Anginal Chest Pain Research Articles

Long-term morbidity and mortality among medically managed patients with angina and multivessel coronary artery disease

There are little data regarding outcomes in patients with angina and severe coronary artery disease (CAD) treated with medical management. Using the Duke Databank of Cardiovascular Disease, we describe the prevalence and long-term outcomes of patients with angina and multivessel CAD treated medically after catheterization. Patients undergoing catheterization for angina (chest pain without recent revascularization or myocardial infarction) with severe CAD (>or=75% stenosis in >or=2 epicardial vessels) were identified (n = 8,555). One and five year outcomes in the 32% (n = 2,776) of patients who did not receive revascularization in the 30 days after catheterization were described. Predictors of 1-year death, cardiac rehospitalization, and late revascularization in this population were identified. The population had a median age of 66, were mostly male, had significant comorbidities, and most had prior revascularization. Outcomes were poor at 1 and 5 years: death (11% and 37%), cardiac rehospitalization (29% and 61%), and late revascularization (10% and 27%). The cumulative rate of death, myocardial infarction, late revascularization, or cardiac rehospitalization occurred in 38% at 1 year and 76% at 5 years. Prior coronary artery bypass grafting was the only variable independently associated with protection from death, cardiac rehospitalization, and late revascularization. Medical management after catheterization is a common in patients with severe CAD and angina. Of patients treated with medical management, one third will have a recurrent cardiac event within the first year highlighting the poor outcomes and high utilization of resources by this patient population.

Chronic total occlusion of left circumflex artery after radiofrequency ablation of left ventricular outflow tract tachycardia

In this report, we present a 22-year-old female patient referred to our institution for evaluation of anginal chest pain. Her medical history revealed two ablation procedures of the left ventricular outflow tract tachycardia performed 1 month a part, 2 years ago. Coronary angiography revealed chronic total occlusion of the proximal left circumflex artery. To our knowledge, this is the first report of ablation-related chronic total occlusion of a coronary artery.

Progressive Left Coronary Stenosis After Rotablator Ablation Appreciated by Doppler Echocardiography

We describe a patient with a history of Kawasaki disease who showed coronary jet flow in the giant aneurysm on color-Doppler echocardiography caused by progressive coronary stenosis. A 6-year-old boy who had bilateral giant coronary aneurysms (14.9 mm in diameter) of the left main trunk (Fig. 1a) as sequelae of Kawasaki disease presented to us with anginal chest pain. Two years ago he had undergone coronary artery bypass graft surgery using the bilateral internal mammary artery grafted to the left anterior descending and left circumflex artery. Coronary angiography this time showed obstruction of both right and left internal mammary arteries. A color-Doppler echocardiography showed an aliased jet originating from the coronary ostium and flowing into the left giant coronary aneurysm with an early peak diastolic flow of 1.6 m/s (normal: 0.18– 0.3) with acute deceleration, being much faster than peak systolic flow velocity of 1.0 m/s (Fig. 1b). Because it was difficult to repeat the bypass graft surgery, he underwent successful rotablator ablation of the left coronary stenosis using 1.5-mm burr and the left coronary stenosis was significantly alleviated with a decreased peak diastolic flow velocity of 1.0 m/s (Fig. 1c) and temporary resolution of anginal chest pain. However, 2 months later, he complained of refractory chest pain again, with accelerated diastolic left coronary flow velocity of 2.0 m/s and underwent another attempt at rotablator ablation, but, unfortunately, he fell into shock during the procedure and could not be saved with multiple resuscitations. This case illustrates that color-Doppler echocardiography is a useful tool for evaluating coronary artery stenosis with a giant coronary aneurysm caused by Kawasaki disease and also emphasizes the difficulty of treating these small children with coronary stenosis [1, 2].

Les indications actuelles du scanner cardiaque

There is a need to define the current indications for coronary CT angiography (CCTA) even as technology continuously evolves. CCTA using 64 MDCT units has shown to be highly accurate for diagnosis of stenoses >or=50% on selected populations. It is currently used for its negative predictive value (96-98%). Stenosis quantification remains inferior to conventional coronary angiography with tendency to overestimate stenoses <70%. For diagnosis of coronary artery disease, CCTA is considered based on clinical findings (pre-test probability of coronary artery disease) and presence of myocardial ischemia on other functional studies. The main appropriate indications include: In the setting of acute coronary syndrome, CCTA excludes coronary artery disease with excellent NPV and good negative likelihood ratio (0.05) when ECG is non-contributory, 2 consecutive troponin levels at 6 hours are negative in a patient with low risk of coronary artery disease. In the setting of stable angina or atypical precordial chest pain, CCTA is indicated in patient with low to medium risk when functional test are non-contributory or unavailable, or ECG is non-interpretable. CCTA is a complement to coronary angiography for morphological evaluation of some lesions prior to angioplasty and stent placement (long segment occlusion, proximal lesions involving LAD and circumflex arteries). In selected patients, CCTA may replace coronary angiography prior to valvular surgery.

Downregulation of T Helper Cell Type 3 in Patients with Acute Coronary Syndrome

There is an imbalance between Th1 and Th2 in the development and progression of atherosclerosis and in patients with acute coronary syndrome (ACS) including acute myocardial infarction (AMI) and unstable angina. T helper cell type 3 (Th3), which primarily secretes transforming growth factor beta-1 (TGF-beta1), has been shown to inhibit both Th1 and Th2 cells. The present study was designed to investigate whether Th3 cells are involved in plaque destabilization and the onset of ACS. Ninety one patients who underwent diagnostic catheterization were classified into four groups (AMI group, unstable angina group, stable angina group and chest pain syndrome group). The cell frequencies of Th1, Th2 and Th3 were detected using flow cytometry, and the concentrations of their related cytokines IFN-gamma, IL-4 and TGF-beta1 were studied by ELISA. Apart from the imbalance between Th1 and Th2, results revealed a significant decrease in peripheral Th3 number and levels of TGF-beta1 in patients with ACS as compared with those in patients with stable angina and chest pain syndrome (p<0.01). Downregulation of Th3 cells in patients with ACS may play a potential role in plaque destabilization and the onset of ACS.

Takotsubo cardiomyopathy: A transient phenomenon in the cardiac catheter laboratory

Takotsubo cardiomyopathy is a rare stress-induced cardiomyopathy, most often seen in post menopausal women after an emotional stressor. The syndrome usual presents with anginal type chest pain. The electrocardiogram typically shows precordial ST-segment elevation and/or T-wave inversion suggesting left anterior descending coronary artery occlusion. Cardiac ischaemic markers are elevated but coronary angiography reveals a lack of significant coronary artery disease. Left ventricle angiography demonstrates hypokinesis and ballooning of the apex. Wall motion abnormalities resolve over weeks and overall prognosis is favourable. Two case studies are reported here that demonstrate typical presentation of the transient cardiomyopathy.

Tako-Tsubo cardiomyopathy following colonoscopy: Insights on pathogenesis

We report a case of Tako-tsubo cardiomyopathy (TTC) occurring after colonoscopy. A 60-year-old post menopausal female with syncope following an acute abdominal syndrome underwent diagnostic colonoscopy. Anginal chest pain with marked ST segment elevation occurred the day following the procedure. Coronary angiogram was entirely normal, but left ventriculography showed marked reduction in systolic function along with mid ventricular and apical akinesis. The patient's symptoms completely improved with eventual normalization of ventricular function. The occurrence in this patient of initial vagal syndrome followed by sympathetic stimulation preceding TTC is compared to prior reports with similar provocateurs and implications for pathogenesis discussed.

Mitochondrial Death Channels.

Coronary artery disease is the lead ing c us of morbidity and mor tality in North America and Europe. More than 12 million people in the United States have coronary artery dis ease, and more than 7 million have had a myocardial infarction (heart attack). Chronic stable angina (chest pain) is the initial manifestation of coronary artery disease in approximately half of all presenting patients, and about 16.5 million Americans (more than 5 per cent) currently have stable angina. Surgical interventions to prevent or treat acute myocardial infarction are increasing: More than 1.7 million coro nary angioplasty and coronary artery bypass procedures were performed in 2006 in the United States. A major goal of clinical cardiac research is to estab lish treatment criteria that will limit

Priapism as a manifestation of tetania

In a 40-year old male admitted because of anginal chest pain, priapism developed after coronary angiography. Chest pain and priapism most probably were due to severe hypocalcaemia 6 weeks after thyroidectomy. Both chest pain and priapism disappeared after substitution of calcium.

Frequency and predictors of urgent coronary angiography in patients with acute pericarditis.

To determine the frequency of urgent coronary angiography in patients with acute pericarditis and to examine clinical characteristics associated with coronary angiography. This is a retrospective analysis of all incident cases of acute viral or idiopathic pericarditis evaluated at Mayo Clinic's site in Rochester, MN, between January 1, 2000, and December 31, 2006. The main outcome measures were use of urgent coronary angiography and rate of concomitant coronary artery disease in patients with pericarditis. There were 238 patients with a final diagnosis of acute pericarditis (mean age, 47.7+/-17.9 years; 157 [66.0%] were male). On the initial electrocardiogram, 146 patients (61.3%) had ST-segment elevation, and 92 (38.7%) had no ST-segment elevation. Coronary angiography was performed in 40 patients (16.8% of all patients); the frequency was 5-fold higher among those with ST-segment elevation (24.7% vs 4.3%; P<.001). Additionally, 7 patients (4.8%) with ST-segment elevation received thrombolytics before transfer to our institution; no patients without ST-segment elevation received thrombolysis (P=.05). Characteristics associated with a higher likelihood of coronary angiography included typical anginal chest pain, ST-segment elevation, previous percutaneous coronary intervention, elevated troponin T values, diaphoresis, and male sex. Coronary angiography revealed concomitant mild to moderate coronary artery disease in 14 (35.0%) of the 40 patients who underwent this procedure. Urgent coronary angiography is commonly performed in patients with acute pericarditis, particularly those with ST-segment elevation, typical myocardial infarction symptoms, and elevated troponin T values. Coronary artery disease was present angiographically in one-third of patients undergoing the procedure. Although patients with ST-segment elevation myocardial infarction must receive prompt reperfusion, clinicians must also consider the diagnosis of pericarditis to avoid unneeded coronary angiography.

CAUSES OF ANGINA WITH NORMAL OR NONOBSTRUCTIVE CORONARY ARTERIES

Up to 20 percent of patients with anginal chest pain, the coronary angiogram, usually obtained because of «positive» findings on one or more noninvasive tests, does not show clinically significant narrowing of the vessel lumen. The most common causes of these conditions such as variant angina, X-syndrome, gastrointestinal disorders and others are systematizing in this article. The practical algorithm for management of patients with symptoms and nonobstructive coronary artery disease is presented.

Endotoxin Levels Are Associated With High‐Density Lipoprotein, Triglycerides, and Troponin in Patients With Acute Coronary Syndrome and Angina: Possible Contributions From Periodontal Sources

Recent studies have reported an association between poor dental health and acute coronary syndrome (ACS). The purpose of this study was to correlate the presence of periodontitis with serum endotoxin/lipopolysaccharides (LPS), lipid profiles, troponin, and immunoglobulin G (IgG) antibody to Porphyromonas gingivalis in control patients or patients with ACS or angina at the time of hospital admission. Blood samples from 194 subjects presenting with ACS, angina, or non-cardiac chest pain were analyzed for endotoxin/LPS (Limulus amebocyte lysate assay), lipid profile, troponin, and IgG antibody to P. gingivalis. Data were collected from hospital charts and dental records, and health questionnaire responses. Subjects with ACS or angina were more likely to have poor oral care, fewer remaining teeth, and increased alveolar radiographic bone loss compared to subjects with chest pain. In all subjects, endotoxin/LPS and IgG antibody to P. gingivalis tended to increase in association with increased radiographic bone loss. Endotoxin/LPS increased directly with triglyceride and troponin levels (P = 0.04 and P = 0.006, respectively) and inversely with high-density lipoprotein (HDL) levels (P = 0.002). IgG antibody to P. gingivalis levels was directly correlated with very low-density lipoprotein (P = 0.03) and triglycerides (P = 0.06) and inversely with low-density lipoprotein (P = 0.01). Results showed more alveolar bone loss in patients with cardiac disease than in patients without cardiac disease, but there was no difference between the groups in the serum levels of endotoxin/LPS or IgG antibody to P. gingivalis. However, there were associations between endotoxin/LPS and levels of serum triglycerides, troponin, and HDL.

Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children

The diagnostic value of various signs and symptoms (clinical markers) in predicting oropharyngeal aspiration (OPA) or swallowing dysfunction has not been established in children. The present retrospective study was undertaken to: 1) identify specific clinical markers associated with radiographic evidence of OPA, isolated laryngeal penetration (ILP) and post-swallow residue (PSR); 2) determine the sensitivity and specificity of clinical markers associated with OPA; and 3) determine the influence of age and neurological impairment on clinical markers of OPA. In total, 11 clinical markers of dysphagia were compared with the videofluoroscopic swallow study (VFSS) results (OPA, ILP and PSR) in 150 children on diets of thin fluid and purée consistencies. Chi-squared and logistic regression were used to analyse the association between clinical markers and VFSS-identified swallowing dysfunction. In children with OPA, wet voice (odds ratio (OR) 8.90, 95% confidence interval (CI) 2.87-27.62), wet breathing (OR 3.35, 95% CI 1.09-10.28) and cough (OR 3.30, 95% CI 1.17-9.27) were significantly associated with thin fluid OPA. Predictive values included: wet voice (sensitivity 0.67; specificity 0.92); wet breathing (sensitivity 0.33; specificity 0.83); and cough (sensitivity 0.67; specificity 0.53). No clinical markers were significantly associated with OPA, ILP or PSR on the purée consistency. Cough was significantly associated with PSR on thin fluids (OR 3.59, 95% CI 1.22-10.55). Differences were found for age. Wet voice, wet breathing and cough were good clinical markers for children with oropharyngeal aspiration on thin fluid but not on purée. Age and neurological status influenced the significance of these clinical markers.

Carotid intima–media thickness in patients with cardiac syndrome X and its association with high circulating levels of asymmetric dimethylarginine

Background The cause of myocardial ischemia and chest pain in patients with cardiac syndrome X (CSX) has been explained by mechanisms including endothelial dysfunction. CSX patients have higher levels of asymmetric dimethylarginine (ADMA) and increased mean common carotid intima–media thickness (C-IMT). Accordingly, this study was designed to examine C-IMT with its association serum endothelial function parameters in patients with CSX. Methods The study population consisted of 30 enrolled consecutive patients with diagnosis of CSX. As a control group, 30 individuals with the complaint of anginal chest pain without any ischemia on myocardial perfusion scintigraphy and with normal coronary angiographies were selected. C-IMT was measured by recording ultrasonographic images of both the left and the right common carotid artery. Plasma levels of l-arginine, ADMA, and nitrate/nitrite (NO x ) were measured from blood samples. Results Both C-IMT (mm) and carotis atherosclerotic plaques were significantly higher in patients with CSX than in control group. Also, the plasma level of NO x , l-arginine, and l-arginine/ADMA ratio were lower in patients with CSX than they were in the control group subjects. Plasma ADMA level increased in the CSX patients group. Correlation analysis showed significant positive correlation with C-IMT and plasma ADMA levels and showed significant negative correlation with plasma NO x and l-arginine levels. l-arginine/ADMA ratio and C-IMT was also showed significant negative correlation with the same analysis. Conclusions CSX patients had higher plasma ADMA levels and C-IMT values than the controls, reflecting the presence of subclinical atherosclerosis. These findings suggest that, besides endothelial dysfunction, presence of atherosclerosis may also contribute to the etiopathogenesis of the CSX phenomenon.

Initial risk stratification and presenting characteristics of patients with evolving myocardial infarctions

Objectives:To describe the presenting characteristics and risk stratification of patients presenting to the emergency department with chest pain who have a normal initial troponin level followed by a raised troponin...

An accordion phenomenon with ST-segment elevation of electrocardiogram and anginal chest pain: A case report

Tortuous coronary arteries frequently make percutaneous coronary intervention (PCI) difficult by causing less accessibility of guidewire toward the target lesion. After guidewire has been passed through the target lesion, it often assists a balloon catheter and stent system insertion along the stiff guidewire. However, artificial kinking and wrinkling might induce pseudo-narrowing of coronary arteries, which has been recognized as an “accordion phenomenon.” We describe an educational case of an accordion phenomenon with ST-segment elevation of electrocardiogram and anginal chest pain when the stiff guidewire which had been withdrawn was advanced again into the distal site after deploying stents.

The missing spade: apical hypertrophic cardiomyopathy investigation

Hypertrophic cardiomyopathy (HCM) is the com monest hereditary cardiac disease and the most frequently found cardiomyopathy. However, diagnosis and management remains very challenging. This condition is very heterogeneous with respect to genotypic and phenotypic expression, natural history, prognosis, and overall the treatment strategy remains contentious [1]. Despite the varying degrees and patterns of hypertrophy, ventricular systolic and diastolic dysfunction, dynamic intraventricular pressure gradients and microvascular ischemia, the key challenge is to accurately identify which patients will develop symptoms and which patients will respond to therapy. The same issues apply to the stratification of individual risk for sudden cardiac death (SCD), as debate continues over whether a single risk factor for SCD is enough to justify implantation of a cardioverter-defribillator (ICD), for primary prevention alone [2]. The definition of hypertrophy for diagnosis of HCM is currently arbitrary. Despite the conventional 15 mm diastolic septal wall thickness diagnostic threshold, HCM can present with milder degrees of septal hypertrophy [1, 3]. Clear recognition of this condition is crucial, not only from the point of view of clinical management and SCD risk stratification for the individual concerned, but also as screening of first-degree relatives has now extended into routine practice. One form of HCM that is commonly misdiagnosed is the apical variant, with hypertrophy predominantly involving the left ventricular apex and varying degrees of extension basally. Although uncommon is the Western world [4], it is common in Japanese and Chinese populations, accounting for up to 40% in these areas [5, 6]. Typical features include giant negative T waves on electrocardiogram (ECG), a spade-like configuration of the left ventricle, absence of an intraventricular pressure gradient, mild symptoms, and a generally more benign course with lower mortality rates than other forms of HCM [4–8]. Despite being a well-described entity, the diagnosis of apical HCM may be frequently missed by conventional imaging techniques. In this issue of the Journal, Duygu and co-workers studied a group of patients with suspected coronary disease who were subsequently referred for coronary angiography, and found to have the characteristic ‘‘ace of spades’’ appearance typical of apical HCM on contrast ventriculography [9]. Notably, although almost all patients were referred reportedly with anginal chest pain, none of them had significant coronary artery disease. Myocardial ischemia is common and multifactorial in HCM. Major causes may include small vessel disease, myocardial bridging, and impaired F. Alpendurada (&) S. K. Prasad CMR Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK e-mail: f.alpendurada@rbht.nhs.uk

Fatal spontaneous left main coronary artery thrombosis as a rare complication of noncardiac surgery

A 72-year-old man with a history of anterior wall myocardial infarction, who had stenting to his left anterior descending artery, developed an acute episode of dyspnea, hypoxemia and anginal chest pain three days after above-the-knee amputation for dry gangrene of the left leg. A physical examination revealed bilateral lung rales and a soft ejection systolic murmur at the left sternal border. Transient new lateral ST segment elevation associated with reciprocal inferior ST segment depression and prior anterior-septal infarct were evident on his electrocardiogram. Cardiac catheterization showed a filling defect in the middle segment of the left main coronary artery (Figure 1). During the procedure, the patient became more dyspneic and developed fatal cardiopulmonary arrest; he did not respond to resuscitative measures (1). Figure 1) Coronary angiogram showing a filling defect (arrow) in the middle segment of the left main coronary artery, representing a thrombus. Also noted was severe in-stent stenosis of the proximal left anterior descending artery

A 64 Years Old Man with Multiple Myeloma and Low HDL

In a 64 year old man with dyspnea and palpitation and fatigue and non angina chest pain, we found all the Para clinics prefect but only it showed low HDL and a normocytic, normochromic anemia. In searching about cause of anemia, in bone marrow biopsy showed Paraproteinemia. Therefore false low HDL because of paraproteinemia, leads to miss-diagnosis of cardiovascular disease.

Evaluation of post-stress left ventricular dysfunction and its relationship with perfusion abnormalities using gated SPECT in patients with cardiac syndrome X

Cardiac syndrome X defines patients with typical angina, a positive exercise ECG stress test and angiographically documented normal coronary arteries. In previous studies, post-stress prolonged left ventricular dysfunction (PLVD) using gated SPECT (G-SPECT) had been well correlated with myocardial perfusion abnormalities and degree of stenotic vessels in CAG in patients with coronary artery disease. However, evaluation of left ventricular myocardial perfusion, wall motion and left ventricular ejection fraction (LVEF) in patients with cardiac syndrome X, using G-SPECT had not been studied yet. Thus, the aim of this study was to analyse PLVD using (99m)Tc-MIBI GSPECT in patients with cardiac syndrome X. Of the patients in whom G-SPECT was performed in our institution between 2004 and 2006, 17 patients with anginal chest pain, positive exercise ECG stress test and normal coronary angiograms were retrospectively included to the study (group I). Fifteen patients with normal myocardial perfusion and another 15 patients with ischaemia on G-SPECT were selected as control groups (groups II and III). (99m)Tc-MIBI G-SPECT was performed for all patients according to 2 day (stress-rest) protocol. Stress and rest LVEF were derived automatically (SLVEF and RLVEF). Difference LVEF (DLVEF) (stress-rest) was calculated. Semiquantitative analyses were made both for myocardial perfusion and wall motion (WM), using a 20-segment model and a 5-point scoring system. DLVEF, perfusion and WM scores of all groups were compared among three groups and relationship between DLVEF, perfusion and WM scores were evaluated. Abnormal perfusion were detected in eight (47.1%) of patients, while the remaining nine (52.9%) had normal myocardial perfusion, in group I. Six of 17 (35.3%) patients in group I had post-stress WM abnormalities. Mean of DLVEF values were -3.1+/-3.0%, 4.4+/-2.0% and -6.0+/-5.1% in groups I, II and III, respectively (P<0.05 for group II vs. group I and group III; P>0.05 for group I vs. group III). LVEF response impairment (< or =5% increase from rest to post-stress images) was found in 17 (100%), seven (46.6%), 14 (93.3%) of patients in groups I, II and III, respectively. Abnormal myocardial perfusion, concordant transient segmental WM abnormalities and LVEF response impairment are not uncommon in patients with cardiac syndrome X of this cohort of the study population. Therefore, post-stress prolonged stunning may be attributed to these findings in some of cardiac syndrome X patients as in true ischaemic patients. However, further studies with larger number of subjects and long-term follow-up are necessary to support these findings.