Cuando el betabloqueador revela el diagnóstico: feocromocitoma simulando síndrome coronario agudo: reporte de caso

Efficacy of Myocardial Contrast Echocardiography in the Diagnosis and Risk Stratification of Acute Coronary Syndrome

BackgroundThe HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has...

To compare the diagnostic power of separately integrating on-site computed tomography (CT)-derived fractional flow reserve (CT-FFR) and static CT stress myocardial perfusion (CTP) with coronary computed tomography angiography (CCTA) in detecting patients with flow-limiting CAD. The flow-limiting stenosis was defined as obstructive (≥ 50%) stenosis by invasive coronary angiography (ICA) with a corresponding perfusion deficit on stress single photon emission computed tomography (SPECT/MPI). Forty-eight patients (74 vessels) were enrolled who underwent research-indicated combined CTA-CTP (320-row CT scanner, temporal resolution 137 ms) and SPECT/MPI prior to conventional coronary angiography. CT-FFR was computed on-site using resting CCTA data with dedicated workstation-based software. All five imaging modalities were analyzed in blinded independent core laboratories. Logistic regression and the integrated discrimination improvement (IDI) index were used to evaluate incremental differences in CT-FFR or CTP compared with CCTA alone. The prevalence of obstructive CAD defined by combined ICA-SPECT/MPI was 40%. Per-vessel sensitivity and specificity were 95 and 42% for CCTA, 76 and 89% for CCTA + CTP, and 81 and 96% for CCTA + CT-FFR, respectively. The diagnostic performance of CCTA (AUC = 0.82) was improved by combining it with CT-FFR (AUC = 0.92, p = 0.01; IDI = 0.27, p < 0.001) or CTP (AUC = 0.90, p = 0.02; IDI = 0.18, p = 0.003). On-site CT-FFR combined with CCTA provides an incremental diagnostic improvement over CCTA alone in identifying patients with flow-limiting CAD defined by ICA + SPECT/MPI, with a comparable diagnostic accuracy for integrated CTP and CCTA. • Both on-site CT-FFR and CTP perform well with high diagnostic accuracy in the detection of flow-limiting stenosis. • Comparable diagnostic accuracy between CCTA + CT-FFR and CCTA + CTP is demonstrated to detect flow-limiting stenosis. • Integrated CT-FFR and CCTA derived from a single widened CCTA data acquisition can accurately and conveniently evaluate both coronary anatomy and physiology in the future management of patients with suspected CAD, without the need for additional vasodilator administration and contrast and radiation exposure.

To evaluate the diagnostic accuracy of a combined non-invasive assessment of coronary artery disease with coronary CT angiography (CTA) and myocardial perfusion imaging (MPI) for the detection of flow-limiting coronary stenoses and its potential as a gatekeeper for invasive examination and treatment. In 78 patients (mean age 65 +/- 9 years) referred for coronary angiography (CA), additional CTA and MPI (using single-photon emission-computed tomography) were performed and the findings not communicated. Detection of flow-limiting stenoses (justifying revascularization) by the combination of CTA and MPI (CTA/MPI) was compared with the combination of quantitative coronary angiography (QCA) plus MPI (QCA/MPI), which served as standard of reference. The findings of both combinations were related to the treatment strategy (revascularization vs. medical treatment) chosen in the catheterization laboratory based on the CA findings. Sensitivity, specificity, positive and negative predictive value, and accuracy of CTA/MPI for the detection of flow-limiting coronary stenoses were 100% each. More than half of revascularization procedures (21/40, 53%) was performed in patients without flow-limiting stenoses and 76% (47/62) of revascularized vessels were not associated with ischaemia on MPI. The combined non-invasive approach CTA/MPI has an excellent accuracy to detect flow-limiting coronary stenoses compared with QCA/MPI and its use as a gatekeeper appears to make a substantial part of revascularization procedures redundant.

Significant aortic regurgitation (AR) is sometimes accompanied by regional wall motion abnormalities (RWMA) during exercise stress echocardiography. The aim of this study was to estimate the association between RWMA after exercise and in the presence of significant AR in patients with coronary artery disease (CAD) or volume overload and to predict the eventual need for aortic valve replacement (AVR). We retrospectively reviewed 182 patients with significant AR who underwent exercise echocardiography. In addition, we investigated patients with AR who underwent coronary angiography (CAG) or coronary computed tomography angiography (CCTA) and were diagnosed with CAD. The presence of RWMA after exercise was defined as newly developed RWMA after exercise and included all changes in wall motion. Patients were divided into two groups according to the presence of RWMA after exercise: the RWMA group (n=42) and non-RWMA group (n=140). In the RWMA group, 31 patients (73.8%) underwent coronary artery evaluation by CAG or CCTA. Only two patients in the RWMA group were diagnosed with current CAD and underwent percutaneous coronary intervention. Patients with RWMA were older (61.6±10.8 vs 52.0±13.7years, P<.001), had more severe AR (54.8% vs 32.9%), and underwent AVR more frequently (40.5% vs 14.3%, P=.001) than patients without RWMA. METs (odds ratio [OR], 0.796; P=.019), difference between rest and postexercise left ventricular end-diastolic volume (OR, 0.967; P=.001), and the difference between pre- and postexercise left ventricular end-systolic volume (OR, 1.113; P<.001) were identified as independent factors associated with RWMA after exercise according to multivariable logistic regression analysis. The majority of wall motion changes were seen in the lateral and inferior segments, and the locations of wall motion changes were relatively consistent with the direction of the AR jet. The relationship between RWMA after exercise and time to AVR was investigated by simple linear regression (hazard ratio [HR], 3.402; P<.001). After adjusting for baseline parameters of diastolic blood pressure, left ventricular end-systolic dimension (LVESD), aorta size, deceleration time, and METs, the presence of RWMA after exercise was not predictive of time to AVR (HR, 1.106; P=.81). On the other hand, without forcible entry of RWMA after exercise, LVESD (HR, 1.119; P<.001) and METs (HR, 0.828; P=.006) independently predicted the eventual need for AVR as an outcome. The degree of change in wall motion from rest to exercise in those with significant AR was not correlated with CAD, but was correlated with the severity of volume overload and exercise-induced preload changes, as well as the direction of the AR jet. In addition, RWMA after exercise had no role in predicting the need for AVR.

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

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A 63-year-old man with no significant past medical history presented to the emergency department (ED) on a cold February morning with several hours of nonradiating substernal 6/10 chest heaviness since waking. He reported shoveling large amounts of snow during the ‘Boston Blizzard of 2015’ 7 days before presentation but denied subsequent dizziness, dyspnea, diaphoresis, nausea, or vomiting. Initial serum troponin-T testing was negative (<0.01 ng/ml), and ECG demonstrated sinus bradycardia without ischemic changes. The patient was administered full-dose aspirin and one spray of sublingual nitroglycerin with a reduction in his discomfort to 3/10. Coronary computed tomography angiography (CTA) was requested by the ED physician as the patient met institutional guidelines including low to intermediate risk (TIMI score≤4 at the time of scan), symptoms suspicious for acute coronary syndrome, unimpaired renal function, one set of negative serum biomarkers, and absence of ischemic ECG changes. Given the TIMI score of 1, the patient underwent coronary CTA monitored by a cardiac radiologist. A standard ED coronary CTA protocol was utilized, with prospective ECG–triggered acquisition in systole and a widened acquisition window to allow simultaneous evaluation of ventricular function. Coronary CTA demonstrated right coronary artery (RCA) dominance with short-segment focal subtotal occlusion of the distal RCA and adjacent fat stranding suspicious for acute plaque rupture. Multiphase cine images demonstrated regional hypokinesis of the basal and mid-inferior and inferoseptal left ventricle, consistent with an RCA territory ischemic event (Fig. 1; Supplemental video file 1, Supplemental digital content 1, https://links.lww.com/MCA/A58 and Supplemental video file 2, Supplemental digital content 2, https://links.lww.com/MCA/A59). Cardiology consultation led to a plan for admission and early elective invasive coronary angiography. Repeat serum troponin-T evaluations several hours after the scan showed elevations in troponin-T levels to 0.05 ng/ml, followed by 0.84 ng/ml.Fig. 1: Maximal-intensity projection coronary CTA image of the RCA demonstrating focal subtotal distal RCA occlusion (arrows) with adjacent fat stranding suspicious for acute plaque rupture. CTA, computed tomography angiography; RCA, right coronary artery.Coronary angiography confirmed distal RCA subtotal occlusion and demonstrated left-to-right collaterals. Percutaneous coronary intervention was performed with angioplasty, followed by placement of a 2.5×24 mm drug-eluting stent and postdilation (Fig. 2). Final postintervention stenosis was 0%. The patient was discharged home 2 days later on aspirin, atorvastatin, lisinopril, and clopidogrel. At the 2-month follow-up, he reported complete resolution of symptoms and had returned to work and his normal active baseline state of health.Fig. 2: (Left) Invasive coronary angiography confirms focal subtotal distal RCA occlusion (arrows). (Right) Post-PCI image shows 0% residual stenosis of the distal RCA after angioplasty, drug-eluting stent placement, and postdilatation. PCI, percutaneous coronary intervention; RCA, right coronary artery.Coronary CTA has been demonstrated by multiple large randomized controlled trials to improve the efficiency of care for low-to-intermediate risk patients with acute chest pain presenting to the ED, and it has an excellent negative predictive value for obstructive coronary artery disease (CAD) 1–3. In the largest published trials and in our own clinical experience, ∼85% of appropriately selected patients have no plaque or only nonobstructive CAD, defined as less than 50% luminal narrowing, and thus can be safely discharged home. In a minority of patients, potentially obstructive CAD is identified more rapidly than by the standard of care. At our institution, management for moderate stenoses (50–69% luminal narrowing) detected by CTA includes consideration of functional testing and complete 24-h serum biomarker and ECG evaluation, whereas management of severe stenoses (>70%) includes immediate cardiology consultation for consideration of invasive coronary angiography. This case demonstrates the utility of coronary CTA in rapidly and definitively identifying acute coronary syndrome in a low-risk patient with acute chest pain, resulting in immediate catheterization and revascularization. In addition, a coronary CTA protocol including multiphase images allows evaluation of ventricular function, which in this case demonstrated a regional wall-motion abnormality corresponding to the culprit ischemic lesion. Acknowledgements Conflicts of interest There are no conflicts of interest.

Objectives: Whether coronary artery changes are a main mechanism in the development of carbon monoxide (CO)-induced cardiomyopathy remains unknown. We investigated the effects of coronary artery stenosis on the presence or patterns of cardiomyopathy in CO-poisoned patients with myocardial injury defined as elevation of troponin I.Materials and methods: This prospective observational study collected data from consecutive patients who were diagnosed with CO poisoning and myocardial injury during the 24-month study period. Transthoracic echocardiography (TTE) and coronary computed tomography angiography (CCTA) were performed to evaluate cardiac function and coronary artery status.Results: TTE and CCTA were performed in 32 consecutive patients. The observed echocardiographic patterns included non-cardiomyopathy (59.4%), left ventricular global dysfunction (25%), Takotsubo cardiomyopathy (6.3%), and cardiomyopathy matching the distribution of the left anterior descending (LAD) artery (9.4%). Four patients had more than moderate stenosis, while stenoses of the LAD, left circumflex, and right coronary arteries were observed in two (6.3%), three (9.4%), and zero patients, respectively. Patients with coronary artery stenosis did not develop cardiomyopathy except for one patient; this patient also did not have regional wall motion abnormalities (RWMA) matched with the stenosis territory.Conclusions: Because there was no difference in coronary artery stenosis according to the presence or patterns of CO-induced cardiomyopathy, coronary artery stenosis is not the main mechanism for the development of CO-induced cardiomyopathy. Thus, the evaluation of coronary arteries is not necessary in all patients with CO-induced cardiomyopathy unless there is RWMA consistent with ischemic changes in electrocardiograms and elevated troponin I levels.

Relationship of regional wall motion abnormalities detected by biplane transesophageal echocardiography and electrocardiographic changes in patients undergoing coronary artery bypass graft surgery

The Case for Takotsubo Cardiomyopathy (Syndrome) as a Variant of Acute Myocardial Infarction

Introduction:Myocardial bridge (MB) is a congenital coronary artery malformation, generally considered benign. However, we reported 2 cases of long and deep coronary MB in children and their surgical treatment.Patient concerns and diagnosis:Two children with coronary MB presented with syncope as the initial symptom. Case 1: female, 11 years old, body weight 32.5 kg. Cardiac enzymes were elevated. Electrocardiograms showed ST-T changes. Echocardiography: No abnormalities were found in cardiac function and ventricular wall motion. Coronary computed tomography angiography (CCTA) showed that the left anterior descending artery (LAD) and its branches were located deep and long within the myocardium. Coronary angiography (CAG) revealed that the LAD was nearly occluded during systole and thin during diastole, and the right coronary artery was small. Case 2: male, 12 years old, body weight 32 kg. Cardiac enzymes were elevated. Electrocardiograms showed abnormal Q waves, and the inferior and anterior ventricular walls were elevated in ST-segment. Regional wall motion abnormality and diastolic dysfunction were shown in echocardiography. CCTA showed the LAD and its branches were located deep and long within the myocardium. CAG showed that the LAD was slender in diastole and further narrowed in systole, while the right coronary artery ran short.Interventions:Both cases were given surgical MB release.Outcomes:In case 1, postoperative reexamination showed the MB was completely released, and postoperative cardiac enzymes, electrocardiograms, echocardiograms, and CCTA demonstrated the patient was gradually recovering. The 3-month follow-up found nothing abnormal detected. In case 2, partial release was performed. The LAD was located in the middle and inner part of the interventricular septum. Partial release was performed at the proximal end, while complete release was performed at the middle and distal ends. The cardiac enzymes and electrocardiograms in the 3-month postoperative follow-up examination indicated the patient recovered, while the cardiac echocardiogram revealed that there was still regional wall motion abnormality and diastolic dysfunction.Conclusion:MB in children can cause syncope and myocardial infarction. Surgical unroofing of MB is an effective clinical option. Careful preoperative examination, including CCTA and CAG, and a detailed surgical planning system are critical to the surgery.

High-Risk Plaque Detected on Coronary CT Angiography Predicts Acute Coronary Syndromes Independent of Significant Stenosis in Acute Chest Pain: Results From the ROMICAT-II Trial

Some authors have suggested that a zero calcium score (CAC) can be used to rule out the diagnosis of acute coronary syndrome. Objective this study is to evaluate the diagnostic accuracy of a zero CAC when compared to the coronary computed tomography angiography (CCTA) at the emergency department. 135 symptomatic patients with no previous coronary heart disease (CHD) who presented to the emergency department were submitted to CAC and CCTA to rule out CHD. All patients had normal electrocardiogram and cardiac biomarkers and were TIMI risk score 0 to 2. The CCTA was considered positive if any obstructive lesion (> 50%) was identified. The mean age was 51.7 ± 13.6 years with 50.6% of men. Seventy-three (54.1%) patients had a calcium score of zero. Of them, 3 (4.1%) had an obstruction > 50 % and underwent invasive coronary angiography. Calcium score showed a sensitivity of 92.9%, specificity of 75.3%, positive and negative predictive values of, respectively, 62.9% and 95.9%. Positive and negative likelihood ratios were respectively of 3.7 and 0.09 to detect lesions greater than 50% in the CCTA. A negative likelihood ratio of 0.09 is very good to rule out most cases of significant coronary obstruction in epidemiologic studies. However, it is important to understand that in a clinical scenario, all evidence including history, clinical examination, data from eletrocardiogram and myocardial biomarkers have to be interpreted together. In our study, three cases with a zero CAC score had coronary obstruction higher than 50% at the CCTA.

Computed Tomography coronary angiography and fractional flow reserve (CTCA and CT-FFR) are noninvasive diagnostic tools for the detection of flow-limiting coronary artery stenoses. Although their negative predictive values are well established, there is a concern that the high sensitivity of these tests may lead to overestimation of coronary artery disease (CAD) and unnecessary invasive coronary angiography (ICA). We compared the positive predictive value (PPV) of CT-FFR with computerized tomography coronary angiography (CTCA) against the gold standard of ICA in different real-world patient groups. A retrospective analysis of 477 patients referred for CTCA or CT-FFR for investigation of possible coronary ischemia. Patients were excluded if the image quality was poor or inconclusive. Patient-based PPV was calculated to detect or rule out significant CAD, defined as more than 70% stenosis on ICA. A sub-analysis of PPV by indication for the scan was also performed. Patients who underwent invasive nonhyperemic pressure wire measurements had their instant wave-free ratio or resting full-cycle ratio compared with their CT-FFR values. In a patient-based analysis, the overall PPV was 59.3% for CTCA and 76.2% for CT-FFR. This increased to 81.0% and 86.7%, respectively, for patients with stable angina symptoms. In patients with atypical angina symptoms, CT-FFR considerably outperformed CTCA with a PPV of 61.3% vs. 37.5%. There was not a linear relationship between invasive pressure wire measurement and CT-FFR value (r = 0.23, P = 0.265). The PPV of CTCA and CT-FFR is lower in the real world than in previously published trials, partly due to the heterogeneity of indication for the scan. However, in patients with typical angina symptoms, both are reliable diagnostic tools to determine the presence of clinically significant coronary stenoses. CT-FFR significantly outperforms CTCA in patients with more atypical symptoms and the targeted use of CT-FFR in this group may help to avoid unnecessary invasive procedures.