Coronary artery disease (CAD) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive. This process can be modified by lifestyle adjustments, pharmacological therapies, and invasive interventions designed to achieve disease stabilization or regression. The disease can have long, stable periods but can also become unstable at any time, typically due to an acute atherothrombotic event caused by plaque rupture or erosion. However, the disease is chronic, most often progressive, and hence serious, even in clinically apparently silent periods. The dynamic nature of the CAD process results in various clinical presentations, which can be conveniently categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS). The Guidelines presented here refer to the management of patients with CCS. The natural history of CCS is illustrated in Figure 1.

/pdf/2019-esc-guidelines-for-the-diagnosis-and-management-of-5b7mv2v506.pdf

2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes.

Background: 
Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown.

Methods: 
In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.

Results: 
The median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.

Conclusions: 
In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others; SCOT-HEART ClinicalTrials.gov number, NCT01149590).

/pdf/coronary-ct-angiography-and-5-year-risk-of-myocardial-6ejqigv030.pdf

Coronary CT Angiography and 5-Year Risk of Myocardial Infarction.

Cardiovascular disease continues to be the leading cause of death among women in the United States, accounting for ≈1 of every 3 female deaths. Sex-specific data focused on cardiovascular disease have been increasing steadily, yet is not routinely collected nor translated into practice. This comprehensive review focuses on novel and unique aspects of cardiovascular health in women and sex differences as they relate to clinical practice in the prevention, diagnosis, and treatment of cardiovascular disease. This review also provides current approaches to the evaluation and treatment of acute coronary syndromes that are more prevalent in women, including myocardial infarction associated with nonobstructive coronary arteries, spontaneous coronary artery dissection, and stress-induced cardiomyopathy (Takotsubo Syndrome). Other cardiovascular disease entities with higher prevalence or unique considerations in women, such as heart failure with preserved ejection fraction, peripheral arterial disease, and abdominal aortic aneurysms, are also briefly reviewed. Finally, recommendations for cardiac rehabilitation are addressed.

/pdf/cardiovascular-disease-in-women-clinical-perspectives-4vy30dhvgy.pdf

Cardiovascular Disease in Women: Clinical Perspectives

Emerging evidence has spurred a considerable evolution of concepts relating to atherosclerosis, and has called into question many previous notions. Here I review this evidence, and discuss its implications for understanding of atherosclerosis. The risk of developing atherosclerosis is no longer concentrated in Western countries, and it is instead involved in the majority of deaths worldwide. Atherosclerosis now affects younger people, and more women and individuals from a diverse range of ethnic backgrounds, than was formerly the case. The risk factor profile has shifted as levels of low-density lipoprotein (LDL) cholesterol, blood pressure and smoking have decreased. Recent research has challenged the protective effects of high-density lipoprotein, and now focuses on triglyceride-rich lipoproteins in addition to low-density lipoprotein as causal in atherosclerosis. Non-traditional drivers of atherosclerosis—such as disturbed sleep, physical inactivity, the microbiome, air pollution and environmental stress—have also gained attention. Inflammatory pathways and leukocytes link traditional and emerging risk factors alike to the altered behaviour of arterial wall cells. Probing the pathogenesis of atherosclerosis has highlighted the role of the bone marrow: somatic mutations in stem cells can cause clonal haematopoiesis, which represents a previously unrecognized but common and potent age-related contributor to the risk of developing cardiovascular disease. Characterizations of the mechanisms that underpin thrombotic complications of atherosclerosis have evolved beyond the ‘vulnerable plaque’ concept. These advances in our understanding of the biology of atherosclerosis have opened avenues to therapeutic interventions that promise to improve the prevention and treatment of now-ubiquitous atherosclerotic diseases. This Review discusses recent research that has transformed our understanding of the biology of atherosclerosis, and examines its implications for the treatment of atherosclerotic cardiovascular disease.

The changing landscape of atherosclerosis.

Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data

BACKGROUND Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care. METHODS We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure. RESULTS The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P = 0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P = 0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001). CONCLUSIONS In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.)

/pdf/outcomes-of-anatomical-versus-functional-testing-for-ycven9jugs.pdf

Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease

ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee.

The present study was undertaken to study clinical, biochemical and echocardiographic characteristics of patients with Chronic Kidney Disease crash- landing and initiating hemodialysis at first presentation in our centre.


MATERIAL
Ours was a cross-sectional study of one hundred and seventy patients with chronic kidney disease starting hemodialysis. Detailed history and examination were done. Apart from routine biochemical tests and CKD-MBD profile, all patient underwent ultrasonography, urine examination and echocardiography. Efforts were made to delineate etiology in each patient.


OBSERVATION
Out of 170 patients 64% were males, 36% were females. Mean age at presentation in our study was 41.27 (±16.47) yrs. Chronic glomerulonephritis was the most common etiology accounting for 54% of cases followed by Diabetes (20%). Mean eGFR at presentation was <5 ml/min/1.73 m². Hypocalcemia was present in 87.1%, hyperphosphatemia in 84.2% and elevated PTH levels in 98% with mean PTH levels being 588.07±309.58 ng/ml. LVH on echocardiogram was present in 58.4 % of patient with diastolic dysfunction being reported in 31 % of patients. DCM was present in 28% of patients and 21% of patients had frank left ventricular failure at presentation.


CONCLUSION
Chronic Kidney Disease patients referred late have clinical and lab characteristics which are worse as compared to routine CKD patients .This calls for a mandatory CKD screening programme for increasing awareness and early identification of CKD patients.

Clinical Characteristics of Patients with Ckd Crash Landing and Initiating Dialysis…… Is it Time for Mandatory Screening Programme for Detection of CKD?

Resistant nephrotic syndrome is a group of disorders with diverse histological findings, which are by definition resistant to corticosteroids given in adequate dose for adequate duration and many are resistant to other therapy as well. In many patients progression to end-stage renal disease is the ultimate outcome. The role of B cells has not been fully explained in man, agents that specifically interfere with B cells would ideally represent the first step toward selective therapy. We studied short term and long term effects of rituximab in patients with resistent primary nephrotic syndrome.


MATERIAL
Study was conducted at SMS-medical college and Hospital Jaipur, four doses of rituximab were given weakly, in fixed dose of 500 mg per dose and proteinuria was evaluated before start of therapy and at 3 months, 6 months and 12 months of therapy. Patients with resistant primary nephrotic syndrome who failed to respond to other therapies, with stable eGFR >30, and controlled BP were included in study. Patients with Active infection, Uncontrolled hypertension, pregnancy were excluded from study.


OBSERVATION
10 patients were enrolled in study out of which 7 FSGS (focal segmental glomeruloscllerosis) and 3 were IMN (idiopathic membranous nephropathy), 5 were female and 5 were male, age 17-61years (average 34.6), weight were 48-70 kg (avg 57.9), BMI 19.4-23 (AVG 21.18), all patients have normal renal function (average creatinine value of 0.8, range= 0.5 to 1.1). At 3 months 1 patient had partial response and 9 had no response. At 6 months of treatment 2 patients had partial response, 3 had complete response and 5 no response. At 12 months of treatment 4 had partial response, 5 had complete response and 1 no response. Out of 10 patients no one had relapse of Nephrotic syndrome at 12 month of therapy. Renal function remain normal in all patients over 12 months followup.


CONCLUSION
This prospective, observational study evaluated 3 month, 6 month, and 12 month outcome of 3 IMN and 7 FSGS patients, with persistent nephrotic range proteinuria and showed that rituximab promoted sustained remission in proteinuria in resistent nephrotic syndrome with normal renal function.

Vinay Malhotra

Papers

Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease

ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee.

Clinical Characteristics of Patients with Ckd Crash Landing and Initiating Dialysis…… Is it Time for Mandatory Screening Programme for Detection of CKD?

Role of Rituximab in Patients with Resistant Nephrotic Syndrome.

Rare Cause of Anuria in a Patient with Horseshoe Kidney