Overview
The prevalence of critical ab extrinsic compression of left main coronary artery (LMCA) is very high in patients with pulmonary arterial hypertension (PAH) symptomatic for angina (up to 40% according to a recent study of 121 patients with PAH). The element that most of all correlates with the degree of coronary stenosis is the diameter of the pulmonary artery (PA). In particular, a diameter ≥ 40 mm has a sensitivity of 83% and a specificity of 70% in patients with angina. Critical stenosis of LMCA is a risk factor for sudden death and in these condition percutaneous coronary angioplasty with stent implantation has proven to be a safe and effective long-term procedure. Preliminary data from a retrospective analysis of the registry of patients with PAH in Bologna (ARCA registry, 109/2016/U/Oss) highlights that even in PAH patients asymptomatic for angina, compression of LMCA can occur in up to 13% of patients and the main predictive parameter of compression was found to be a diameter ≥ 42 mm (with a sensitivity of 87% and a specificity of 77%). Performing a screening test by coronary-CT scan in all subjects suffering of PAH with a PA diameter ≥ 40 mm even if asymptomatic for angina could therefore help to identify patients with PAH at increased risk for sudden death at an early stage.
Eligibility
Inclusion Criteria:
- Patients with PAH (group 1 of World Health Organization pulmonary hypertension classification) who have undergone at least one pulmonary CT angiography with a PA trunk diameter ≥ 4 cm
- Age ≥18 years
- Asymptomaticity for angina pectoris or anginal equivalent
Exclusion Criteria:
- Severe chronic kidney disease [Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rate <30 ml/min) or need for dialysis
- Major allergy to iodinated contrast agent
- Intolerance or allergy to acetylsalicylic acid or clopidogrel
- History of stroke or transient ischemic attack in the last 6 months or a history of intracranial haemorrhage
- Known cerebral arteriovenous malformation or aneurysm
- Known moderate or severe hepatic insufficiency (Child Pugh B or C)
- Thrombocytopenia (<100.000/μL) or anemia (hemoglobin <10 g/dL)
- Active bleeding or factors which, in the investigator's judgment, significantly increase the risk of bleeding
- Major surgery in the past 30 days
- Cancer in the active phase
- Pregnancy or breastfeeding
- Patient prognosis <1 year in the opinion of the investigator
- Any condition that increases the risk of non-compliance or of being lost to follow-up
- Patients who have already undergone a LMCA angioplasty
- Failure to obtain informed consent