Diabetic vascular diseases: molecular mechanisms and therapeutic strategies

Intravascular Imaging Can Improve Outcomes For Complex Stenting Procedures In Patients With High-risk Calcified Coronary Artery Disease

Using intravascular imaging (IVI) to guide stent implantation during complex stenting procedures is safer and more effective for patients with severely calcified coronary artery disease than conventional angiography, the more commonly used technique.

Those are the findings from the largest clinical trial of its kind comparing the two methods during percutaneous coronary intervention (PCI). The "ECLIPSE" trial results were presented on Monday, March 31, in a Late Breaking Clinical Trial Session at the American College of Cardiology Scientific Session (ACC.25) in Chicago. These results could shift treatment options for high-risk patients.

"The ECLIPSE trial shows that use of IVI to guide coronary stenting in severely calcified lesions prevents death, stent thrombosis, and unplanned repeat procedures in this high-risk patient population. These results extend the strong recommendations from recent U.S. And European societal guidelines that intravascular imaging with either optical coherence tomography (OCT) or intravascular ultrasound (IVUS) should be routinely used during complex coronary stent procedures," says first author Gregg W. Stone, MD. Dr. Stone is Director of Academic Affairs for the Mount Sinai Health System and Professor of Medicine (Cardiology) and Professor of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, and the study chair of the ECLIPSE trial. "Currently, IVI is performed in only 20 to 25 percent of these cases in the United States. I suspect its use will rapidly accelerate given study after study now showing reductions in death, stent thrombosis, and nearly every other adverse outcome after PCI when intravascular imaging is used."

Patients with coronary artery disease -- plaque buildup inside the arteries that leads to chest pain, shortness of breath, and heart attack -- often undergo PCI, a non-surgical procedure in which interventional cardiologists use a catheter to place stents in the blocked coronary arteries to restore blood flow. About one-third of these cases in the United States -- hundreds of thousands a year -- have moderate or severely calcified lesions, where calcium builds up in the arteries. Ten percent of those cases are severe, meaning the blood vessels in the arteries essentially turn to bone, making the stenting procedure more challenging and higher-risk. Interventional cardiologists most commonly guide the PCI catheter by using angiography, which involves a special dye (contrast material) and X rays to see how blood flows through the heart arteries to highlight any blockages.

Angiography has limitations that make it difficult to determine the true artery size and the makeup of the plaque, and is suboptimal in determining whether the stent is fully expanded post-PCI and identifying other complications that affect the safety and effectiveness of the procedure. These limitations are amplified in calcified coronary arteries. By creating detailed two-dimensional cross-sectional images and three-dimensional views of the coronary arteries and blockages, IVUS and OCT provide a more accurate and specific picture of the coronary arteries than when the coronary angiogram is used alone. These high resolution imaging techniques can also better assess the adequacy of the implanted stent than angiography. Together, both imaging techniques allow for a more accurate measurement of vessel and plaque dimensions and composition and better assessment of stent implantation than can be read from the coronary angiogram.

In the ECLIPSE study, researchers analyzed the outcomes of PCI in severely calcified lesions of 2,005 patients to see if IVI guidance improves survival without adverse cardiac events compared with angiography guidance. Patients with severely calcified coronary lesions were randomized at 104 sites across the United States. One group, 1,246 patients or 62 percent, had PCI with either OCT or IVUS guidance, and the other 759 patients, or 38 percent, had PCI with angiography guidance. The primary endpoint was the one-year rate of target vessel failure, the composite occurrence of either cardiac death, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization.

Overall rates of target vessel failure were 26 percent lower among patients who had IVI guidance than among those with angiography guidance. Researchers also observed a significant reduction in all-cause death, stent thrombosis, and target lesion and vessel revascularization among patients in whom intravascular imaging was used compared with angiography.

Researchers further analyzed the two imaging modalities -- IVUS and OCT -- to determine whether one was more effective. In the unadjusted analysis, patients had better outcomes with OCT compared to IVUS; however, the differences between the two were no longer significant when adjusting for factors including age, diabetes, and the number and severity of lesions.

"Overall, both OCT and IVUS were effective; additional studies are required to determine whether OCT is more beneficial in severely calcified lesions," Dr. Stone adds. "Regardless, IVI with either OCT or IVUS should be used rather than angiography guidance to guide PCI in patients with severely calcified lesions."

The ECLIPSE trial was funded by Abbott Vascular, Inc. (Abbott), Santa Clara, CA.

An Earlobe Crease May Predict Heart Disease For People Under 40 — Here's What To Look For

If the part of your earlobe where earrings usually go has a distinctive crease, it might be an indication that you have coronary artery disease (CAD). The crease is usually at a 45° angle and extends diagonally backward. 

The diagnoal earlobe crease is also called Frank's sign — named for the doctor who first observed this correlation in the 1970s.

While the crease isn't always a sign of CAD, experts recommend seeing a healthcare provider to check for cardiovascular disease if you have it.

Here's what experts know so far about Frank's sign and how it's related to cardiovascular health. 

Does an earlobe crease mean you have CAD? A distinctive earlobe crease on an elederly man's ear. Fairfax Media Archives/Getty Images

Many researchers have studied the predictive value of earlobe creases for CAD over the years and found the following results: 

However, a 2021 systemic review — the most recent work that attempted to summarize the diagnostic utility of the earlobe crease — reported that its accuracy to detect chronic coronary syndromes remains insufficient.

Overall, the predictive value of an earlobe crease isn't as strong as well-known risk factors such as smoking, diabetes type 2, and hypertension, says Dr. Jesus Lizarzaburu, a family medicine physician at TPMG Grafton Family Medicine.

Why would an earlobe crease indicate CAD?

There are plenty of theories about the relationship between diagonal earlobe creases and CAD, such as:

1. Lack of blood supply

Arteries normally supply your earlobes with the oxygenated blood they need to keep the tissue healthy. But if your arteries aren't working properly — a sign of CAD — then your earlobes may crease due to lack of blood supply.

2. Changes in DNA

In a 1984 letter to the health journal The Lancet, a professor from the Guy's Hospital Medical School in London suggested a potential hereditary link. 

He theorized that changes in the DNA strand of a particular chromosome may be related to the diagonal ear lobe crease because they are both associated with atherosclerosis, the cause of CAD.

3. Loss of elastin

Elastin, a protein in the body responsible for the elasticity and strength of tissues, may also play a role. 

The loss of elastin in the earlobes has been associated with the loss of elastin in the major arteries, says says Dr. William Elliott, chair of Biomedical Sciences at the Pacific Northwest University of Health Sciences. The physical crease may come as a result of the lack of blood supply.

4. Obesity

An earlobe crease may be a sign of obesity, which is an established risk factor for cardiovascular disorders.

5. Aging

A large study found that visible signs of aging, like an earlobe crease, are associated with the increased risk of CAD and heart attack, independent of chronological age.

Overall, the mechanism is not fully understood and more studies are needed to identify the root cause(s) of Frank's sign.

When to see a doctor

Those with an earlobe crease should see a healthcare provider to get checked for cardiovascular disease, says Dr. Arnon Blum, the author of the previously-cited study that linked earlobe creases with ischemic stroke, and vascular biology professor at the Bar-Ilan University Faculty of Medicine.

It's even more important to see a doctor if you experience other symptoms associated with CAD, says Dr. Alex McDonald, a family and sports medicine physician at Kaiser Permanente. 

Other sympomts of CAD tend to get worse with exertion and resolve at rest. These include the following:

Chest pain or pressure

Vague pain in the shoulders or lower jaw

Chest pain radiating to the left arm

Leg pain or swelling

Shortness of breath

Fatigue

Given that heart disease is still the leading cause of death in the US, it's not unreasonable to see a healthcare provider to check your cardiovascular health even if you don't see an earlobe crease, Elliot says.

Generally, adults should get their blood pressure checked at least every two years. If you're over 40 years old or you have certain risk factors for heart disease — like smoking or diabetes — you may need check-ups more frequently.

Insider's takeaway

A diagonal earlobe crease may be an indicator of coronary artery disease, but the mechanism is still unknown.

If you have an earlobe crease, experts advise that you see a healthcare provider to check for heart disease.

But even if you don't, it's diligent to get your blood pressure checked at least every two years to stay on top of your cardiovascular health.

Carla Delgado

Freelance Reporter, Insider Reviews

Inside A Coronary Bypass Surgery

Coronary artery disease, CAD, is a condition where the arteries that supply blood to the heart muscle become clogged and narrow, making it difficult for blood and oxygen to reach the muscles of the heart. Coronary bypass surgery is one treatment option to help restore blood flow, when other surgical procedures may not be recommended.

While coronary bypass surgery does not cure the underlying cause of CAD, it can alleviate symptoms, like chest pain, fatigue, difficulty breathing, and palpitations. It is done using general anesthesia, so you will be asleep during the entire procedure. Your surgeon will make an incision in your chest to access your heart and will use a machine to take over blood flow while your heart is temporarily stopped.

In some cases, minimally invasive procedures are possible, where smaller incisions are used or the heart does not need to be stopped. They will remove a healthy blood vessel from a different part of your body-- commonly from the lower leg, arm, or chest-- and relocate it to your heart. The healthy blood vessel will be attached to the heart above and below a blockage to allow blood to bypass the obstruction and flow more freely.

Once your surgeon confirms that blood is circulating properly, they will drain any fluids and sew the incision closed. Follow up with your doctor if you experience post-surgical complications, such as fever, any redness, pain, or discharge from the incision site. ","publisher":"WebMD Video"} ]]>

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Coronary artery disease, CAD, is a condition where the arteries that supply blood to the heart muscle become clogged and narrow, making it difficult for blood and oxygen to reach the muscles of the heart. Coronary bypass surgery is one treatment option to help restore blood flow, when other surgical procedures may not be recommended.

While coronary bypass surgery does not cure the underlying cause of CAD, it can alleviate symptoms, like chest pain, fatigue, difficulty breathing, and palpitations. It is done using general anesthesia, so you will be asleep during the entire procedure. Your surgeon will make an incision in your chest to access your heart and will use a machine to take over blood flow while your heart is temporarily stopped.

In some cases, minimally invasive procedures are possible, where smaller incisions are used or the heart does not need to be stopped. They will remove a healthy blood vessel from a different part of your body-- commonly from the lower leg, arm, or chest-- and relocate it to your heart. The healthy blood vessel will be attached to the heart above and below a blockage to allow blood to bypass the obstruction and flow more freely.

Once your surgeon confirms that blood is circulating properly, they will drain any fluids and sew the incision closed. Follow up with your doctor if you experience post-surgical complications, such as fever, any redness, pain, or discharge from the incision site.

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