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This systematic review investigates the diagnostic and prognostic utility of coronary flow reserve (CFR) assessment through echocardiography in patients with left bundle branch block (LBBB), a condition known to complicate the clinical evaluation of coronary artery disease (CAD). The literature search was performed on PubMed, EMBASE, Web of Science, Scopus, and Google Scholar, was guided by PRISMA standards up to March 2024, and yielded six observational studies that met inclusion criteria. These studies involved a diverse population of patients with LBBB, employing echocardiographic protocols to clarify the impact of LBBB on coronary flow dynamics. The findings emphasize the importance of CFR in stratifying cardiovascular risk and guiding clinical decision‐making in patients with LBBB. Pooled results reveal that patients with LBBB and significant left anterior descending (LAD) artery stenosis exhibited a marked decrease in stress‐peak diastolic velocity (MD = ‐19.03 [‐23.58; ‐14.48] cm/s; p <.0001) and CFR (MD = ‐.60 [‐.71; ‐.50]; p <.0001), compared to those without significant LAD lesions, suggesting the efficacy of stress echocardiography CFR assessment in the identification of clinically significant CAD among the LBBB population. This review highlights the clinical relevance of echocardiography CFR assessment as a noninvasive tool for evaluating CAD and stratifying risk in the presence of LBBB and underscores the need for standardized protocols in CFR measurement. [ABSTRACT FROM AUTHOR]

Background Parvovirus ( PV) B19 DNA is detected in endothelial cells and may cause endothelial dysfunction, which is involved in in-stent restenosis. We aimed at performing an exploratory analysis that evaluated if PVB19 DNA at the culprit coronary stenosis would be associated with an increased rate of major adverse cardiac events ( MACE) after coronary stenting. Materials and methods Consecutive patients undergoing stent implantation for stable or unstable coronary artery disease were enroled. Serology for PVB19 infection and presence of DNA for PVB19 on balloons used for predilatation were assessed in all patients. MACE rate, as a composite of cardiac death, myocardial infarction ( MI) or clinically driven target lesion revascularization ( TLR) was obtained at 24 month follow-up. Adjusted hazard ratio ( HR) with 95% confidence interval ( CI) was calculated for variables associated with MACE. Results One hundred and nine patients [age 66 ± 10, male sex 89 (82%)] were enroled. At 24-month follow-up, 18 patients experienced a MACE. Two patients (2%) experienced MI, while 16 patients (15%) experienced clinically driven TLR. At multiple Cox regression analysis, the presence of PVB19 DNA on the balloon and the use of bare-metal stents were independent predictors of MACE [ HR 3·30, 95% CI (1·12-10·08), P = 0·03 and HR 4·19, 95% CI (1·60-10·94), P = 0·003]. Conclusions PVB19 DNA detected on the balloon used for dilatation of coronary stenosis before stent implantation is associated with MACE rate at follow-up, mainly due to clinically driven TLR. The results of this exploratory analysis should be confirmed in a larger population. [ABSTRACT FROM AUTHOR]

Eur J Clin Invest 2011; 41 (11): 1210-1219 Abstract Background In models of acute ischaemia, erythropoietin (EPO) administration has been found to attenuate vascular injury largely through reduced apoptosis, suppressed inflammation and increased nitric oxide availability. We studied the association between circulating endogenous EPO and no-reflow in patients with first ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods Blood sampling was performed before PPCI. Consecutive patients with ( n = 24) or without ( n = 24) evidence of angiographic no-reflow after PPCI were enrolled. Angiographic no-reflow was defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 2 or as TIMI flow = 3 but with myocardial blush grade < 2. We also assessed electrocardiographic (ECG) no-reflow as ≤ 50% resolution of maximal ST elevation 60 min after PPCI. Results Baseline characteristics did not correlate significantly with EPO concentrations. In contrast, both angiographic and ECG no-reflow correlated with lower EPO levels at univariate analysis [median (interquartile): 4·2 (0·6-9·5) vs. 12·2 (5·2-20·3) mIU mL−1, P = 0·001, and 4·0 (0·6-7·1) vs. 9·3 (1·0-12·6) mIU mL−1, P = 0·01, respectively]. At multivariable analysis, decreasing EPO tertiles and left anterior descending as the infarct-related artery were the only factors that predicted both angiographic and ECG no-reflow ( P = 0·017 and P = 0·02 for EPO; P < 0·005 and P > 0·05 for left anterior descending artery, respectively). Conclusions We found an independent, graded, inverse relation between endogenous EPO levels and angiographic and ECG no-reflow following PPCI. In animal models of ischaemia, EPO has been found to be protective. In humans, endogenous EPO may contribute to offset the mechanisms responsible for no-reflow. [ABSTRACT FROM AUTHOR]

Count Neipperg (1775–1829), the morganatic husband of Maria Luigia of Habsburg, Napoleon's former wife, presented with typical heart failure symptoms and died of bilateral bronchopneumonia. Neipperg's case is an example of the conflict in the medical field, which led to the birth of modern evidence‐based medicine (EBM), and although Neipperg died almost 200 years ago, his case presents the same critical issues that more complex geriatric patients face today. First, the attending physicians provided divergent opinions without reaching an agreement. For example, Francesco Rossi correctly diagnosed heart disease by evaluating the patient's signs and symptoms, a clinical approach that is an early example of modern EBM. By contrast, Giacomo Tommasini made a misdiagnosis based on the philosophical principles of John Brown's vitalist theory, as reworded by Giovanni Rasori. Second, Tommasini's medical report also includes evidence of the Geriatric 5Ms for older patient care, such as multi‐complexity, multimorbidity, medication, mobility, and the mind. Moreover, both physicians considered “what matters most” for the patient and his family. Third, the Count's status and political role were identified as the social and structural determinants of health (SSDoH) and used to justify the exceptional intensity of the health care provided. Subsequently, the ante litteram application of EBM and a clinical evaluation based on Geriatrics 5Ms principles anticipate current multidisciplinary management focused on the patient rather than a single disease. The systematic revision of past clinical cases not examined before could open new windows in the dissemination of the geriatric methodology and discipline. [ABSTRACT FROM AUTHOR]

Background Intracoronary physiologic indexes such as coronary flow reserve (CFR) and left ventricular ejection fraction (LVEF) have been regarded as prognostic indicators in patients with coronary artery disease. The current study evaluated the association between intracoronary physiologic indexes and LVEF and their differential prognostic implications in patients with coronary artery disease. Methods and Results A total of 1889 patients with 2492 vessels with available CFR and LVEF were selected from an international multicenter prospective registry. Baseline physiologic indexes were measured by thermodilution or Doppler methods and LVEF was recorded at the index procedure. The primary outcome was target vessel failure, which was a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization over 5 years of follow-up. Patients with reduced LVEF <50% (162 patients [8.6%], 202 vessels [8.1%]) showed a similar degree of epicardial coronary artery disease but lower CFR values than those with preserved LVEF (2.4±1.2 versus 2.7±1.2, P <0.001), mainly driven by the increased resting coronary flow. Conversely, hyperemic coronary flow, fractional flow reserve, and the degree of microvascular dysfunction were similar between the 2 groups. Reduced CFR (≤2.0) was seen in 613 patients (32.5%) with 771 vessels (30.9%). Reduced CFR was an independent predictor for target vessel failure (hazard ratio, 2.081 [95% CI, 1.385-3.126], P <0.001), regardless of LVEF. Conclusions CFR was lower in patients with reduced LVEF because of increased resting coronary flow. Patients with reduced CFR showed a significantly higher risk of target vessel failure than did those with preserved CFR, regardless of LVEF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.

Background In the absence of obstructive coronary stenoses, abnormality of noninvasive stress tests (NIT) in patients with chronic coronary syndromes may indicate myocardial ischemia of nonobstructive coronary arteries (INOCA). The differential prognosis of INOCA according to the presence of coronary microvascular dysfunction (CMD) and incremental prognostic value of CMD with intracoronary physiologic assessment on top of NIT information remains unknown. Methods and Results From the international multicenter registry of intracoronary physiologic assessment (ILIAS [Inclusive Invasive Physiological Assessment in Angina Syndromes] registry, N=2322), stable patients with NIT and nonobstructive coronary stenoses with fractional flow reserve >0.80 were selected. INOCA was diagnosed when patients showed positive NIT results. CMD was defined as coronary flow reserve ≤2.5. According to the presence of INOCA and CMD, patients were classified into 4 groups: group 1 (no INOCA nor CMD, n=116); group 2 (only CMD, n=90); group 3 (only INOCA, n=41); and group 4 (both INOCA and CMD, n=40). The primary outcome was major adverse cardiovascular events, a composite of all-cause death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 5 years. Among 287 patients with nonobstructive coronary stenoses (fractional flow reserve=0.91±0.06), 81 patients (38.2%) were diagnosed with INOCA based on positive NIT. By intracoronary physiologic assessment, 130 patients (45.3%) had CMD. Regardless of the presence of INOCA, patients with CMD showed a significantly lower coronary flow reserve and higher hyperemic microvascular resistance compared with patients without CMD ( P <0.001 for all). The cumulative incidence of major adverse cardiovascular events at 5 years were 7.4%, 21.3%, 7.7%, and 34.4% in groups 1 to 4. By documenting CMD (groups 2 and 4), intracoronary physiologic assessment identified patients at a significantly higher risk of major adverse cardiovascular events at 5 years compared with group 1 (group 2: adjusted hazard ratio [HR adjusted ], 2.88; 95% CI, 1.52-7.19; P =0.024; group 4: HR adjusted , 4.00; 95% CI, 1.41-11.35; P =0.009). Conclusions In stable patients with nonobstructive coronary stenoses, a diagnosis of INOCA based only on abnormal NIT did not identify patients with higher risk of long-term cardiovascular events. Incorporating intracoronary physiologic assessment to NIT information in patients with nonobstructive disease allowed identification of patient subgroups with up to 4-fold difference in long-term cardiovascular events. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.