Establishment of a rat model with diet-induced coronary atherosclerosis

Coronary atherosclerotic disease is a serious disease in humans,but no suitable animal model is available currently for further studies.We used apolipoprotein E gene knockout（ApoE KO） rats to induce hypercholesterolemia through a special high cholesterol/bile salt diet（Paigen diet）,then analyzed aortic and coronaiy atherosclerosis lesions and the myocardial injury in order to establish a novel small animal model of coronary atherosclerosis.Plasma cholesterol of ApoE KO rats increased 7.6-fold compared with wild-type rats after 8 weeks on the Paigen diet.After 10 to 12 weeks of subsisting on the Paigen diet,ApoE KO rats developed mild aortic atherosclerosis with severe coronary atherosclerosis.Hematoxilyn and eosin staining showed that 11 out of 12 ApoE KO male rats had right coronary artery atherosclerosis,7 of them were〉70%occluded.Oil Red O（Lipid Stain）,Mac2 immuno-staining and Masson＇s tnchrome staining demonstrated substantial amounts of lipid,macrophages and collagen fibers in coronary atherosclerosis plaques.In addition,ApoE KO male rats had severe myocardial focal lesions with cholesterol ester as the main component in the lesions.In conclusion,ApoE KO rats developed severe hypercholesterolemia,coronary atherosclerosis and myocardial cholesterol ester deposition after subsisting on the Paigen diet and can be used as a novel animal model for studies on cholesterol metabolism and coronary atherosclerotic disease.

Influence of coronary bifurcation angle on atherosclerosis

Hemodynamics plays a crucial role in the development and progression of coronary atherosclerosis,which is prone to occur in branch bifurcation.A n individual aortic-coronary artery model and three changed bifurcation angle models are constructed by Mimics and Freeform based on computed tomography angiography.The influence of different coronary bifurcation angles between left main(LM),left anterior descending(LAD),and left circumflex(LCX)on the blood flow field and related hemodynamic parameters are studied.It is shown that a wider bifurcation angle between LAD and LCX can cause a wider low-wall shear stress area,leading to atherosclerosis.Similarly,a decreased angle between LM and LAD is predisposed to prevent atherosclerosis.The results help to better understand the hemodynamic causes of atherosclerosis with various bifurcation angles in coronary arteries and to provide guidance for clinical assessment and prevention.

Carotid Endothelial VCAM-1 Is an Early Marker of Carotid Atherosclerosis and Predicts Coronary Artery Disease in Swine

Objective: The aim was to determine if endothelial VCAM-1 (eVCAM-1) expression in the common carotid artery (CCA) would correlate with predictive markers of atherosclerotic disease, would precede reduction of markers of endothelial cell function and would predict coronary artery disease (CAD). Methods and results: Carotid arterial segments (bifurcation, proximal and distal CCA) were harvested from 14 and 24 month-old male castrated familial hypercholesterolemic (FH) swine, a model of spontaneous atherosclerosis. Quantification of local expression of eVCAM-1, intimal macrophage accumulation, oxidative stress, intima-media (I/M) ratio, intima-media thickness (IMT), endothelial nitric oxide synthase (eNOS) and phosphorylated eNOS (p-eNOS) in selected regions of the carotids revealed a relationship between local inflammation and atherosclerotic plaque progression. Importantly, inflammation was not uniform throughout the CCA. Endothelial VCAM-1 expression was the greatest at the bifurcation and increased with age. Finally, eVCAM-1 best estimated the severity of CAD compared to blood levels of glucose, hypercholesterolemia, carotid IMT, and p-eNOS. Conclusion: Our data suggested that eVCAM-1 was closely associated with atherosclerotic plaque progression and preceded impairment of EDD. Thus, this study supported the use of carotid VCAM-1 targeting agents to estimate the severity of CAD.

Roles of Human Epicardial Adipose Tissue in Coronary Artery Atherosclerosis

This study examined the adipocytokine-vascular interactions and link between epicardial adipose tissue and coronary artery atherosclerosis.Thirty-four patients undergoing open heart surgery were chosen randomly, and divided into groupⅠ(non-coronary artery disease group) and group Ⅱ(coronary artery disease group).Blood samples were taken through peripheral vein prior to surgery.Plasma levels of a panel of proteins (adiponectin, IL-10, TNF-α) were detected by using ELISA.Epicardial adipose tissue was taken near the proximal tract of the right coronary artery and subcutaneous adipose was taken from the leg before cardiopulmonary bypassing, adiponectin and CD68+ were detected by using RT-PCR and immunohistochemistry.Our results showed that plasma adiponectin level was significantly lower in the group Ⅱ as compared with group Ⅰ(P【0.05).There were no differences in plasma concentration (IL-10, TNF-α, tatal-chol, HDL-chol, LDL-chol) between group Ⅰ and group Ⅱ.The number of CD68+ cells in epicardial adipose tissue of group Ⅱ was significantly higher than that in subcutaneous adipose tissue.Adiponectin mRNA expression was 6 fold higher in subcutaneous adipose tissue than in epicardial adipose tissue of group Ⅱ (P【0.01).Furthermore, the level of adiponectin mRNA in the epicardial adipose tissue in group Ⅱ was also significantly lower than in group Ⅰ (P【0.05).We are led to conclude that inflammation that occurs locally in epicardial adipose tissue of CAD contributes to the pathogenesis of coronary artery disease.

Ultrasound screening of multifocal atherosclerosis: markers for coronary heart disease

Background and Objective The frequency of multifocal atherosclerosis (MFA) in patients with coronary heart disease (CHD) has not been thoroughly studied. The purpose of our study was to perform ultrasound screening for MFA in patients with coronary atherosclerosis and make evaluation of the sensitivity and significance of different atherosclerosis markers. Methods Using Color Dupplex Ultrasound (CDU), we studied 32 clinically healthy persons and 87 patients of the city of B with clinical data for CHD where we also performed coronarography. Results In patients with coronary atherosclerosis we found high frequency of carotid atherosclerosis (93%) and peripheral artery disease (PAD) (81%). We established verifiable thickening of the intima-media (IMT) of the common carotid artery (CCA) and common femoral artery (CFA) in patients with CHD. There is a correlation between the frequency of carotid and femoral stenoses and CHD proven by coronarography. Patients with CHD had a high relative risk to develop carotid (RR = 5) and peripheral atherosclerosis (RR=3.5) and high frequency of asymptomatic stenoses and thromboses of the internal carotid artery (86.9%) and femoral artery (78.3%), as well as aneurisms of the abdominal aorta (8.1%). Markers for CAD with high sensitivity were the atherosclerotic plaques of ICA (0.93) and CFA (0.81) as well as IMT of the CFA (0.84). Conclusions MFA are common among patients with CHD. Ultrasound diagnosis is the method of choice for simultaneous non-invasive screening of carotid, peripheral and MFA and provides sensitive markers for coronary atherosclerosis. The most sensitive and specific markers for CHD are the combination of the IMT and atherosclerotic plaques of CCA, ICA and CFA (100% sensitivity and 0.92 specificity).

Cardiac Computed Tomography for the Diagnosis of Coronary Artery Atherosclerosis

Coronary artery disease (CAD) is a leading cause of mortality and morbidity in developed countries, although percutaneous coronary intervention and coronary artery bypass grafting have developed recently. Appropriate diagnosis will improve the prevention, treatment, and care of all patients. We could diagnose only calcification in the coronary arteries with the past computed tomography. Recently, multislice computed tomography has been already accepted as an efficient non-invasive tool for the detection of coronary artery stenosis. We get to estimate the coronary artery stenosis with cardiac computed tomography. We discuss the usefulness of cardiac computed tomography for the risk stratification of coronary artery atherosclerosis.

Inhibitory effect of the paraoxonase gene on the formation of rabbit coronary atherosclerosis

Objective:To observe the effect on the inhibition of coronary atherosclerosis hardening of the paraoxonase gene(PON-1) which transfected to the rabbit epicardial adipose tissue.Methods: Rabbit coronary atherosclerosis model was established by high-fat feeding,liposome-encapsulated recombinant plasmid pEGFP-PON-1 50μL was injected to the rabbit pericardial cavity,and was harvested 4 weeks after transfection.Results:The epicardial fat transfected PON-1 gene had effect on the high lipid level.It significantly increased expression of PON-1 in peripheral arterial vascular tissue(P【0.05);and significantly reduced total cholesterol and low-density lipoprotein cholesterol levels(P【0.05).and the thickness ratio of coronary artery intima/ media(P【0.05).Conclusions:The injection of the PON-1 gene in the pericardial cavity can effectively suppress the formation of coronary atherosclerosis.

Ultrasound features of carotid atherosclerosis in patients with coronary heart disease and their correlation with disease severity

Objective:To study the ultrasound features of carotid atherosclerosis in patients with coronary heart disease and their correlation with disease severity. Methods:180 patients with coronary heart disease treated in our hospital between December 2010 and December 2015 were collected as observation group and divided into single-vessel disease group (n=50), double-vessel disease group (n=72) and triple-vessel disease group (n=58) according to the degree of coronary artery stenosis;50 healthy subjects receiving physical examination in our hospital during the same period were selected as control group. Carotid ultrasound was used to measure carotid atherosclerosis parameters, cardiac color Doppler ultrasound was used to detect cardiac function parameters, enzyme-linked immunosorbent assay (ELISA) was used to detect serum endothelial function indexes, and Pearson test was used to analyze the correlation between carotid ultrasound parameters and the cardiac function as well as endothelial function. Results:Carotid ultrasound parameters stiffness (β), elastic modulus (Ep), arterial compliance (AC) and pulse wave velocity (PWVβ) value of observation group were higher than those of control group, and with the increase of coronary artery lesion severity, the changes ofβ, Ep, AC and PWVβvalue increased (P<0.05);cardiac function parameters left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD) value of observation group were higher than those of control group while left ventricular ejection fraction (LVEF) value was lower than that of control group, and with the increase of coronary artery lesion severity, the changes of LVEDD, LVESD and LVEF value increased (P<0.05);endothelial function indexes endothelin-1 (ET-1) and von willebrand factor (vWF) levels of observation group were higher than those of control group while nitric oxide (NO) level was lower than that of control group, and with the increase of coronary artery lesion severity, the changes of ET-1, vWF and NO levels increased (P<0.05). Carotid ultrasound parameterβ, Ep, AC and PWVβvalue in patients with coronary heart disease were directly correlated with the levels of cardiac function parameters and endothelial function indexes. Conclusions:The ultrasound parameter levels of carotid atherosclerosis in patients with coronary heart disease are directly correlated with the disease severity and can be used as the noninvasive and reliable means for early judgment of the disease.

Coronary atherosclerosis burden is not advanced in patients with β-thalassemia despite premature extracardiac atherosclerosis： a coronary artery calcium score and carotid intima-media thickness study

Background Thalassemic patients demonstrate an increased rate of extracardiae vascular complications and increased carotid wall intima-media thickness （cIMT）, but very low prevalence of coronary artery disease （CAD）. We investigated the atheroma burden by assessing the coronary artery calcium （CAC） and elMT in these patients. Methods We examined 37 patients with β-thalassemia and 150 healthy control volunteers with multi-detector computer tomography （CT） and ultrasonography to determine CAC score and cIMT, respectively. Results Propensity score matching （C-statistic： 0.88; 95% CI： 0.83-0.93） resulted in 27 pairs of patients; severe CAC was observed in 2 （7.4%） and 0 of β-thalassemia patients and healthy volunteers respectively （P = 0.5）. Median calcium score was 0 （0-0） in β-thalassemia patients and 0 （0-4） in healthy volunteers （P = 0.8）. Median intima-media thickness was higher in β-thalassemia patients compared to control group [0.45 （0.06-0.65） vs. 0.062 （0.054-0.086）; P = 0.04]. Conclusions Patients with β-thalassemia in comparison with healthy control subjects exhibit similar CAC score and increased cIMT. Our findings indicate a disparate rate of progression of atherosclerosis between coronary and extracardiac arteries in these patients lending support to the epidemiological evidence.

Correlation between Serum Level of Adiponectin and Severity of Coronary Artery Atherosclerosis

Objectives To investigate the correlation between serum level of adiponectin and severity of coronary artery atherosclerosis. Methods Coronary angiographies were performed and serum levels of adiponectin were measured in 88 patients with suspected coronary heart disease （CHD）. Patients were divided into groups according to the coronary angiographies and Gensini＇s scores of coronary artery atherosclerosis. The serum levels of adiponectin were compared in different groups, and multiple regressions were used to analyze the correlation factors of adiponectin. Results （1）Serum adiponectin concentration in CHD group [ 7. 1 mg/L （2.4 - 21.1 mg/L） ] was decreased as compared with that in control group [ 11.6 mg/L （4.4 - 28.2 mg/L ）, P 〈 0. 01 ] ; （2）The serum levels of adiponectin fell while the Gensini＇ s scores of coronary artery atherosclerosis increased （P 〈 0. 05, P 〈 0. 01 ） ; （3）Serum level of adiponectin was positively correlated with the high-density lipoprotein cholesterol, while negatively correlated with the Gensini＇ s score of coronary artery atherosclerosis and triglyceride （P 〈 0. 01 ）. Conclusions Serum adiponectin concentration was decreased in patients with CHD. Low serum levels of adiponectin reflected the severity of coronary artery atherosclerosis. Adiponectin was a protective factor of cardiovascular system.

Exploring the Treatment of Coronary Artery Atherosclerosis from the Direction of Inflammatory Vesicles with Wind-Extinguishing and Phlegm-Resolving Medicine

Atherosclerosis is a fundamental pathological change in coronary heart disease,with vulnerable plaque formation leading to decreased plaque stability and plaque rupture,and is a major cause of acute cardiovascular events.The inflammatory response is an important mechanism in the development and progression of atherosclerosis,and plaque stability is closely related to the inflammatory response.In recent years,the role of NLRP3 inflammatory vesicles,which are involved in macrophage foaminess,in the inflammatory response to atherosclerosis has received increasing attention.Chinese medicine is able to modulate inflammatory vesicles to improve atherosclerotic plaque stability,showing good promise in the prevention and treatment of atherosclerotic vulnerable plaques.Based on the role of inflammatory vesicles in atherosclerosis and the results of previous studies that wind-extinguishing and phlegm-resolving medicine can effectively modulate the inflammatory response to intervene in the treatment of atherosclerosis,this paper aims to investigate the treatment of coronary atherosclerosis by wind-extinguishing and phlegm-resolving medicine from the direction of inflammatory vesicles.

Testosterone is negatively associated with the severity of coronary atherosclerosis in men

This study aimed to determine whether plasma testosterone is associated with the severity of coronary atherosclerosis in a group of 803 men who underwent elective coronary angiography. Testosterone levels were measured in 803 male patients who were categorized into three groups according to testosterone level tertiles. All patients underwent elective coronary angiography, and the severity of coronary artery disease （CAD） was determined by the Gensini score. Moreover, patients were classified into two groups according to Gensini scores （score ≤ 26 and score 〉26） using the median values as cutoff points. The plasma testosterone levels were measured by an ELISA kit. The level of testosterone was negatively associated with the Gensini score （r=-0. 188; P=0.000）. A multiple linear regression analysis revealed that testosterone was an independent risk factor for the Gensini score （β=-0,110; P=0.002） after adjusting for confounding covariates. In a multivariate logistic regression model, the severity of CAD was shown to be significantly lower in the third tertile （highest） of testosterone compared to the first tertile （lowest） of testosterone （odds ratio （0R）=0.465; 95% confidence interval （C1）. 0.327-0.662; P=0.000）. In this study, patients with lower testosterone levels had higher Gensini scores in a group of 803 men who underwent elective coronary angiography. Additional studies are needed to clarify the direction of causality and possible underlying mechanisms.

Hepatitis B virus infection and coronary atherosclerosis: Results from a population with relatively high prevalence of hepatitis B virus

AIM: To investigate the possible association between hepatitis B virus (HBV) infection and angiographically proven coronary artery disease (CAD) in a population with relatively high prevalence of HBV.METHODS: Sera from 434 patients who underwent coronary angiography were tested for HBV antigens (HBsAg, HBeAg) and antibodies (Anti-HBs, Anti-HBc and Anti-HBe) by ELISA.RESULTS: Seventy-seven percent (224/291) of the patients with CAD and 73.4% (105/143) of the patients without angiographic evidence of atherosclerosis were seropositive for HBV (P＞0.05). However, C-reactive protein (CRP) levels were significantly higher in patients with CAD (P = 0.008), while lower in HBV seropositive population (P= 0.043 and P = 0.021 after adjustment for conventional risk factors).CONCLUSION: Our results suggested HBV infection negatively correlates with CRP levels, but seems not to be associated with coronary atherosclerosis.

HDL signaling and protection against coronary artery atherosclerosis in mice

Atherosclerosis is a leading underlying factor in cardiovascular disease and stroke,important causes of morbidity and mortality across the globe.Abundant epidemiological studies demonstrate that high levels of high density lipoprotein（HDL） are associated with reduced risk of atherosclerosis and preclinical,animal model studies demonstrate that this association is causative.Understanding the molecular mechanisms underlying the protective effects of HDL will allow more strategic approaches to development of HDL based therapeutics.Recent evidence suggests that an important aspect of the ability of HDL to protect against atherosclerosis is its ability to trigger signaling responses in a variety of target cells including endothelial cells and macrophages in the vessel wall.These signaling responses require the HDL receptor,scavenger receptor class B type 1（SR-B1）,an adaptor protein（PDZK1） that binds to the cytosolic C terminus of SR-B1,Akt1 activation and（at least in endothelial cells） activation of endothelial NO synthase（eNOS）.Mouse models of atherosclerosis,exemplified by apolipoprotein E or low density lipoprotein receptor gene inactivated mice（apoE or LDLR KO） develop atherosclerosis in their aortas but appear generally resistant to coronary artery atherosclerosis.On the other hand,inactivation of each of the components of HDL signaling（above）in either apoE or LDLR KO mice renders them susceptible to extensive coronary artery atherosclerosis suggesting that HDL signaling may play an important role in protection against coronary artery disease.

Effects of different statins application methods on plaques in patients with coronary atherosclerosis

BACKGROUND Discontinued application of statins may be related to adverse cardiovascular events.However,it is unclear whether different statins administration methods have effects on coronary artery plaques.AIM To evaluate the effects of different statins application methods on plaques in patients with coronary atherosclerosis.METHODS A total of 100 patients diagnosed with atherosclerotic plaque by coronary artery computed tomography were continuously selected and divided into three groups according to different statins administration methods(discontinued application group,n=32;intermittent application group,n=39;sustained application group,n=29).The effects of the different statins application methods on coronary atherosclerotic plaque were assessed.RESULTS The volume change and rate of change of the most severe plaques were significantly reduced in the sustained application group(P≤0.001).The volume change of the most severe plaques correlated positively with low-density lipoprotein(LDL-C)levels only in the sustained application group(R=0.362,P=0.013).There were no changes in plaques or LDL-C levels in the intermittent and discontinued application groups.CONCLUSION Continuous application of statins is effective for controlling plaque progression,whereas discontinued or intermittent administration of statins is not conducive to controlling plaques.Only with continuous statins administration can a reduction in LDL-C levels result in plaque volume shrinkage.

Increased plasma levels of Lp(a) enhance the development of coronary atherosclerosis

Objective To test the hypothesis that increased plasma levels of Lp(a)may enhance the development of atherosclerosis in the setting of hypercholesterolemia.Methods The plasma Lp(a)was analyzed by SDS-PAGE Western blotting and quantitated using specific ELISA kits.Plasma total cholesterol,triglycerides and HDL-cholesterol were determined using Wako assay kits.The left coronary artery was used for the evaluation of coronary atherosclerosis(stenosis %).For quantitative study of the lesions in coronary atherosclerosis,hematoxylin-eosin and Elastica-van Gieson staining were used.To study cellular components(SMC vs.macrophages)and Lp(a)deposits in the lesions,immunohistochemical staining was performed and then image analysis system was used.Results Plasma total cholesterol,triglycerides,or HDL-C were not significantly different between transgenic(Trg)and nontransgenic(nonTrg)rabbits.Trg rabbits had 200% increase in coronary stenosis caused by atherosclerosis.The lesions of Trg WHHL rabbits contained more SMCs and less macrophage than those of nonTrg WHHL rabbits.Conclusions The results suggest that increased plasma levels of Lp(a)enhance the development of coronary atherosclerosis.

Rapid progression of atherosclerosis in a patient with acute coronary syndrome and ANCA-associated vasculitis:split or confluence?

A59-year-old female patient was admitted to our hospital on 9 March 2021,due to recurrent chest pain.She underwent percutaneous coronary intervention,with a focus on the proximal segment of the left anterior descending(LAD)artery,six months prior to admission.The patient had a long-term history of hyperlipidaemia and obstructive sleep apnoea syndrome(OSAS).She also had rheumatoid arthritis and ANCA-associated vasculitis that lasted for more than 10 years and a 9-year history of concomitant hypertension.She was on long-term oral leflunomide and intermittent oral prednisone.The patient underwent a computed tomography angiogram(CTA)six years ago(2015),which showed minor atherosclerotic plaque build-up in the LAD artery and the right coronary artery(RCA)(Figure 1).

Preventing Heart Disease via Coronary Artery Calcium Scoring to Make a Definitive Diagnosis of Atherosclerosis

Purpose: Cardiovascular disease is the number one cause of death in the Western world. The purpose of this manuscript is to compare the benefits and deficiencies of coronary artery calcium scanning versus computer generated risk equations in identifying atherosclerotic cardiovascular disease. These two approaches provide significantly different cardiovascular risk assessments and often lead to therapeutic differences in recommendations from the physician to the patient. Methods: Pertinent medical literature is reviewed concerning both risk assessment approaches (i.e., coronary artery scanning and computer generated risk equations). The strengths and weaknesses of both approaches are discussed, and recommendations are provided based upon available data. Results: Cardiovascular risk equations are simple and readily obtained at no charge by physicians. However, their drawbacks are several, including non-applicability to specific populations, disagreements among different cardiovascular society risk equations, wide ranges of risk outputs (e.g., intermediate 10-year risk is between 5% and 20%), inability to definitively identify coronary artery plaques, and lack of definitive anatomical coronary disease. Alternatively, coronary artery calcium scanning costs approximately $100/scan (if not covered by insurance), requires time and effort by the patient, and exposes the patient to a minimal amount of radiation. However, coronary calcium scanning identifies specific atherosclerotic coronary disease and provides additional information about the anatomical location (i.e., coronary artery) of the atherosclerotic plaque. Conclusion: Based on the published literature, coronary artery calcium scanning is the preferred approach for identifying atherosclerotic cardiovascular disease. Although there are minor drawbacks, overall it provides superior clinical information compared with computer generated risk equations.

Correlation between serum Hcy content and coronary atherosclerosis severity in patients with H-type hypertension and coronary heart disease

Objective:To analyze the correlation between serum Hcy content and coronary atherosclerosis severity in patients with H-type hypertension and coronary heart disease. Methods: 48 patients with H-type hypertension and coronary heart disease were selected as observation group, and 57 patients with normal hypertension and coronary heart disease were selected as control group. Echocardiography was used to determine coronary lesion parameters, enzyme-linked immunosorbent assay (ELISA) was used to determine serum levels of homocysteine (Hcy) and coronary heart disease-related indexes, and the correlation between Hcy levels and coronary heart disease was further analyzed. Results:Serum Hcy level of observation group was higher than that of control group (P<0.05), absolute GLPSS value and E/A value under echocardiography were less than those of control group while E-DT and E/e value were higher than those of control group (P<0.05);serum adiponectin (APN) level was lower than that of control group while P-selectin, asymmetric dimethylarginine (ADMA), oxidized high-density lipoprotein (OX-HDL), MMP-2, MMP-9, lipoprotein-associated phospholipase A2 (Lp-PLA2) and Resistin levels were higher than those of control group (P<0.05);Hcy was negatively correlated with absolute GLPSS value, E/A value and APN level, and was positively correlated with E-DT value, E/e value as well as P-selectin, ADMA, OX-HDL, MMP-2, MMP-9, Lp-PLA2 and Resistin levels (P<0.05). Conclusions:There is direct correlation between serum Hcy levels and the severity of coronary heart disease in patients with H-type hypertension and coronary heart disease, it can be a reliable way to early screen for coronary heart disease and evaluate the illness, and it is also a new target of coronary heart disease intervention.

Challenging situation of coronary artery anomaly associated with ischemia and/or risk of sudden death

Coronary artery anomaly is known as one of the causes of angina pectoris and sudden death and is an important clinical entity that cannot be overlooked.The incidence of coronary artery anomalies is as low as 1%-2%of the general population,even when the various types are combined.Coronary anomalies are practically challenging when the left and right coronary ostium are not found around their normal positions during coronary angiography with a catheter.If there is atherosclerotic stenosis of the coronary artery with an anomaly and percutaneous coronary intervention(PCI)is required,the suitability of the guiding catheter at the entrance and the adequate back up force of the guiding catheter are issues.The level of PCI risk itself should also be considered on a caseby-case basis.In this case,emission computed tomography in the R-1 subtype single coronary artery proved that ischemia occurred in an area where the coronary artery was not visible to the naked eye.Meticulous follow-up would be crucial,because sudden death may occur in single coronary arteries.To prevent atherosclerosis with full efforts is also important,as the authors indicated admirably.