Cengiz BURAK, Doğan İLİŞ, Ahmet KARAKURT

Evaluation of long-term mortality in patients with stable angina pectoris whose SYNTAX score was found to be zero in coronary angiography

Aim: The number of diagnostic coronary angiography is increasing. Although previously thought that non-obstructive coronary artery disease (CAD) does not cause an increase in mortality risk, there is recently evidence that it increases mortality. In this study, we aimed to determine the mortality rates and possible predictors of all-cause death in long-term follow-up of patients who underwent coronary angiography (CAG) due to stable angina and whose SYNTAX score was zero including normal coronary arteries, minimal CAD or non-obstructive CAD, coronary slow flow, coronary artery aneurysms and ectasia. Materials and Methods: This study included 1489 patients who underwent CAG due to stable angina pectoris. In-hospital and post-discharge follow-up data were obtained. Patients' CAG images were evaluated and SYNTAX scores were calculated using the website calculator. Results: Among the 1489 patients, 64 (4.3%) all-cause deaths were observed during the 19 ± 1.1 months of follow up period. Although, no significant difference was observed between the 2 groups in terms of the presence of plaque in coronary arteries with a vessel diameter of ≤ 1.5 mm, the rate of patients with plaque in coronary arteries with a diameter of > 1.5 mm was significantly higher in the group of patients who died compared to the patients living (48 (75%) vs 842 (% 59.1), p = 0.011). The cumulative survival curve of the patients was obtained and in patients with coronary plaque in any of the coronary arteries with a vessel diameter of > 1.5 mm was significantly associated with worse survival. Conclusion: There was increase in all-cause mortality in patients who underwent CAG due to stable angina and who have at least one non-obstructive lesion in the coronary arteries > 1.5 mm. Therefore, appropriate risk classification, life style changes and appropriate medical follow-up may be important in these patients.

PDF

___

1. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362:886-95.
2. Johnston N, Schenck-Gustafsson K, Lagerqvist . Are we using cardiovascular medications and coronary angiography appropriately in men and women with chest pain? Eur Heart J 2011;32:1331-6.
3. Lee BK, Lim HS, Fearon WF, et al. Invasive evaluation of patients with angina in the absence of obstructive coronary artery disease. Circulation 2015;131:1054- 60.
4. Jespersen L, Hvelplund A, Abildstrom SZ, et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 2012;33:734-44.
5. Sianos G, Morel MA, Kappetein AP,et al. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention 2005;1:219- 27.
6. Head SJ, Milojevic M, Daemen J, et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 2018;391:939-48.
7. Beltrame JF, Limaye SB, Horowitz JD. The coronary slow flow phenomenon--a new coronary microvascular disorder. Cardiology 2002;97:197-202.
8. Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation 1996;93:879-88.
9. Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary artery disease. Circulation 1983;67:134-8.
10. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002;105:2449-54.
11. Chiu CZ, Shyu KG, Cheng JJ, et al. Angiographic and clinical manifestations of coronary fistulas in Chinese people: 15-year experience. Circ J 2008;72:1242-8.
12. Ridker P, Libby P. Risk markers for atherothrombotic disease. Saunders 2012:914-31.
13. Qin R, Chen T, Lou Q, et al. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: Meta-analysis of observational prospective studies. Meta-Analysis 2013;167:342-50.
14. Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA 1996;275:1571-6.
15. William BK. Rational for Treatment of Hypertension in the Elderly. Am J Geriatr Cardiol 1994;3:33-45.
16. Wilson PWF KW. Hypertension, other risk factors and the risk of cardiovascular disease.: Raven Press: New York; 1995.
17. Lemieux I, Pascot A, Prud’homme D, et al. Elevated C-reactive protein: another component of the atherothrombotic profile of abdominal obesity. 2001;21:961-7.
18. Miller M, Zhan M, Havas SJAoim. High attributable risk of elevated C-reactive protein level to conventional coronary heart disease risk factors: the Third National Health and Nutrition Examination Survey. Arch Intern Med 2005;165:2063-8.
19. Buckley DI, Fu R, Freeman M, et al. C-reactive protein as a risk factor for coronary heart disease: a systematic review and meta-analyses for the US Preventive Services Task Force. Review 2009;151:483-95.
20. Hwang I-C, Lee H, Yoon YE, et al. Risk stratification of non-obstructive coronary artery disease for guidance of preventive medical therapy. Atherosclerosis 2019;290:66-73.
21. Rader DJ. Inflammatory markers of coronary risk. N Engl J Med 2000.
22. Ross RJNEjM. Atheroslcerosis-an inflammatory disease. The New England J of Med 1999;340:115-26.
23. Kabat GC, Kim MY, Manson JE, et al. White Blood Cell Count and Total and Cause-Specific Mortality in the Women's Health Initiative. Am J Epidemiol 2017;186:63-72.
24. Wang T, Jiang CQ, Xu L, et al. White blood cell count and all-cause and cause-specific mortality in the Guangzhou biobank cohort study. BMC Public Health 2018;18:1232.
25. Friedman GD, Klatsky AL, Siegelaub AJNEJoM. The leukocyte count as a predictor of myocardial infarction. N Engl J Med 1974;290:1275-8.
26. Grimm RH, Neaton JD, Ludwig WJJ. Prognostic importance of the white blood cell count for coronary, cancer, and all-cause mortality. Clinical Trial 1985;254:1932-7.
27. De Labry LO, Campion EW, Glynn RJ, et al. White blood cell count as a predictor of mortality: results over 18 years from the Normative Aging Study. J Clin Epidemiol 1990;43:153-7.
28. Jee SH, Park JY, Kim H-S, et al. White blood cell count and risk for all-cause, cardiovascular, and cancer mortality in a cohort of Koreans. Am J Epidemiol 2005;162:1062-9.
29. Shankar A, Mitchell P, Rochtchina E, et al. The association between circulating white blood cell count, triglyceride level and cardiovascular and allcause mortality: population-based cohort study. Atherosclerosis 2007;192:177-83.
30. Mosseri M, Yarom R, Gotsman M, et al. Histologic evidence for small-vessel coronary artery disease in patients with angina pectoris and patent large coronary arteries. Circulation1986;74:964-72.
31. Mangieri E, Macchiarelli G, Ciavolella M, et al. Slow coronary flow: clinical and histopathological features in patients with otherwise normal epicardial coronary arteries. Cathet Cardiovasc Diagn 1996;37:375-81.
32. Cannon ROJJotACoC. Microvascular angina and the continuing dilemma of chest pain with normal coronary angiograms. J Am Coll Cardiol 2009;54:877- 85.
33. Wożakowska-Kapłon B, Niedziela J, Krzyżak P, et al. Clinical manifestations of slow coronary flow from acute coronary syndrome to serious arrhythmias. Cardiol J 2009;16:462-8.
34. Falsetti HL, Carroll RJJC. Coronary artery aneurysm: a review of the literature with a report of 11 new cases. Chest 1976;69:630-6.
35. Befeler B, Aranda JM, Embi A, et al. Coronary artery aneurysms: study of their etiology, clinical course and effect on left ventricular function and prognosis. Am J Med 1977;62:597-607.
36. Papadakis MC, Manginas A, Cotileas P, et al. Documentation of slow coronary flow by the TIMI frame count in patients with coronary ectasia. Am J Cardiol 2001;88:1030-2.
37. Krüger D, Stierle U, Herrmann G, et al. Exercise-induced myocardial ischemia in isolated coronary artery ectasias and aneurysms (“dilated coronaropathy”). J Am Coll Cardiol 1999;34:1461-70.
38. Lichtlen PR, Bargheer K, Wenzlaff P. Long-term prognosis of patients with anginalike chest pain and normal coronary angiographic findings. J Am Coll Cardiol 1995;25:1013-8.
39. Kemp HG, Kronmal RA, Vlietstra RE, et al. Seven year survival of patients with normal or near normal coronary arteriograms: a CASS registry study. J Am Coll Cardiol 1986;7:479-83.
40. Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: A systematic review and metaanalysis. Int J Cardiol 2018;254:1-9.
41. Suwaidi JA, Hamasaki S, Higano ST, et al. Longterm follow-up of patients with mild coronary artery disease and endothelial dysfunction. Circulation 2000;101:948-54.