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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 70-80

Correlation between the presence of aortic valve sclerosis and mitral annular calcification and severity of coronary artery disease


1 Department of Cardiovascular Diseases, Al-Azhar University, Assiut; Department of Cardiology, Al-Azhar University, Assiut, Egypt
2 Department of Lecturer of Cardiology, National Heart Institute, Egypt

Date of Submission23-Nov-2019
Date of Decision10-Dec-2019
Date of Acceptance12-Jan-2020
Date of Web Publication26-Mar-2020

Correspondence Address:
Tariq Abdelwadoud Hamed Bakr
Kafr Elsheikh 00247
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_156_19

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  Abstract 


Background Despite numerous improvements in risk scoring regarding assessment of severity of coronary artery disease (CAD), there still remain patients distinguished as being low risk who experience CAD events, just as patients regarded high risk who stay free of CAD events.
Aim To evaluate whether the presence and severity of aortic valve sclerosis (AVS) and/or mitral annular calcification (MAC) as detected by transthoracic echocardiography could be a predictor for the presence and extent of CAD in patients less than or equal to 65 years
Patients and methods The study included 80 patients with suspected CAD, referred for coronary angiography for assessment of chest discomfort between January 2015 and April 2017. The patients were divided into two primary groups: group I included 20 patients with ordinary aortic and mitral valve, and group II included 60 patients with AVS and/or MAC. The group II was additionally subdivided into group IIa, comprising 30 patients with AVS, and group IIb, comprising 30 patients with AVS and MAC. The following was accomplished for all groups: detailed clinical history taking, total general and cardiovascular assessment, full laboratory data, 12-lead resting ECG, complete transthoracic echocardiographic assessment, and coronary angiography.
Results In the correlation between group I and group II with respect to number of vessels affected, there was an extremely high statistically significant difference between both groups. There was a high statistically significant positive correlation between the sum of aortic valve cusp thickness and severity of CAD evaluated by vessel score in group IIa. Among group IIb, there was a high significant positive correlation between MAC and severity of CAD assessed by vessel score.
Conclusions AVS is firmly interrelated with the coronary angiographic Friesinger score to yield a proportion of the degree and of severity of CAD. There is a positive correlation between MAC severity and CAD. Echocardiographically detected MAC can be an indicator of significant CAD.

Keywords: aortic valve calcification, coronary angiography, coronary artery disease, echocardiography, mitral annulus calcification


How to cite this article:
Mahmoud M, Abdelwadoud Hamed Bakr T, Elsharkawi A. Correlation between the presence of aortic valve sclerosis and mitral annular calcification and severity of coronary artery disease. Al-Azhar Assiut Med J 2020;18:70-80

How to cite this URL:
Mahmoud M, Abdelwadoud Hamed Bakr T, Elsharkawi A. Correlation between the presence of aortic valve sclerosis and mitral annular calcification and severity of coronary artery disease. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Jul 10];18:70-80. Available from: http://www.azmj.eg.net/text.asp?2020/18/1/70/281351




  Introduction Top


Coronary artery disease (CAD) is a significant reason for death and disability in developed nations. CAD remains responsible for ∼33% or greater number of all deaths in people older than 35 years. It has been evaluated that approximately a portion of all middle-aged men and 33% of middle-aged women will build up some manifestations of CAD [1]. Overall, 15.5 million people more than or equal to 20 years old in the USA have CAD, with equal increments with age for both women and men, and it has been assessed that approximately every 42 s, an American will endure for a myocardial infarction [2]. Despite numerous improvements in risk scoring regarding assessment of severity of CAD, there still remain patients recognized as being low risk who experience CAD occasions, just as patients considered high risk who stay free of CAD occasions. This had prompted a quest for additional risk variables that may help in further hazard appraisal. Mitral annulus calcification (MAC) is a chronic, degenerative process of the fibrous structure of the mitral valve. The detailed pervasiveness of MAC is somewhere in the range of 8 and 15%, yet it altogether increments with age and in patients with various cardiovascular hazard factors or chronic kidney disease [3]. MAC and atherosclerosis share comparative hazard factors, and the presence of MAC may mirror the power and span of introduction to these hazard factors. Strikingly, MAC has been proposed as an unmistakable gauge of the weight of atherosclerotic ailment. MAC is a growing problem in the elderly. Moreover, studies have proposed that the presence of MAC is autonomously connected with a higher frequency of cardiovascular illness, cardiovascular death, and stroke [4]. Aortic valve sclerosis (AVS) is, by its temperament, asymptomatic and is determined via cardiovascular imaging with either echocardiography or computed tomography. AVS is present in ∼30% of people with more than 65 years of age [5]. All in all, conclusion of AVS on echocardiography depends on appraisal of central or on the contrary diffuse aortic valve thickening with or without expanded echogenicity (reminiscent of calcification) yet with generally unlimited leaflets opening, along with no critical hemodynamic effect, which is typically demonstrated by a maximal transvalvular velocity of less than 2 [6]. There is growing evidence suggesting that AVS is deeply associated with cardiovascular events [7]. Despite the fact that its biochemical factors have not been totally explained, this relationship is as of now generally known. Inflammatory and degenerative processes are thought to affect coronary vases near to the valve and the artery walls, further disturbing prior atherosclerotic processes [8].


  Aim Top


The aim was to assess whether the presence and severity of AVS as well as MAC as detected by transthoracic echocardiography (TTE) could be an indicator for the presence and degree of CAD in patients less than or equal to 65 years.


  Patients and methods Top


Patients

We had selected 80 patients with suspected CAD, referred for coronary angiography for assessment of chest discomfort between January 2015 and April 2017. The study is approved by the ethical committee of Al-Azhar Assiut Faculty of Medicine. The study participants were divided into two main groups: group I included 20 patients with normal aortic and mitral valve, and group II included 60 patients with AVS and/or MAC. The patients of group II were subgrouped into group IIa, which included 30 patients with AVS, and group IIb, which included 30 patients with AVS and MAC. Patients were chosen by fulfilling the following inclusion criteria: age under 65 years and patients indicated for coronary angiography as per AHA rules.

Exclusion criteria

Patients older than 65 years, patients with aortic stenosis, rheumatic disease, bicuspid aortic valves, congenital heart disease, hypertrophic cardiomyopathy, poor echocardiography windows, patients with hyperparathyroidism, and patients on hemodialysis were excluded.

Methods

All patients were subjected to the following: informed consent, detailed clinical history taking, complete general and local cardiac examination, full laboratory data, 12-lead resting ECG, complete TTE examination, and coronary angiography. History taking included complete history, with emphasis on hypertension, diabetes mellitus, history of ischemic heart disease, smoking, and dyslipidemia. Clinical evaluation included general and cardiac examination. Laboratory assessment included renal function tests, and hormonal profile, for example, parathormone, blood sugar level, serum calcium level, and serum low-density lipoprotein level. ECG, echocardiographic evaluation, and complete TTE studies were performed as indicated by the proposals of the American Society of Echocardiography. Echocardiography images were acquired from the standard views (parasternal long axis, parasternal short axis, apical four chambers, apical five chambers, and apical two chambers). Recordings and calculations of different cardiac chambers and ejection fractions were made [9]. Regarding aortic valve assessment, two-dimensional echocardiography evaluations of the aortic valve were produced using the parasternal long-axis, short-axis, and apical views with adjusted gain settings. Peak transaortic flow velocity was calculated from the apical view by continuous wave Doppler. AVS was characterized as a central region of expanded echogenicity and thickening of the aortic valve leaflets without confinement of handout movement and a transaortic stream speed (<2.5 ms) on TTE. The thickness of sclerotic aortic cusps was resolved from the end diastolic images obtained in either short-axis or long-axis view. Mild, moderate, and severe AVSs were graded as cusp thickness 2–3.9 mm, 4–6 mm, and more than 6 mm, respectively [10]. The area and degree of AVS were characterized. Additionally, the quantity of influenced cusps was recorded. As per Tolstrup et al. [11], four morphologic sorts of AVS were recognized: type I: localized, non-nodular sclerosis; type II: localized, nodular sclerosis; type III: diffuse sclerosis, and type IV: mixed sclerosis. Regarding mitral valve assessment, mitral valve was assessed in different views including parasternal long-axis view, which is the first view to assess mitral valve; in this view, thickness of leaflets and their movement during the heart cycle can be assessed. Parasternal short-axis view uncovers mitral leaflet movements and their connection to the chorda. Apical four-chamber view visualizes both mitral leaflets and their coaptation, which ought to be at the degree of the plain of the mitral annulus [12]. MAC was characterized as intense echocardiography-producing structure situated at the intersection of the atrioventricular section and posterior mitral leaflet in parasternal long-axis view. MAC was estimated in millimeters from the driving foremost to the trailing back edge and measured as mild to moderate (1–4 mm) and extreme (>4 mm) thinking about its thickness [11]. Regarding coronary angiography, diagnostic coronary artery catheterizations were done to all patients to assess the severity and the extent of CAD. Assessment of every single coronary angiogram was made by two onlookers. CAD on coronary angiograms was characterized as stenosis of half or more prominent narrowing of the width in coronary arteries, interpretations of coronary angiogram were finished by visual estimation by two cardiologists to evaluate the severity of CAD, which was graded according to vessel score and Friesinger score. Vessel score represents the quantity of vessels with a noteworthy stenosis (for left main coronary artery 50% or greater and for others 70% or greater reduction in luminal diameter). Score ranges from 0 to 3, contingent upon the quantity of vessel involved. Left main coronary artery was scored as single vessel disease [13]. Score 0 indicates no vessel involvement; score 1, single vessel inclusion; score 2, two vessel contribution; and score 3, triple vessel inclusion. Friesinger score ranges from 0 to 15. Every one of the three fundamental coronary arteries is scored independently from 0 to 5 [14]. Score 0 indicates no arteriographic variation from the norm; score 1, trivial irregularities (lesion, 1–29%); score 2, localized 30–68% luminal narrowing; score 3, multiple 30–68% luminal narrowing of the same vessel; score 4, 69–100% luminal narrowing without 100% impediment of proximal segments; and score 5, total obstruction of a proximal segment of a vessel.

Statistical analysis

The clinical and exploring information was gathered and moved to measurable program ‘SPSS’ version 22 (IBM SPSS Inc., Chicago, USA) for Windows, V6.12 to get minimum, maximum, mean±SD, number, and rate (from quantitative information). Regarding analytic statistics, t tests were used to compare multiple groups. Regarding conclusion matrix, P value was taken as a level of significance. P value more than 0.05 was not significant, P value less than 0.05 was significant, and P value less than 0.001 was highly significant.


  Results Top


Comparison between groups I and II was done for the following:
  1. Demographic data: group I included 20 patients. Their mean ±SD age was 51.9±5.72 years. The group comprised 13 (65%) males and seven (35%) females. Regarding risk factors, 10 (50%) patients were diabetics, nine (45%) patients were hypertensive, and 11 (55%) patients were smokers. Group II included 60 patients. Their mean±SD age was 53.08±5.2 years. The group comprised 35 (58.3%) male and 25 (41.7%) female patients. Regarding risk factors, 30 (50%) patients were diabetics, 32 (53.3%) patients were hypertensive, and 30 (50%) patients were smokers.
  2. Sum of aortic valve cusps thickness: regarding sum of aortic valve cusps thickness, there was an extremely statistically significant difference between the two groups (mean±SD was 4.4 mm±0.6% in group I, and 12.12 mm±2.38% in group II) (P<0.001).
  3. Number of vessels affected: regarding the number of vessels affected, there was an extremely statistically significant difference between the two groups (P<0.0001), as shown in [Table 1] and [Figure 1] .
    Table 1 Comparison between the two groups according to the number of vessels affected

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    Figure 1 Comparison between the two groups according to the number of vessels affected.

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  4. Left main CAD: regarding left main CAD, there was no statistically significant difference between the two groups. A total of 1 patient in group I and seven patients in group II had left main disease (P=0.35).
  5. Friesinger score: regarding Friesinger score, there was an extremely statistically significant difference between the two groups (mean±SD was 2.5±2.2% in group I and 8.42±2.84% in group II; P<0.0001).


The patients of the group II were further subdivided into two subgroups: group IIa included 30 patients with AVS, and group IIb included 30 patients with AVS and MAC.

Comparison between the two subgroups (IIa and IIb) was done regarding the following:
  1. Sum of aortic valve cusps thickness: regarding sum of aortic valve cusp thickness, there was a statistically significant difference between the two subgroups (mean±SD was 11.34±2.5% in group IIa, and 12.9±2.03% in group IIb; P=0.015).
  2. Number of vessels affected: regarding the number of vessels affected, there was a statistically significant difference between the two subgroups (P=0.005), as shown in [Table 2] and [Figure 2].
    Table 2 Comparison between the two subgroups according to the number of vessels affected

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    Figure 2 Comparison between the two subgroups according to the number of vessels affected.

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  3. Left main disease: regarding left main disease, there is no statistically significant difference between the two subgroups (P=0.21).
  4. Friesinger score: regarding Friesinger score, there was a high statistically significant difference between the two subgroups (mean±SD was 7.3±2.87% in group IIa, and 9.53±2.36% in group IIb; P<0.001).


Comparison between group I and the two subgroups (IIa and IIb) was done according to the following:
  1. Number of vessels affected: regarding number of vessels affected, there was an extremely statistically significant difference between group I and the two subgroups (P=0.0001), as shown in [Table 3] and [Figure 3].
    Table 3 Comparison between group I and the two subgroups according to the number of vessels affected

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    Figure 3 Comparison between group I and the two subgroups according to number of vessel.

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  2. Friesinger score: there was a statistically significant difference between group I and the subgroup IIa (P<0.01), whereas there was an extremely statistically significant difference between group I and the subgroup IIb regarding Friesinger score (P<0.001), as shown in [Table 4] and [Figure 4].
    Table 4 Comparison between group I and the two subgroups according to Friesinger score

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    Figure 4 Comparison between group I and the two subgroups according to Friesinger score.

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Comparison among the four types of AVS according to Friesinger score showed the following:

As seen in [Table 5], mixed AVS was the most common type of AVS representing 36% of patients in group II, followed by diffuse type (34%), with high statistically significant difference among these types (P<0.001), as shown in [Table 5] and [Figure 5].
Table 5 Types of aortic valve sclerosis thickness in group II

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Figure 5 Comparison between types of AVS according to Friesinger score. AVS, aortic valve sclerosis.

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Regarding the correlation between sum of aortic valve cusps thickness and severity of CAD (assessed by vessel score) in group IIa, there was a high statistically significant positive correlation between sum of aortic valve cusps thickness and severity of CAD assessed by vessel score in group IIa (P<0.001), as shown in [Table 6] and [Figure 6].
Table 6 Correlation between sum of aortic valve cusps thickness and severity of coronary artery disease (assessed by vessel score) in group IIa

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Figure 6 Correlation between sum of aortic valve cusp thickness and vessel score.

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Regarding the correlation between sum of aortic valve cusps thickness and severity of CAD (assessed by Friesinger score) in group IIa, there was a highly statistically significant positive correlation between sum of aortic valve cusps thickness and severity of CAD assessed by vessel score in group IIa (P<0.001), as shown in [Table 7] and [Figure 7].
Table 7 Correlation between sum of aortic valve cusps thickness and severity of coronary artery disease (assessed by Friesinger score) in group IIa

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Figure 7 Correlation between sum of aortic valve cusp thickness and severity of CAD assessed by Friesinger score. CAD, coronary artery disease.

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Regarding the correlation between MAC and severity of CAD (assessed by vessel score) in group IIb, there was a highly significant positive correlation between MAC and severity of CAD assessed by vessel score in group IIb (P<0.001), as shown in [Table 8] and [Figure 8].
Table 8 Correlation between mitral annular calcification and severity of coronary artery disease (Assessed by vessel score) in group IIb

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Figure 8 Correlation between MAC and severity of CAD (assessed by vessel score) in group IIb. CAD, coronary artery disease; MAC, mitral annular calcification.

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Regarding the correlation between MAC and severity of CAD (assessed by Friesinger score) in group IIb, there was a highly significant positive correlation between MAC and severity of CAD (assessed by Friesinger score) in group IIb (P≤0.001), as shown in [Table 9] and [Figure 9].
Table 9 Correlation between mitral annular calcification and severity of coronary artery disease (assessed by Friesinger score) in group IIb.

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Figure 9 Correlation between MAC and severity of CAD (assessed by Friesinger score) in group IIb. CAD, coronary artery disease; MAC, mitral annular calcification.

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  Discussion Top


CAD is a major cause of death and disability in developed countries. CAD remains responsible for ∼33% or a greater amount of all deaths in people over the age of 35 years. It has been evaluated that approximately one portion of all middle-aged men and 33% of middle-aged women will build up some manifestations of CAD [1]. MAC and atherosclerosis share comparative hazard factors, and the presence of MAC may mirror the power and span of introduction to these hazard factors. Strikingly, MAC has been proposed as an unmistakable gauge of the weight of atherosclerotic ailment. MAC is a developing issue in the elderly. It causes mitral stenosis and incompetence, which are difficult to treat. Moreover, studies have proposed that the presence of MAC is freely connected with a higher occurrence of CVD, CV death, and stroke [4]. AVS might be used as a hazard marker for CAD. Despite the fact that its biochemical instrument has not been totally explained, this relationship is as of now generally known. Inflammatory and degenerative processes are thought to affect coronary vases near to the valve and affect the arteries walls, further disturbing prior atherosclerotic processes [8]. The purpose of this study was to investigate relationship between AVS, MAC, and the presence and severity of CAD in patients undergoing coronary angiography. For this purpose, we assessed AVS and MAC in 80 patients (M/F=48/32) referred for diagnostic coronary angiography between January 2015 and April 2017. The severity of coronary atherosclerosis was defined by using vessel and Friesinger score systems. Regarding the relationship between AVS and CAD, in 1997, 5201 patients more than 65 years of age were enrolled in the Cardiovascular Health Study by Fendley and colleagues, and the relation between aortic sclerosis distinguished on echocardiography and clinical risk factors for atherosclerosis was assessed using stepwise strategic regression analysis. AVS was present in 26%, and in patients more than 75 years of age, sclerosis was present in 37%.

Autonomous clinical variables that related with degenerative aortic valve included age (twofold expanded hazard for every 10-year increment in age), male sexual orientation (twofold abundance chance), present smoking (35% expansion in chance), and a background of hypertension (20% expansion in chance) [15]. In 2001, the study carried out by Yoram and colleagues, on 381 patients, concluded that atherosclerosis hazard factors and proximal aortic atherosclerosis are independently connected with aortic valve anomalies in the general populace. These perceptions recommend that AVS is an atherosclerosis-like process including the aortic valve [16]. In our study, we found that Friesinger score was significantly higher in the sclerotic group (group IIa) (7.30±2.87) compared with the normal group (group I) (2.50±2.21) (P<0.001). This finding is comparable with those of earlier studies linking AVS to CAD. In 2005, Serdar and colleagues studied the relationship among AVS and the degree of coronary atherosclerosis by methods for the Gensini score system, and they inferred that AVS is emphatically interrelated with the coronary angiographic Gensini score. Echocardiography detection of AVS in patients experiencing coronary angiography can give another surrogate marker of the degree of coronary atherosclerosis [17]. Regarding the number of vessels affected, there was an extremely statistically significant difference between group I and group IIa (AVS group) (P=0.0001). Consistent with these findings, in 2006, Yoram et al. [18] analyzed clinical, angiographic highlights, and TTE findings reflectively in a blinded design for 138 sequential patients, of whom 58 had AVS and 80 had non-AVS diseases. They reported that AVS and CAD had comparable clinical hazard factors. The AVS group had a higher positive rate of coronary angiography and a higher frequency of multivessel CAD than the non-AVS group [18]. The advancement of AVS on screening echocardiography could mean fundamental CAD and brief progressive forceful administration of risk factors.

However, as of now there is no corroborative proof to help routine AV assessment to screen patients for CAD. Understanding the components basic, the advancement of AVS, and unwinding its relationship with CAD will without a doubt produce potential regions for therapeutic interventions. In comparison among the four types of AVS and its relation to Friesinger score, we found that mixed AVS was the most common type, representing 36% of patients in group II, followed by diffuse type (34%), with high statistically significant difference among these types regarding Friesinger score (P<0.001). This comes in agreement with previous study performed by Tolstrup and colleagues, who correlated the subtypes of AVS with the presence of CVD. It concluded that it is conceivable to distinguish a subgroup of patients with blended nodular and diffuse sclerosis, who are at expanded hazard for CAD including multivessel disease. This distinguishing proof may demonstrate financially savvy in recognizing patients who need further workup for CVD [11]. Regarding the relationship between MAC and CAD, a retrospective analysis of 3169 echocardiograms, which were performed for clinical reasons in southern California somewhere between 1983 and 1998 in patients somewhere in the age range of 16 and 99 years old, was performed. Mortality information was separated from the national mortality database toward the finish of 2007. Utilizing univariate and multivariate analysis, associations between total mortality and the echocardiography presence of MAC documented in the final report by the interpreting cardiologist were assessed [16]. MAC was altogether connected with all-cause mortality [174 of 334 (52.1%) patients with MAC died versus 709 of 2835 (25.0%) patients without MAC; P<0.001] [19]. Utilizing an enormous echocardiography database, MAC was seen as independently connected with all-cause mortality. This finding affirms the significance of an abnormal mitral annulus as an important prognostic marker [20]. In our study, we founded that Friesinger score is significantly higher in the MAC group (group IIb) (9.53±2.36) compared with the sclerotic group (group IIa) (7.3±2.87) and the normal group (group I) (2.5±2.2) (P<0.001). This comes in agreement with a previous study performed by Rahman and colleagues, who assessed 140 patients with IHD enrolled by purposive sampling. Study populations were divided into MAC group and non-MAC group. MAC was detected by TTE. Evaluation of angiographic seriousness of CAD was done in a similar clinic setting by Vessel score, Friesinger score, and Leaman score. Their outcomes demonstrated that anterior myocardial infarction was essentially higher in MAC group (P=0.03), left main and three vessel disease were altogether higher in MAC group (P=0.001, P=0.01), whereas normal vessels were more in non-MAC group (P=0.001). Intermediate and high Friesinger score (e‘5) were altogether higher in MAC group whereas low Friesinger score (<5) was more in non-MAC group. There was noteworthy (P=0.01) positive connection between MAC and CAD severity as far as vessel score (r=0.76), Friesinger score (r=0.75), and Leaman score(r=0.42) are concerned. Multivariate strategic relapse analysis demonstrated that MAC was an autonomous indicator of significant CAD [21]. Regarding the number of vessels affected, there was an extremely statistically significant difference between group I and group IIb (MAC group) (P=0.0001). This comes in agreement with a previous study performed by Atar and colleagues, which assessed 100 patients who had MAC and were less than 65 years old. Coronary angiography was done, basically for anginal episodes or a positive treadmill test.A control group of 121 patients was screened too. There was no noteworthy distinction between the groups in patient characteristics, indication for angiography, or atherosclerotic hazard factors. Angiography demonstrated a higher predominance of serious CAD in patients with MAC than in those without (88 vs. 68%, P=0.0004), and a higher predominance of left main CAD (14 vs. 4%, P=0.009) and triple-vessel disease (54 vs. 33%, P=0.002) [22].


  Conclusion Top


From the present study, we concluded the following: (a) AVS is firmly interrelated with the coronary angiographic Friesinger score to yield a proportion of the degree and severity of coronary atherosclerosis. (b) Our outcomes stressed the idea that AVS is a sign of atherosclerotic process. (c) Echocardiography recognition of AVS in patients experiencing coronary angiography might be applied as another surrogate marker of the degree of coronary atherosclerosis. (d) It is conceivable that after further thorough research, AVS could be used in concert with other factors such as family history, comorbidities, and C-reactive protein, to help hazard stratify patients and outline how forceful way of life and medical intervention ought to be sought after. This could be particularly helpful on account of borderline patients without known CAD. (e) The relationship of CAD with AVS exhibits an open door for screening. Assuming early identification of AVS quickened the finding and treatment of CAD, this could hypothetically decline morbidity and mortality. (f) AVS has a high prescient and analytic incentive for CAD. (g) Echocardiography distinguished MAC can be an independent indicator of significant CAD. (h) There is a certain relationship between severity of MAC and CAD severity. (i) Cheap, accessible, and radiation-free nature of the echocardiography recognition of MAC as well as AVS might be a marker of noteworthy CAD.

Recommendation

Noninvasive quantitative indices of the atherosclerotic spectrum of coronary arteries are promising new parameters for an improved prognostic stratification of patients with hazard factors that go for individualized hazard factor evaluation and change. In our view, AVS and MAC may speak to a significant, noninvasive marker in the risk stratification of patients experiencing coronary angiography. Echocardiography assessment of AVS or potentially MAC may identify CAD and address the severity of relevant CAD during rest utilizing a noninvasive system that requires just a couple of moments. The present findings call for future research to decide whether AVS or potentially MAC screening is better than the current CAD risk assessment of individuals.

Limitations of the study

This study has some limitations which should be addressed in further studies. Limitations are summarized in the following points: (a) this study was retrospective. Observations with prospective and more samples are important to clarify unmistakably the connection among MAC, AVS, and atherosclerosis. (b) This study has the significant confinement of including just patients experiencing coronary angiography for suspected CAD. Thus, the CAD was regularly diagnosed, both in the group with no AVS or MAC and in the group with AVS and/or MAC. In this manner, the conclusion does not really apply to patients who have not experienced coronary angiography with a potential conclusion of CAD. (c) Our study findings should be approved against pathology or surgical anatomy in a larger group of asymptomatic people with AVS and/or MAC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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