CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 AFRICA 93 Association between bifurcation angle of the left main coronary artery and severity of stenosis of the proximal left anterior descending artery Mohamed Yahia, Walaa Farid, Mohamed Lotfy, Mohamed Osama, Hend Abdo El Deep Abstract Aim: The aim of this study was to evaluate the association between the left main coronary artery (LM) bifurcation angle and the severity of the proximal left anterior descending coronary artery (LAD) stenosis. Methods: Two hundred patients with suspected coronary artery disease who had coronary angiography were included in this observational study. The severity of coronary artery stenosis was analysed using quantitative coronary angiography software (QCA analysis). The LM–LAD and LAD–left circumflex artery (LCX) angles were measured using software (IC MEASURE) in two-dimensional axial images. Results: The patients were divided into two groups. The first group included 100 patients with significant proximal LAD stenosis (≥ 50%) and the second, those with LAD stenosis < 50% (100 patients). Patients with significant proximal LAD stenosis were older and had a higher frequency of diabetes mellitus, and higher serum creatinine and low-density lipoprotein levels than those with non-significant LAD stenosis. The LM–LAD and LAD–LCX angles in patients with significant proximal LAD stenosis were wider than in patients with non-significant LAD stenosis (p < 0.001). The cut-off value of 42° of the LM–LAD angle had a sensitivity of 73% and specificity of 70% to predict significant proximal LAD stenosis. The cut-off value of 68° of the LAD–LCX angle had a sensitivity of 68% and specificity of 62% to predict significant proximal LAD disease. In a multivariate logistic regression analysis, LM–LAD and LAD–LCX angles were independent factors for the development of significant proximal LAD stenosis. Conclusion: Wider LM–LAD and LAD–LCX angles were associated with the severity of proximal LAD disease. Preventative measures and close follow up are needed in such cases to improve their cardiovascular outcome. Keywords: coronary artery disease, left main coronary artery bifurcation angle, left anterior descending artery stenosis Submitted 8/10/21; accepted 31/5/22 Published online 17/8/22 Cardiovasc J Afr 2023; 34: 93–97 www.cvja.co.za DOI: 10.5830/CVJA-2022-031 Alteration of coronary wall shear stress is a major cause of coronary atherosclerosis. Maintaining a laminar shear stress is necessary for optimal vascular function, which includes the regulation of vascular diameter and inhibition of vessel wall inflammation.1,2 At the arterial bifurcation and vessel curvatures, blood flow is disturbed and becomes non-laminar, reducing shear stress (low endothelial shear stress). Atheromatous plaques are frequently developed at these sites. Non-laminar blood flow causes endothelial dysfunction as it initiates oxidative and inflammatory stress, with subsequent plaque formation.3,4 Coronary bifurcation angles have previously been investigated because a wide bifurcation angle is associated with low shear stress. This alters coronary blood flow, resulting in progression of coronary atherosclerosis and formation of atheromatous plaques.5-8 The angles of the left main coronary artery (LM)–left anterior descending coronary artery (LAD) and LAD–left circumflex artery (LCX) have previously been investigated. All these studies used multi-slice computed tomography (CT) coronary angiography.9-13 To our knowledge, these bifurcating angles have not been investigated before using invasive coronary angiography. This study aimed to determine the relationship between the LM–LAD and LAD–LCX angles and the severity of proximal LAD stenosis in individuals who had coronary angiography for suspected coronary artery disease. Methods This was an observational study that included 200 patients with suspected coronary artery disease who had coronary angiography at the Cardiology Department of Menoufia University Hospital in Egypt between January and July 2021. Patients with prior coronary artery bypass graft or prior percutaneous coronary intervention (PCI) and those with significant valvular heart diseases were excluded from the study. Each patient signed an informed consent form. Menoufia University’s institutional review board evaluated and approved the study (IRB approval number: 11/2019CARD3) according to the declaration of Helsinki. Patients were subjected to a complete medical history, including cardiovascular risk factors and a physical examination. Resting electrocardiogram and echocardiography reports were reviewed for all patients. Department of Cardiology, University of Menoufia, Shebin Alkoum, Egypt Mohamed Yahia, MD, m_yahia2000@hotmail.com Walaa Farid, MD Hend Abdo El Deep, MD Department of Cardiology, National Heart Institute, Cairo, Egypt Mohamed Lotfy, MD Mohamed Osama, MD
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