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*Corresponding Author: Carlos José Oliveira de Matos, Department of Postgraduate Studies in Health Sciences, Department of Physiotherapy Federal University of Sergipe.
Citation: Carlos José Oliveira de Matos, Enaldo Vieira de Melo, Anthony Medeiros Calado de Lima, Lorena Almeida Sant’Ana, Paulo Victor Silva,. et all (2022). The Assessment of Severity in Patients with Coronary Artery Disease Through Coronary Angiotomography and Physical-Functional Assessment. J. Clinical Cardiology and Cardiovascular Interventions, 5(7); DOI:10.31579/2641-0419/272
Copyright: © 2022 Carlos José Oliveira de Matos, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 11 July 2022 | Accepted: 29 July 2022 | Published: 08 August 2022
Keywords: coronary artery disease; exercise test; computed tomography angiography; coronary stenosis; functional assessment
Background: The assessment of the coronary artery calcium score and the degree of coronary stenosis with the aim of tracking a higher risk for coronary events, when associated with an assessment of functional health, may indicate possible physical disabilities that will impact their quality of life.
Design: Cross-sectional study.
Methods: 208 patients underwent coronary artery calcium score quantification and were divided into absent (0), low (1-100), intermediate (101-400) and high / very high (> 400), as well as the degree of coronary artery stenosis through percentage. Functional assessment was performed through the measure of functional independence, modified Katz index and Barthel index, and for physical capacity and the 6-minute walk test, with statistical analysis through analysis of variance.
Results: The middle ages were 57±11,2 years and 61,5% were females. The most frequent risk factors were high blood pressure (78,4%) and family history to CAD (72,1%). The most common level was intermediate, 23,8%. The functionality showed a deficit of 19%; the distance travelled was 67,9% of the predicted distance, with differences observed between coronary arterial calcium score groups (p=0,03). The functionality was associated with the sedentary lifestyle (p=0,007) and dyspnea (p=0,008), while the physical capacity was associated with the dyspnea (p=0,03).
Conclusions: Patients with coronary artery disease with a higher calcium score (>400) had reduced physical capacity. Functionality showed that there was an association with a sedentary lifestyle and dyspnea.
Cardiovascular disease is the leading cause of global mortality. Studies show that approximately 17.5 million deaths are caused by cardiovascular disease worldwide, of which approximately 7.5 million are due to atherosclerosis, and in Brazil it accounts for 30.4% of the total number of deaths [1,2,3].
Diagnosing coronary artery disease (CAD) is important not only with respect to disease state but also to assess its impact on the functional activities of daily life (ADL). Measurement of quality of treatment includes how well the function is restored in terms of mobility in relation to daily activities, exercise, and quality of life as well as preventing functional incapacity [4].
Therefore, health must be measured not only by the presence or absence of disease but also by the degree to which it affects functional capacity and the capacity to carry out ADL. Therapy can be considered to be successful when the autonomy of an individual is maintained and he/she can continue his/her normal social interactions [5,6]. Heart disease represents a biophysical imbalance because it is also associated with a social/mental impact [7,8].
In addition to evaluating coronary arterial calcium score (CACS) and the stenosis arterial, and the analyzing functional independence in cardiac patients should be considered as an indicator of the success of treatment and the prognosis of morbidity and mortality [6].
Coronary computed tomography angiography (CCTA) is a method for evaluating symptomatic patients and its function is to identify whether or not there are significant obstructive lesions that justify the symptoms. These two techniques are routinely used in clinical cardiological evaluations and are employed to detect and quantify coronary calcification and assess the presence of stenosis [7,8].
This study aimed to evaluate the association between CACS and coronary stenosis with functionality and the physical capacity of patients with suspected CAD. This would allow patients with CAD to set appropriate limits for physical effort to try to maintain activities of daily living at an optimum level.
This was a cross-sectional study on consecutive patients with CAD of both genders under clinical investigation. Participants comprised patients referred by their cardiologists for CCTA. During the initial evaluation of the patient, the likelihood of CAD was assessed according to the score calculated using the Diamond–Forrester algorithm [12]. Data were collected in a public hospital and other private service providing CCTA (Toshiba Aquilion and GE Healthcare VCT), in Aracaju, Brasil. The study was approved by the research ethics committee of the Federal University of Sergipe under protocol 0289.0.107.000-11. Following CCTA, patients were divided into four groups according to their CACS: absent, 0; low, 1–100; intermediate, 101–400; and high/very high, >400.
Inclusion criteria [3,7] for the study were as follows: patients of both sexes with suspected CAD, agreement to participate in the study, and the capacity to understand and sign the informed consent and answer the questions in the instruments. The exclusion criteria [3,7] were as follows: clinically unstable patients; refusal to participate in the study; patients with cerebrovascular diseases associated with motor sequelae; a known allergy to iodinated contrast medium; nephropathy; a history of multiple myeloma or organ transplant; a high serum creatinine level (>1.5 mg/dL); clearance of calculated creatinine < 60>
208 patients, users of the cardiology service, were randomly those who completed the CACS and the assessment of functionality. Of these, 164 patients underwent only the assessment of the coronary arterial calcium score.
Functionality was assessed using the Functional Independence Measure (FIM), and activity levels of daily living (ADL) were assessed using the Barthel scale and the modified Katz index. In addition to these instruments, the 6-minute walk test (6MWT) was used as a marker for physical capacity [4,5,12].
Categorical variables studied were divided into general characteristics [3,5,6]: age, gender, weight, body mass index (BMI); life habits: smoking, alcohol use and physical activity; risk factors: high blood pressure, diabetes mellitus, dyslipidemia, obesity, and family history of CAD; and symptoms: typical and atypical precordialgia, dyspnea, and CAD. The outcome variables were as follows: FIM, Barthel index, modified Katz index, distance traveled in meters in 6MWT, percentage of predicted distance achieved, CACS (absolute values), coronary stenosis (%), and the number of arteries affected.
The FIM scale is broad in scope and its validity is accepted in the international literature. It is easy to implement and understand, and assesses motor and cognitive components in various clinical conditions. Furthermore, it is considered a measure that meets the criteria of reliability, validity and precision [9].
The Barthel index also measures functional independence in relation to personal care, mobility, locomotion, and bowel and bladder function. The version used in this study evaluated functional independence in 10 tasks: feeding, bathing, dressing, grooming, bowel elimination, bladder eliminations, toilet, chair/bed transfers, walking, and stairs. Patients who required assistance from another person in any of the tasks were considered to be “dependent” [10].
The modified Katz index was used because it evaluates independence in terms of ADL when accomplishing activities without supervision or any kind of direct guidance. The index indicates the ability of the patient to have an independent life. This instrument assesses functionality in six areas (bathing, dressing, going to the bathroom, bed/chair transfer, continence, and feeding) [11].
Physical capacity was assessed by the ability to walk and was assessed by the distance covered in meters during the 6MWT, being performed according to the recommendations of the American Thoracic Society [12]. The predicted distance was calculated according to individual characteristics and anthropometric parameters for the Brazilian population [13].
Coronary arterial calcium score (CACS) was calculated using Coronary Tomography Angiography (CCTA). Coronary artery calcification was defined as regions of the arteries with density >130 Hounsfield units (HU), as described by Agatston [14]. The sum of the calcium present in each coronary artery and its derivatives gives the total value and CACS and quantified in Agatston units (AU), as follows: absence (0 AU), low (1–100 AU), intermediate (101–400 AU), high (401–1000) or very high (> 1000 AU). For coronary stenosis, they were considered obstructive when >50% of the light was obstructed, being classified as low when the reduction was <50>
The Shapiro-Wilk test was used to assess the normality assumption, with a result for the normality of the sample. The chi-square test for hypotheses about categorical variables. Categorical variables are presented as: CACS groups, sex, alcohol, smoking, physical activity, hypertension, obesity, diabetes, hypertension, dyslipidemia, family history, asymptomatic, dyspnea, typical and atypical precordialgia, and history of CAD. While the variables are continuous in the study, the functional variables of FIM, KATZ and Barthel, and the distance covered and predicted.
For comparison between the CACS groups, One-way ANOVA was used if there was a statistically significant difference between the groups compared, followed by Tukey's test. To analyze the mean, Student's t-test, unpaired test, or Mann-Whitney test was used to compare means of the distance walked and the predicted distance between calcium score groups. The level of significance adopted was p≤0.05 (95%) and the analyzes were performed using the SPSS program, version 21.0.
While to analyze the variables in relation to the distance covered, a general linear model was used for the dependent function variables and the fixed factors of sedentary lifestyle, dyspnea, CACS categories and degree of stenosis. Analysis of associations between functional dependence and factors such as age, gender, sedentary lifestyle, dyspnea, diabetes mellitus, hypertension, degree of CACS (absent, low, intermediate and high / very high) and degree of stenosis (absent, < 50> 50%) were performed using “backward” logistic regression.
The sample consisted of 208 patients with an average age of 57±11,2 years, with a higher frequency of females (61,5%). With respect to lifestyle, only 39,5% reported including regular physical activity, whereas alcohol use and smoking presented similar frequencies (Table 1).
VARIABLES | TOTAL (n=208) (%) |
| |
| Age (years) ¹ | 57 ± 11,2 |
| Female gender | 128 (61,5) |
| Weight (kg) ¹ | 72,9 ± 16 |
Body mass index1 Alcohol use Smoking Physical activity High blood pressure Obesity | 28 ± 5,6 67 (32,7) 54 (26,3) 77 (39,5) 160 (78,4) 74 (36,5) |
| Diabetes mellitus | 61 (29,9) |
Dyslipidemia Family history | 119 (58) 137 (72,1) |
| Asymptomatic | 47 (23) |
| Dyspnea | 70 (34,5) |
| Precordialgia typical | 80 (39) |
Precordialgia atypical CAD history2 | 74 (26,1) 20 (9,9) |
1Values expressed as mean ± standard deviation. Other values expressed in absolute value (n) and relative frequency (%) CAD = coronary artery disease. Some patients have more than one of the symptoms (dyspnea, atypical pain and pain). 2 Previous acute myocardial infarction was considered as prior history of disease.
Table 1: General and clinical characteristics of patients with CAD.
The proportion of patients with CACS of >0 was 49,5% [95% confidence interval (95% CI) 42,7–56,3], 23,8% patients had CACS of 1–100, 16,5% patients had CACS of 101–400, and 9,2% patients had CACS of >400 (Table 2).
| CORONARY ARTERY CALCIUM SCORE (CACS) | TOTAL (N=206) | RELATIVE FREQUENCY (%)1 | CI 95%2 | RR3 | |
| HIGH/VERY HIGH (CACS > 400) | 19 | 9.2 | 5.8-13.6 | 7,2 | |
| INTERMEDIATE (CACS 101-400) | 34 | 16.5 | 11.7-22.3 | 4,3 | |
| LOW (CACS 1-100) | 49 | 23.8 | 18.0-30.1 | 1,9 | |
| ABSENT (CACS = 0) | 104 | 50.5 | 43.7-57.3 |
| |
1Values expressed in n and percentage (%) of patients. 2CI 95%: confidence interval estimated by Bootstrap technique. 3 Relative Risk (RR) according to the II MRI Directive and computed tomography Brazilian society of Cardiology cardiovascular and Brazilian College of Radiology,2014.
Table 2: CACS distribution score in patients.
Of the 208 patients, CCTA was performed on 164 patients. The degree of stenosis and number of affected arteries were as follows: 44% showed an absence of stenosis, and 33% had coronary stenosis obstructive (>50%). Furthermore, 44% patients had no affected arteries, 18% had single-artery involvement, 26% had involvement in two arteries, and 11% had involvement of ≥3 arteries (Table 3).
Degree of Stenosis | Total (N=164) | Relative Frequency (%) |
CI 95% | Number of Arteries Affected | Total (N=164) | Relative Frequency (%) |
CI 95% | ||
0 | 73 | 44 | 69.8-77.4 | 0 | 73 | 44 | 69.8-77.4 | ||
1-49 % | 36 | 22 | 61.4-73.6 | 1 | 30 | 18 | 65.5-77 | ||
> 50% | 55 | 33 | 58.3-69.3 | 2 | 43 | 26 | 57-70 | ||
|
|
|
| 3+ | 18 | 11 | 49.7-69.4 | ||
Table 3: Angiotomographic data in patients.
Assessment of functionality according to distance walked showed that only 67,9% of the patients reached the expected distance in the 6MWT, (average of 368,2 meters of an expected average of 534,9 meters). FIM showed mean values of Katz and Barthel indicating functional independence.
With respect to age and categories of CACS according to the degree of calcification, a significant association (p=0,0499) was observed. Patients in the CACS>400 group were significantly older (mean=6,5 years, 95% CI 55,6–58,7) than those in the other CACS groups (Table 4).
CLINICAL CHARACTERISTICS | CACS=0 (N=104) | CACS=1-100 (N=49) | CACS=101-400 (N=34) | CACS>400 (N=19) | p |
| Age¹ | 53.4 ± 11.6 | 59.9 ± 8.3 | 59.8 ± 9.3 | 65.9 ± 11.0 | 0.05 |
| Female | 67 (64.4) | 30 (61.2) | 22 (64.7) | 7 (36.8) | 0.146 |
| Male | 37 (35.6) | 19 (38.8) | 12 (35.3) | 12 (63.2) |
|
| BMI¹ | 27.9 ± 5.6 | 29.5 ± 5.9 | 27.3 ± 5.9 | 26.8 ± 4.2 | 0.638 |
| Smoking | 21 (20.6) | 11 (22.9) | 14 (41.2) | 8 (42.1) | 0.041 |
| Alcohol use | 36 (35.3) | 17 (35.4) | 10 (29.4) | 4 (21.1) | 0.616 |
| Physical Activity | 39 (40.2) | 18 (39.1) | 13 (38.2) | 7 (38.9) | 0.534 |
| Obesity | 33 (32.4) | 24 (51.1) | 11 (33.3) | 6 (31.6) | 0.147 |
| High blood pressure | 78 (74.3) | 40 (79.6) | 28 (87.5) | 17 (94.1) | 0.160 |
| Diabetes mellitus | 19 (18.6) | 16 (33.3) | 17 (50) | 8 (42.1) | 0.002 |
| Dyslipidemia | 47 (46.1) | 34 (70.8) | 23 (67.6) | 13 (68.4) | 0.01 |
| Family history | 66 (70.2) | 35 (76.1) | 25 (78.1) | 11 (61.1) | 0.534 |
| Asymptomatic ² | 27 (26.7) | 11 (22.9) | 3 (8.8) | 6 (31.6) | 0.145 |
| Dyspnea | 33 (32.4) | 16 (34) | 11 (32.4) | 10 (55.6) | 0.285 |
| Precordialgia typical | 37 (36.3) | 16 (33.3) | 19 (55.9) | 7 (36.8) | 0.166 |
| Precordialgia atypical | 35 (34.3) | 20 (41.7) | 13 (38.2) | 5 (26.3) | 0.650 |
| CAD history³ | 5 (4.9) | 7 (14.6) | 7 (20.6) | 1 (5.6) | 0.032 |
CACS = 0 (absent), CACS low (1-100), CACS intermediate (101-400) and CACS high/very high (> 400). ¹ values expressed in the form of mean ± standard deviation. Other values expressed in absolute value (n) and relative frequency (%). ² Some patients have more than one of the symptoms (dyspnea, atypical pain and soreness). ³Prior history of acute disease
Table 4: Characterization of coronary artery calcium score (CACS) according to the general characteristics, lifestyle, risk factors and symptoms.
Among the risk factors, dyslipidemia showed a higher (70,8%) frequency in the CACS 1–100 group (p=0,01), followed by the CACS 101–400 (68,4%) and CACS>400 (67,6%) groups. The frequency of related symptoms (dyspnea and typical and atypical precordialgia) was not different between the groups. There was no difference in CAD history between the groups (p=0,03), where CACS 1–100 and CACS 101–400 groups showed greater frequencies relative to other groups (Table 4).
The association between the variables of functionality and degree of calcification showed a significant decrease in the distance walked according to severity of CACS (p=0.03); the post test showed differences between CACS 101–400 and CACS=0 groups (p=0.05). For total FIM, the CACS>400 group presented the lowest average compared with the other groups, with 101.8±13.2 points (maximum=52 points and minimum=119 points) with no significant difference (p=0.397), but indicating a modified functional dependency requiring assistance for 25% of the task.
The Katz index showed lower values in the CACS>400 group, with a minimum of 0 points and a maximum of 6 points, with no significant difference (p=0,224). The Barthel index showed a lower average value in the group with greater severity, i.e., the CACS>400 group, with a minimum value of 25 points and a maximum of 100 points, with no significant difference (p=0,299) (Table 5).
FUNCTIONAL VARIABLES | CACS=0 (N=104)1 | CACS=1-100 (N=49)1 | CACS=101-400 (N=34)1 | CACS>400 (N=19)1 | P2 |
| Distance travelled | 392.4 ± 112.6 | 369.2 ± 105.9 | 319.6 ± 100.7 | 326.3 ± 106.9 | 0.03 |
| Predicted distance (%) | 71.6±18.3 | 69.6±18 | 59.3±16.9 | 59.8±18.2 | 0.02 |
| Self-care | 32.2±4.9 | 32.8±4.6 | 32.3±3.4 | 30.5±5.6 | 0.339 |
| Sphincter control | 13.2±1.8 | 13.4±1.4 | 13.7±0.8 | 13.0±1.9 | 0.315 |
| Transfers | 18.7±3.1 | 19.0±2.9 | 18.3±2.7 | 18.2±3.3 | 0.685 |
| Locomotion | 10.3±2.9 | 10.4±2.5 | 9.8±2.2 | 9.0±2.3 | 0.168 |
| Communication | 12.8±2.2 | 12.9±1.8 | 13.0±1.5 | 12.36±2.0 | 0.635 |
| Cognition | 19.2±2.9 | 19.3±2.5 | 19.2±2.4 | 18.7±3.1 | 0.854 |
| FIM motor | 74.5±11.3 | 75.8±10.1 | 74.2±6.9 | 70.8±11.2 | 0.368 |
| FIM cognitive | 32.1±4.6 | 32.3±4.1 | 32.2±3.0 | 31.0±4.5 | 0.724 |
| FIM total | 106.6±14.8 | 108.2±13.4 | 106.5±8.7 | 101.8±13.2 | 0.397 |
| Katz | 4.8±1.5 | 5.0±1.4 | 4.5±1.1 | 4.3±1.2 | 0.224 |
| Barthel | 83.3 ± 15.0 | 85.3 ± 12.1 | 82.6 ± 9.3 | 78.4 ± 13.0 | 0.299 |
CACS = 0 (absent), CACS low (1-100), CACS intermediate (101-400) and CACS high/very high (> 400). FIM: functional independence measurement. 1values expressed in the form of mean ± standard deviation.2 Statistical significance value (p < 0>
There was a positive correlation between CACS and age (r=0.33, p<0 xss=removed p=0.04) xss=removed p=0.017), xss=removed p=0.002), xss=removed p=0.049), xss=removed p=0.01).>
Table 5: Association of variables of functionality according to coronary artery calcium score (CACS)
Univariate analysis showed that the variables associated with functional capacity included age, gender, physical inactivity, dyspnea, and diabetes mellitus, that is, the older the individual was, the greater the chance of functional dependence. Female gender was associated with a greater chance of functional dependence.
Among these factors, sedentariness, dyspnea, diabetes mellitus, and high blood pressure had higher odds ratios, suggesting a greater association with functional dependency.
The CACS groups were not statistically significant, so the CACS>400 group was equal to the other groups (Table 6).
VARIABLES | OR1 | CI 95%2 | p3 |
Age | 1.015 | 0.987 – 1.043 | 0.31 |
Female | 1.407 | 0.743 – 2.662 | 0.29 |
Male | 3.000 | 1.459 – 6.169 | 0.003 |
Dyspnea | 2.500 | 1.326 – 4.715 | 0.005 |
Diabetes mellitus Dyslipidemia | 2.018 1.05 | 1.056 – 3.856 0.563 – 1.961 | 0.003 0.88 |
High blood pressure | 2.143 | 0.890 – 5.162 | 0.089 |
CACS>400 | 2.443 | 0.899 – 5.162 | 0.80 |
CACS 101-400 | 1.298 | 0.561 – 3.000 | 0.542 |
CACS 1-100 | 0.696 | 0.307 – 1.578 | 0,386 |
Logistic regression for method "Backward Wald" as the dependent variable, the functional dependency and independent variables shown in the table. FIM: functional independence measure, CACS: coronary artery calcium score.
OR1: odds ratio, 95% 2 CI 95%: confidence interval, 3Value of significance (p<0>
Table 6: Factors associated with functional dependency (FIM)
The final fitted model showed a significant association of functional dependency with sedentary lifestyle (p=0.007) and dyspnea (p=0.008). Regression between angiotomographic data (coronary stenosis and number of arteries) with the distance predicted showed no significant difference.
Patients in the CACS 101–400 group showed a reduction in the average distance walked of 91.0 ± 26.6 m (95% CI 19.9–162.0 and p=0.05). In addition, patients in the CACS > 400 group also presented a reduction in distance traveled of 83.6±31.8 m. It should be noted that patients with dyspnea showed a reduction in distance traveled of 41.7±21.7 m (p=0.044).
The high prevalence of risk factors for CAD provides evidence of probable interference with functional health. In this study, individuals with higher CACS and higher percentage of stenosis had a higher risk of cardiovascular disease, with a double increase in the probability of functional impairment, in terms of distance walked for the CACS group > 400 and degree of stenosis group > 50%. It is important to evaluate the functionality of these patients to identify the limitations caused by the symptoms of CAD to try to improve functional aspects. The presence of coronary calcification is an important predictor of risk for cardiovascular events. Using CACS, a noninvasive methodology, to assess this enables better cardiovascular risk stratification [15,16,22].
CACS demonstrated a significant association with cardiovascular events during follow-up in the medium and long-term. Our study highlights that CACS measurement is important when associated with risk factors for cardiovascular disease, such as dyslipidemia and diabetes mellitus [17,18].
Previous studies have shown that anthropometric factors such as BMI can contribute to increased functionality in patients with heart disease, particularly heart failure (HF), although we found no differences in HF between the groups analyzed [19,21].
This study showed that the evaluated patients had 28% of functional dependence classified as partially dependent or modified dependence to perform activities of daily living. Therefore, we consider that measures to promote functionality should be carried out in patients with chronic diseases such as CAD, especially regarding physical-functional performance [20,21].
Another important factor that determines functionality is age; the older the patient is, the greater the lack of independence in everyday activities, which contributes to greater morbidity when associated with other risk factors [19,20,21,22,23]. There is a clear association between greater functionality of patients with HF and severity of the disease. Therefore, HF is a predictor of functionality (Katz index) [22,24].
The physical capacity of patients with CAD in this study, assessed using the 6MWT, showed that almost 30% had a functional impact. In an 8-year follow-up study of 600 patients with chronic heart disease, a median 6MWT of 232 m was found, showing that the evolution of the disease leads to an important functional impact [21]. Therefore, when paired with other functional assessment tools, the 6MWT facilitates the assessment of physical and functional capacity and helps guide exercise levels for patients with heart disease. The distance walked can also act as a marker in these patients with chronic heart disease, with distances between 200 and 300 m more predictive of morbidity and mortality [23,29].
Diastolic dysfunction is associated with dyspnea, with greater dysfunction limiting everyday activities of the individual. This was observed in a 5-year study on 395 patients in which diastolic dysfunction correlated with increased mortality [25,26,29,30,31,32]. Patients with CAD may present changes in circulatory and ventilatory power when coronary stenosis and involvement of more than two coronary arteries are present. A study using specific tests and echocardiography observed an increase in ventilatory variables analyzed, with a potential association with the number of arteries affected by stenosis [26,27].
Few studies have examined the exact relationship between CAD and functionality; however, there is clearly a direct relationship between physical ability and functional capacity because of the effect of CAD on cardiovascular, respiratory, metabolic, and muscular systems, confounded by modulation of the autonomic nervous system. This functional impairment results in low exercise capacity [28,29].
Research on subjects with low risk factor profiles predictably showed a lower CACS than those with high risk factors and subclinical atherosclerosis. However, even among individuals with 5–7 risk factors, it is possible to find low CACS, suggesting that measures of risk factor do not fully account for all factors resulting in CAD [30,33,34].
Thus, the CACS is indicated for the assessment of cardiovascular risk, and, when integrated with the functional assessment, it can allow the assessment of the individual's health more broadly. Therefore, the functional assessment in patients with CAD is an important step to explore its impact on autonomy in activities that involve physical effort, especially in periods of change/worsening of the disease.
Physical capacity was associated with CACS in the groups with greater severity (> 400 CACS). Sedentary lifestyle and dyspnea were associated with functionality (greater dependence) in patients with higher CACS.
Therefore, a greater functional impact was observed in cases of greater severity of heart disease and, therefore, symptomatic, consequently, with greater limitation in the performance of their daily activities.
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Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
