL-C testing was 26.9% among beneficiaries with fee-for-service coverage without pharmacy benefits, and 28.6% among beneficiaries with Medicare Advantage coverage.
UNASSIGNED: LDL-C testing following MI hospital discharge among Medicare beneficiaries was low.

UNASSIGNED: Bleeding events are frequently applied as safety end points for randomized controlled trials (RCTs) investigating the effect of antithrombotic agents in patients with coronary artery disease. However, whether a bleeding event is a valid surrogate for death remain uncertain.
UNASSIGNED: This study aimed to assess the correlation between the treatment effect on bleeding events and mortality.
UNASSIGNED: Multiple databases were searched to identify RCTs studying antithrombotic agents for patients with coronary artery disease through August 2022. Major and minor bleeding events were defined in included trials, mostly defined with BARC (Bleeding Academic Research Consortium) or TIMI (Thrombolysis In Myocardial Infarction) criteria. Trial-level correlations between nonfatal bleeding events and mortality were assessed. We performed subgroup analyses by the definitions of bleeding (BARC vs TIMI criteria), study year, and follow-up duration. We used a cutoff with a lower limit of 95% confidence interval of R2 >0.72 as a strong correlation and with an upper limit of 95% confidence interval of R2 <0.50 as a weak correlation.
UNASSIGNED: A total of 48 RCTs with 181,951 participants were analyzed. Overall, trial-level R2 for major and minor bleeding were 0.09 (95% CI: 0.00-0.26) and 0.09 (95% CI: 0.00-0.27) for all-cause or cardiovascular death, respectively. When confined to major bleeding, R2 were 0.03 (95% CI: 0.00-0.13) and 0.01 (95% CI: 0.00-0.05), respectively. All of the subgroup analyses did not show any significant correlations.
UNASSIGNED: We demonstrated a trial-defined bleeding event may not be a valid surrogate for mortality in RCTs investigating the effect of antithrombotic agents for coronary artery disease.

UNASSIGNED: Fine particulate matter (PM2.5) promotes atherosclerosis progression and plaque vulnerability. Consequently, patients with a high atherosclerotic burden may be at especially increased risk when exposed to air pollution.
UNASSIGNED: The purpose of this study was to examine the relationship between chronic ambient PM2.5 exposure and adverse outcomes after percutaneous coronary interventions (PCI).
UNASSIGNED: Baseline clinical and procedural data from U.S. veterans undergoing elective PCI (2005-2018) were linked to annual ambient PM2.5 exposure. The association between PM2.5 exposure and major adverse cardiovascular events (MACEs) (myocardial infarction, stroke, or all-cause mortality) was determined using time-varying Cox regression models. Using flexible parametric models, we also evaluated the average life months lost for specific PM2.5 levels over the 15-year period.
UNASSIGNED: In the 73,425 veterans that underwent an elective PCI, the mean annual PM2.5 exposure was 8.4 ± 1.8 μg/m3 (median follow-up 6.75 years). The incidence of MACE was 28%, 48%, and 65% at 5, 10, and 15 years, respectively. In adjusted models, each 1-μg/m3 increase in PM2.5 exposure was associated with an 8.7% (95% CI: 8.4%-8.9%; P < 0.001) increase in MACE. Compared to patients exposed to 5 μg/m3, those exposed to 10 μg/m3 lost 1.1, 3.8, and 7.6 months of life at 5, 10, and 15 years of exposure, respectively.
UNASSIGNED: Veterans undergoing elective PCI are at increased risk of MACE and significant life years lost with long-term exposure to fine particulate matter pollution, even at the current low levels in the United States. These findings emphasize the need for improved air quality standards and patient interventions to better protect vulnerable populations.

Blunt chest trauma caused ST-segment elevation myocardial infarction. Diagnosis of intramural hematoma (IMH) using computed tomography was confirmed using electrocardiography, cardiac marker tests, and subsequent coronary angiography. After conservative treatment, the hematoma was completely resolved 1 year later. Differentiating IMH from other arterial injuries is critical for appropriate management.

UNASSIGNED: The effect of atherosclerotic cardiovascular disease (ASCVD) on cardiovascular death in adults with congenital heart disease (CHD) is not well understood.
UNASSIGNED: The purpose of this study was to determine the prevalence and prognostic implications of ASCVD risk factors in adults with CHD. We hypothesized that ASCVD risk factors were associated with cardiovascular events defined as heart failure hospitalization, heart transplant, and cardiovascular death.
UNASSIGNED: This is a retrospective cohort study of adults with CHD at the Mayo Clinic (2003-2019). Patients with a history of coronary artery disease (CAD) were excluded. ASCVD risk factors were defined as hypertension, hyperlipidemia, diabetes, obesity, smoking, and family history of premature CAD.
UNASSIGNED: There were 5,025 patients without a prior history of CAD. The mean age was 35 (23-45) years, and 2,558 (51%) were males. Of 5,025 patients, 2,382 (47%) had ≥1 ASCVD risk factors at baseline, and 16% developed additional ASCVD risk factors within 5 years (new-onset ASCVD risk). ASCVD risk factors at baseline (hazard ratio 1.27, 95% confidence interval 1.06-1.38) and new-onset ASCVD risk factors during follow-up (hazard ratio 1.06, 95% confidence interval 1.02-1.11) were associated with cardiovascular events.
UNASSIGNED: ASCVD factors were associated with cardiovascular events in adults with CHD. Since interventions that modify ASCVD risk have been shown to decrease cardiovascular death in the general population, it is logical to expect that such interventions would also improve clinical outcomes in the CHD population.

UNASSIGNED: Appropriate selection of patients with stable coronary artery disease (CAD) for coronary angiography is dependent on the pretest probability of obstructive CAD; however, little is known about the potential differences in CAD by race and ethnic groups.
UNASSIGNED: The purpose of this study was to evaluate the association of race and ethnicity with coronary obstruction in stable CAD.
UNASSIGNED: We evaluated first coronary angiography for CAD evaluation between 2012 and 2019 in Ontario, Canada. Race and ethnicity were identified by physicians. The main outcome was the rate of obstructive CAD (left main stenosis ≥50% or major epicardial vessel stenosis ≥70%). Multivariable logistic regression analyses evaluated the independent association of race and ethnicity with CAD.
UNASSIGNED: Among 71,199 CAD patients, 14.0% were South Asian (SA), 4.4% were East Asian (EA), and 58,131 were White patients. SA patients were the youngest at 60.9 years vs 62.4 years for EA patients and 65.1 years for White patients but were most likely to have obstructive CAD (46.9%) (EA 43.0% and White patients 37.9%). SA patients had the highest prevalence of 3-vessel CAD at 13.4% (vs 12.5% in EA and 7.7% in White patients). The adjusted odds ratio was 67% higher (1.67; 95% CI: 1.59 to 1.75) for having obstructive CAD in SA patients than that in White patients. EA patients also had significantly increased adjusted odds of obstructive CAD compared with White patients (1.40; 95% CI: 1.29-1.52).
UNASSIGNED: SA patients were younger at presentation but had the highest adjusted odds of obstructive CAD. Incorporation of race and ethnicity information may improve risk-prediction tools for detection of coronary obstruction.