Angina Equivalent Symptoms Research Articles

Prognosis of Zero Coronary Artery Calcium Score in Symptomatic Patients of South Asian Descent - an Experience from a Tertiary Care Center in Pakistan.

The absence of CAC in asymptomatic individuals is associated with a very low incidence of cardiovascular events. Of symptomatic patients, 1-2% with zero CAC score have non-calcified coronary artery atherosclerosis, and at least one third of cardiovascular events occur in individuals with zero CAC. South Asians (SA) have proportionally higher case fatality rates for CVD, relatively younger age of presentation, and accelerated rate of atherosclerosis when compared with other ethnic groups. All consecutive patients who underwent a CTCA to evaluate angina or angina-equivalent symptoms during the study duration were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. MACE was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization. A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (>50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. On a mean follow-up of 96.6 months ± 49.8 (range 21-194 months), all-cause MACE was observed in 8.8% of patients. The most common MACE was angina (3.96%) and all-cause mortality (3%). The baseline characteristics and MACE did not differ in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE. The incidence of soft plaque in this SA cohort is higher than that reported in international studies. However, in symptomatic SA, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.

Effect of cardiac rehabilitation on heart rate recovery in patients with coronary artery disease

Background/Aim: It is well-established that individuals with coronary artery disease (CAD) often exhibit autonomic dysfunction and a reduction in vagal function is associated with increased mortality and morbidity. Vagally mediated heart rate recovery (HRR) can be assessed by analyzing the post-exercise heart rate (HR) decay. It is hypothesized that effective exercise-based cardiac rehabilitation (CR) can enhance post-exercise parasympathetic function. This study aims to evaluate the impact of CR on HRR and other cardiac parameters in CAD patients. Methods: This retrospective cohort study was conducted at a single center. It included patients with CAD who were referred to the CR unit and completed either 30 or 60 sessions. These patients were free from angina or angina-equivalent symptoms at the time of enrollment and were receiving guideline-directed medical therapy for ischemic heart disease. A customized CR program was implemented for each patient. To calculate HRR, the maximum HR during the exercise test and HR values at 1, 2, and 3 minutes after exercise cessation were recorded. The differences between the maximum HR and the HR values at the end of the 1st, 2nd, and 3rd minutes after exercise were designated as HRR1, HRR2, and HRR3, respectively. Results: This study enrolled 104 patients with CAD. Following CR, there was a significant improvement in functional capacity, as assessed by the 6-minute walk test (from 367.83 [56.58] to 381.61 [53.76], P=0.001), and endurance, as measured by the Cycle Ergometer Test Maximum Watts (from 63.22 [22.29] to 77.38 [19.87], P<0.001). CR also led to a noteworthy increase in HRR1, HRR2, and HRR3 (P=0.036, P=0.015, P=0.002, respectively). Conclusion: In our study, both the functional capacity and endurance of CAD patients improved significantly after CR sessions. Additionally, HRR showed a substantial increase following CR, suggesting that exercise-based CR can enhance post-exercise parasympathetic function. HRR may serve as a potential prognostic marker for predicting outcomes in CR.

Prognosis of Zero Coronary Artery Calcium Score in Symptomatic Patients of South Asian Descent – An Experience From a Tertiary Care Center in Pakistan

Objectives: To estimate the prevalence of non-calcified coronary artery disease in patients with chest pain and a zero coronary artery calcium score, and to assess the prognostic significance of a zero coronary artery calcium score in these symptomatic patients.
 Methodology: All consecutive patients who underwent a CT coronary angiogram (CTCA) for evaluation of angina or angina-equivalent symptoms from 2009 to December 2020 were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. Follow-up data was collected by using the hospital's electronic patient record system and telephone communication. The endpoint, major-adverse cardiovascular events (MACE) was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization.
 Results: A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). Chest pain was the most common presenting complaint (97.4%) followed by dyspnea. At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (>50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. The mean follow-up duration was 96.6 months ± 49.8 (range 21 – 194 months). All-cause Major Adverse Cardiovascular Event (MACE) was observed in 8.8% of patients. The most common MACE outcome was angina (3.96%) and all-cause mortality (3%). Only 2.7% required revascularization on follow-up with 1.2% having myocardial infarction and non-urgent revascularization. The baseline characteristics, all-cause MACE (p = 0.79), mortality (0.82), angina (p = 0.765), revascularization (p = 0.45), non-fatal MI, and non-elective revascularization (p = 0.6) did not differ significantly in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE.
 Conclusion: The incidence of soft plaque in this South Asian cohort is higher than that reported in international studies. However, in symptomatic South Asians, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.

Predictive value of systemic inflammatory response index (SIRI) for complex coronary artery disease occurrence in patients presenting with angina equivalent symptoms.

Currently, atherosclerotic cardiovascular disease is the major cause of mortality world-wide. Inflammatory processes are postulated to be a major driving force for coronary plaque initiation and progression and can be evaluated by simple inflammatory markers from whole blood count analysis. Among hematological indexes, systemic inflammatory response index (SIRI) is defined as a quotient of neutrophils and monocytes, divided by lymphocyte count. The aim of the present retrospective analysis was to present the predictive role of SIRI for coronary artery disease (CAD) occurrence. There were 256 patients (174 [68%] men and 82 [32%] women) in the median (Q1-Q3) age of 67 (58-72) years enrolled into retrospective analysis due to angina pectoris equivalent symptoms. A model for predicting CAD was created based on demographic data and blood cell parameters reflecting an inflammatory response. In patients with single/complex coronary disease the logistic regression multivariable analysis revealed predictive value of male gender (odds ratio [OR]: 3.98, 95% confidence interval [CI]: 1.38-11.42, p = 0.010), age (OR: 5.57, 95% CI: 0.83-0.98, p = 0.001), body mass index (OR: 0.89, 95% CI: 0.81-0.98, p = 0.012), and smoking (OR: 3.66, 95% CI: 1.71-18.22, p = 0.004). Among laboratory parameters, SIRI (OR: 5.52, 95% CI: 1.89-16.15, p = 0.029) and red blood cell distribution width (OR: 3.66, 95% CI: 1.67-8.04, p = 0.001) were found significant. Systemic inflammatory response index, a simple hematological index, may be helpful in patients with angina equivalent symptoms to diagnose CAD. Patients presenting with SIRI above 1.22 (area under the curve: 0.725, p < 0.001) have a higher probability of single and complex coronary disease.

Correlation of Heart Rate Response during Exercise and Recovery with Severity of Myocardial Ischemia as Judged by Electrocardiographic Findings during Treadmill Testing: Increase in Heart Rate during Recovery Suggest Severe Ischemia with Exercise Induced Left Ventricular Dysfunction

We evaluated eighty one patients complaining of angina or angina equivalent symptoms on effort. Treadmill tests were performed using Bruce protocol. All confounding factors were excluded. Severity of exercise induced myocardial ischemia was decided by clinical and electrocardiographic findings during exercise and recovery. Heart rate response during exercise and recovery was correlated with severity of myocardial ischemia. Chronotropic incompetence had low sensitivity but high specificity in diagnosing severe myocardial ischemia. Decreased magnitude of reduction in heart rate during the first minute of recovery also correlated with severe exercise induced myocardial ischemia. Combining the two parameters increased sensitivity with mild reduction in specificity. Increase, rather than decrease, in heart rate during recovery period strongly correlated with severe myocardial ischemia with possibility of exercise induced left ventricular dysfunction

Abstract 10852: Stable versus Dynamic Cardiac Symptom Characteristics Are Associated With Adverse Outcomes Among Individuals Transported by Ambulance for Suspected Acute Coronary Syndrome

Introduction: Acute coronary syndrome (ACS) is a potential life-threatening emergency; therefore, rapid diagnosis and life-saving reperfusion therapies are essential to prevent adverse outcomes. Patients with suspected ACS experience an array of symptoms, which cause patients to seek care (9-1-1 or self-transport) to the emergency department [ED]). Little is known, however, about the prognostic value of symptom characteristics experienced in the very early period of evolving ACS and its impact on adverse patient outcomes. The purpose of this study was to determine if early symptom changes reported in the prehospital period are associated with adverse outcomes. Methods Adults &gt; 21 years of age with non-traumatic chest pain and/or anginal equivalent symptoms transported by ambulance were included. Cardiac symptoms were measured prospectively with the ACS Symptom Checklist, a validated 13-item tool that takes approximately one-minute to complete. Trained EMS personnel administered the ACS Symptom Checklist during ambulance transport (T1) and research specialists measured symptoms again in the ED (T2), after acute triage care was completed. Symptom changes were categorized as an increase, decrease, or both from T1 to T2. Changes in symptoms between T1 and T2 were defined as stable (0-3 symptoms) or dynamic ( &gt; 4 symptoms). Adverse hospital outcomes included death, reinfarction, and/or new onset heart failure. Results To date, a total of 280 patients presenting to the ED by ambulance with suspected ACS have been enrolled (mean age 60.1 + 15.5 years; 51.2% female; 14.3% final diagnosis of ACS). Of 255(91.1%) patients with complete data, 143(51.1%) experienced stable symptoms and 112(40%) experienced dynamic symptoms. Patients with stable changes had significantly higher rates of adverse outcomes compared to patients with dynamic changes (11.9 versus 2.9%, p=0.007). Patients reporting shortness of breath at T1 or T2 were over 4 times likely to experience an adverse event (p=0.003, p=0007). Conclusions Patients with suspected ACS who have stable symptom changes were more likely to have an adverse hospital outcome. The underlying mechanism of plaque rupture in ACS may account for these differences in symptom characteristics but needs further study.

ODP498 Myocardial Ischemia precipitating thyroid storm diagnosed during recovery through Wellen's wave: An ECG for an eye

Abstract Introduction: Thyroid storm is a major life-threatening condition in a patient of thyrotoxicosis which can accelerate the cardiovascular morbidity in forms of tachycardia, arrythmia and congestive heart failure. It can be precipitated by acute coronary syndrome. Most literatures have reported acute coronary syndromes during the presentation itself but here we shall describe an intriguing case where the diagnosis was possible after the resolution of the thyroid storm. Clinical case: A 55-year-old graves’ disease patient had presented with classical features of thyroid storm which was precipitated by discontinuation of the anti-thyroid drugs. His initial electrocardiogram (ECG) showed sinus tachycardia. He was promptly started on intravenous fluid, 80 mg of daily carbimazole along with lugol's iodine and intravenous dexamethasone. Within 48 hours of treatment, his vitals became normal with resolution of the thyroid storm. His thyroid hormone status also showed marked improvement (free T4 falls from 90.31 ng/dl to 2.31 ng/dl) (normal range: 0.7 ng/dl-1.7 ng/dl). Due to his persistent jaw pain, mild chest discomfort and hiccough, ECG recordings were done in regular intervals. Interestingly it showed dynamic changes consisted of biphasic T waves. This ECG changes were seen after the resolution of the thyroid storm features. The cardiac enzymes were within normal limits. We thought of wellen's syndrome and sought urgent cardiological consultation. Coronary angiography reveals left anterior descending artery (LAD) obstruction and patient promptly underwent percutaneous transluminal angioplasty. Patient's angina equivalent symptoms had resolved remarkably. He recovered satisfactorily and was discharged after 5 days. Clinical lesson: Ischemic heart disease is a well-known co-morbidity in a case of thyroid storm which can be identified at the initial presentation. But here the dynamic changes of ECG appeared after the resolution of the thyroid storm. It was classical of type A wellen's wave which is a harbinger of imminent massive anterior myocardial wall infarction due to near-complete blockage of LAD. Initial sinus tachycardia probably had hindered the appearance of typical wellen's wave in this case. But as soon as the thyroid storm resolved, typical dynamic changes appeared in the form of wellen's wave. Early suspicion due to following serial dynamic ECG changes has prevented a major catastrophe in this case. This case highlights the importance of tracking serial ECG changes in a patient of thyroid storm which can unmask any underlying ischemic cardiac disease even after apparent improvement of the clinical status. This clinical case also reports a unique association of thyroid storm and type A wellen's syndrome. Presentation: No date and time listed

INOCA affects more than the coronaries

Abstract Background Ischaemia with normal coronary arteries (INOCA) may result in disabling symptoms and has an association with adverse long-term prognosis. The diagnosis of INOCA necessitates invasive coronary angiography to perform a physiological evaluation of microvascular function. The conjunctiva has a readily assessable microvascular network in which physiological parameters can be evaluated. We compared conjunctival haemodynamics in patients with and without coronary microvascular disease (MVD) to assess if systemic microvascular dysfunction was present in this coronary artery disease sub-group. Methods In this study, we recruited patients undergoing invasive coronary angiography for the investigation of angina or angina equivalent symptoms. All patients had physiologically insignificant epicardial disease (FFR≥0.80) and underwent a physiological evaluation of coronary microvascular function. We compared a group with evidence of coronary MVD (IMR≥25 or CFR&amp;lt;2.0); to a group of controls without MVD (IMR&amp;lt;25 and CFR≥2.0). The conjunctival microvasculature was imaged using a previously validated combination of a smartphone and slit-lamp biomicroscope. The conjunctival vasculature was assessed using a semi-automated process of vessel diameter measurement and erythrocyte tracking to obtain haemodynamic parameters of microvascular function. Results A total of 111 patients were included (43 MVD and 68 controls). There were no differences in baseline demographics, co-morbidities, epicardial coronary disease severity or regular pharmacological therapies between the groups. Mean coronary flow reserve (CFR) was lower and mean index of microcirculatory resistance (IMR) higher in the MVD cohort (CFR 2.5±1.3 vs 5.2±2.5, p&amp;lt;0.001 and IMR 28.4±11.8 vs 13.7±5.0, p&amp;lt;0.001). A total of 2295 conjunctival vessels were analysed. The mean number of vessels per patient was 21.0±12.8 (3.2±3.5 arterioles and 14.8±10.8 venules). Significant reductions in axial/cross-sectional velocity, wall shear rate and wall shear stress were observed in the MVD cohort. Table 1 demonstrates a comparison of conjunctival physiological parameters between the groups. The most marked differences were observed in conjunctival arterioles. Due to the heterogenous size distribution of microvessels, arterioles were categorised into 2 diameter sub-groups (10–25 μm and 25–40 μm) for analysis (Table 2). Conclusion The reductions in microvascular blood flow velocity and rate that form the basis for the diagnosis of coronary microvascular dysfunction can be observed non-invasively in the bulbar conjunctiva microcirculation. Conjunctival vascular imaging may have utility as a non-invasive imaging modality to both diagnose microvascular dysfunction and augment conventional cardiovascular risk stratification. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Belfast Trust Heart Trust Fund and Northern Ireland Chest Heart and Stroke

Effect of COVID-19 pandemic on six-month mortality and clinical outcomes of patients with ST-elevation myocardial infarction.

The coronavirus disease 2019 (COVID-19) infection has changed everyday clinical practice, with a shortage of solid data about its implications for ST-elevation myocardial infarction (STEMI) patients. To evaluate the impact of COVID-19 on 6-month clinical outcomes of patients with STEMI and determine the mortality predictors after STEMI during the COVID-19 pandemic. This prospective observational study was conducted on consecutive STEMI patients who presented to our hospital between April and October 2021. A total of 74 COVID-19-positive patients were included in group I and compared to 148 COVID-19-negative patients (group II). We compared the two cohorts' rates of major adverse cardiovascular events (MACEs; composite of death from any cause, recurrent MI, target-vessel revascularization, and stroke) at 6 months. COVID-19 STEMI patients were more likely to present with angina equivalent symptoms, had higher Killip class at admission, and higher levels of high-sensitive cardiac troponin T and serum C-reactive protein. The 6-month rates of MACEs were significantly higher in STEMI patients with COVID-19 compared to non-COVID-19 patients (41.9% vs. 16.9%, respectively; p < 0.001) and were mainly due to higher in-hospital mortality (20.3% vs. 6.1%, respectively; p = 0.001). The independent predictors of 6-month mortality in STEMI patients during the COVID-19 pandemic were the absence of ST resolution, low systolic blood and higher Killip class on admission, presence of severe MR and atrial fibrillation, and anterior wall STEMI. STEMI patients with superimposed COVID-19 infection had worse clinical outcomes, with almost three times higher in-hospital mortality and 6-month MACEs.

Therapeutic Approaches for the No-Option Refractory Angina Patient.

The combination of an aging population and improved survival rates among patients with coronary artery disease has resulted in an increase in the number of patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy. Patients with refractory angina are often referred to the cardiac catheterization laboratory; however, they have often exhausted conventional revascularization options; thus, this population is often deemed as having "no options." We review the definition, prevalence, outcomes, therapeutic options, and treatment considerations for no-option refractory angina patients and focus on novel therapies for this complex and challenging population. We propose a multidisciplinary team approach for the evaluation and management of patients with refractory angina, ideally in a designated clinic. The severe limitations and symptomatology experienced by these patients highlight the need for additional research into the development of innovative treatments.

ASSOCIATION OF THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) RISK SCORE WITH EXTENT OF CORONARY ARTERY DISEASE IN PATIENTS WITH UNSTABLE ANGINA AND NSTEMI

Objective: To evaluate the correlation between thrombolytic in Myocardial Infarction risk score with the severity of coronary lesions found by coronary angiography during hospitalization in patients with non-ST elevation Acute coronary syndrome.&#x0D; Study Design: Cross sectional study.&#x0D; Place and Duration of Study: Adult Cardiology department, Armed Forces Institute of Cardiology &amp; National Institute of Heart Diseases, Rawalpindi from Jul to Dec 2018.Methodology: Patients who had chest pain suggestive of angina or anginal equivalent symptoms and diagnosis of Acute Coronary Syndrome (ACS) were included in the study. Patients with Acute Coronary Syndrome were risk stratified with Thrombolysis In Myocardial Infarction risk scores and were further evaluated with coronary angiograms to assess the extent of coronary artery disease.&#x0D; Results: Total 115 patients were recruited in the study with mean age 57.08 ± 10.2 years. There were 87 (75.7%) male patients while 28 (24.3%) female patients. The most common co-morbidity was hypertension 66 (57.4%) followed by diabetes mellitus 39 (33.9%) and smoking 25 (21.7%). 71 (61.7%) patients had one angina episode in the last 2 hours while 34 patients had two angina episodes in the last 2 hours. Cardiac biomarkers were raised in 36 (31.3%) patients. 60 (52.2%) used aspirin in the last 7 days. Chi-square test was applied between Thrombolysis In Myocardial Infarction Score and Coronaries lesions, which showed statistically significant results (p&lt;0.001).&#x0D; Conclusion: Our study demonstrates that among patients presenting with Non-STE Acute coronary syndrome i.e. unstable angina /NSTEMI who are referred for coronary angiography, clinical risk stratification according......

Clinical characteristics and management of patients with diabetes mellitus and stable coronary artery disease in daily clinical practice. The SCAD–DM Registry

BackgroundPatients with diabetes mellitus (DM) and coronary artery disease (CAD) represent a high-risk population, where comorbidities are common and the progression of coronary heart disease is relatively rapid and extensive. The present survey, conducted nationwide in a Eurozone country, Greece, with a properly organized national health system, aimed to record specific data from a significant number of patients with diabetes and documented stable CAD (SCAD). Methods and resultsWe conducted our survey across the country, in private and public primary, secondary, and tertiary care centers. A total of 1900 patients aged 71 ± 10 years old who suffered from both DM and chronic coronary syndromes were registered. Of the patients registered, 574 (30.24%) were women. It was found that 506 (26.6%) of the 1900 surveyed patients showed typical angina symptoms, while another 560 (29.5%) patients had developed angina-equivalent symptoms according to their history. Additionally, 324 (17%) patients had atypical symptoms that could not easily be attributed to existing CAD and the remaining 510 (26.8%) of the 1900 patients did not exhibit any angina symptoms during their daily activities. Functional testing for myocardial ischemia was not performed in 833 patients (43.8%). Myocardial scintigraphy was the most commonly used noninvasive technique (644 patients, 34%), while 492 patients (25.9%) had an exercise test and 159 (8.4%) underwent stress echocardiography. ConclusionReal-world data in this specific high-risk population of diabetic patients with SCAD offer the opportunity to identify and improve diagnostic and therapeutic practice in the healthcare system of a European Union country.

Frequency of Multivessel Severe Coronary Artery Disease in Patients With Non-ST Segment Elevation Myocardial Infarction Having Markedly Raised Cardiac Troponin T

IntroductionNon-ST segment elevation myocardial infarction (NSTEMI) is becoming more common than ST segment elevation myocardial infarction (STEMI) and data regarding presence of underlying multivessel coronary artery disease (MVCAD) in these patients is consistent in locoregional population that leads to lethal delays in proper management. Therefore, in the current study, we aimed to evaluate the frequency of MVCAD in NSTEMI with markedly raised troponin T levels. This will help to identify patients that should be labeled as high risk and must be referred for coronary revascularization on priority basis, so that clinical outcomes can be improved in these patients.MethodsThis cross-sectional research study was carried out at Chaudhary Pervaiz Elahi Institute of Cardiology, Multan over a period of one year. A total of 326 patients with history of chest discomfort within past 48 hours of presentation or angina equivalent symptoms and cardiac troponin T more than 500 ng/l were included in the study. Coronary angiography was done within 72 hours of same hospital admission. The outcome variable i.e. MVCAD was determined.ResultsMean age of patients was 50.74 ± 7.75 years with range of 30 to 60 years. MVCAD was found in 107 (32.82%) patients, whilst there was no MVCAD in 219 (67.18%) patients. Moreover, no significant association of MVCAD was noted with age or smoking.ConclusionWe found presence of MVCAD in a considerable number of patients presenting with NSTEMI. The key to detect the underlying presence of MVCAD in these patients is lifted troponin T levels. Therefore, we conclude that any patient with elevated troponin T levels, even in the absence of ST segment elevation, should undergo cardiac catheterization to detect presence of MVCAD as this subset of patients can benefit from early revascularization including coronary artery bypass graft (CABG) surgery.

The prevalence of coronary artery anomalies in adults: Studied with computed tomography coronary angiography

Background/Aim. Coronary artery anomalies are an uncommon but important cause of chest pain, and in some cases of hemodynamically significant abnormalities, sudden cardiac death. The aim of the research was to establish the prevalence of the coronary arteries anomalies in our population. Methods. The study group included 1,562 patients (810 men, 752 women, average age 64.3 ? 12.0 years; range 32?80 years) who were scheduled for 64-slice computed tomography (MSCT), which enables detailed visualization of coronary arteries and heart anatomy. All examinations were made due to suspicion (atypical chest pain, angina equivalent symptoms or multiple risk factors for cardiovascular disease) or assumption of progression of coronary artery disease. Results. From January 2010 till December 2014 a total number of 1,562 patients were sent for evaluation of coronary arteries. The coronary anomalies were found in 45 (2.88%) patients. The most frequent coronary anomaly seen in our population group was absence of left main trunk with the separate origin of the left anterior descending artery (LAD) and left circumflex artery (LCx) originating from a left coronary sinus (LCS). This was found in 12 patients (an incidence of 0.77% or 26.7% of all coronary anomalies). Anomalous location of coronary ostium outside normal aortic sinuses in our study was present as right coronary artery (RCA) that arises from left anterior sinus in 5 (0.32%) patients and left coronary artery from non-coronary sinus in two (0.13%) patients. Conclusion. Knowledge of anomalies of the coronary arteries and their recognition on the multislice computed tomography is of great importance for the further planning of a possible therapeutic treatment. Coronary anomalies that are considered insignificant will require no further therapeutic treatment. But the detection of malignant coronary anomalies will certainly save many lives.

Warning symptoms preceding out-of-hospital cardiac arrest: Do patient delays matter?

BackgroundAlthough increasing patient delays between symptom onset and activation of emergency medical services (EMS) can lead to poorer outcomes following acute myocardial infarction, its effect in out-of-hospital cardiac arrest (OHCA) populations is unclear. MethodsBetween 1st January 2003 and 31st December 2011, we included adult patients with anginal warning symptoms and subsequent EMS witnessed OHCA of presumed cardiac aetiology from the Victorian Ambulance Cardiac Arrest Registry. Multivariable logistic regression was used to assess the impact of patient delay time (i.e. symptom onset to EMS call time) on survival to hospital discharge. ResultsA total of 1056 EMS witnessed OHCA were screened, of which 515 (48.8%) reported chest pain or anginal equivalent symptoms. The median patient delay time was 25min (interquartile range [IQR] 9–89min), and did not differ across survivors and non-survivors. However, patients in lowest quartile of patient delay (≤8min) also experienced significantly higher rates of non-shockable arrest rhythms and circulatory compromise. A total of 16 baseline and clinical characteristics were tested in a multivariable model of survival to hospital discharge, of which, only six were retained in the final model, including: age, dyspnoea, vomiting, shockable arrest rhythm, systolic blood pressure, and patient delay time. Every 30min increase in patient delay time was independently associated with a 2.3% (95% CI: 0.4%, 4.1%; p=0.02) reduction in the odds of survival to hospital discharge. Among patients with ST-segment deviation on the pre-arrest ECG, every 30min increase in patient delay time was associated with a 3.4% reduction in the odds of survival (OR 0.966, 95% CI: 0.937, 0.996; p=0.03). ConclusionIncreasing delays in activating EMS before the onset OHCA may be associated with reduced survival. Future research could explore whether increasing public awareness of the warning symptoms leads to earlier medical contact for OHCA.

Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease.

Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI. In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria. Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD. Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Prognostic value of an abnormal response to acetylcholine in patients with angina and non-obstructive coronary artery disease: Long-term follow-up of the Heart Quest cohort

BackgroundThis study aims to determine whether small vessel disease (SVD) or vasospastic disease (VSD) has an impact on prognosis. MethodsThe prospective cohort embraced 718 patients with angina equivalent symptoms and no coronary stenosis ≥50% recruited between 1997 and 2008. At baseline, patients were classified as having SVD, VSD, other cardiac disease or non-cardiac problem based on intracoronary acetylcholine application and fast atrial pacing during coronary angiography. Patients underwent follow-up between 2007 and 2015. Prognostic significance of the diagnosis on cardiovascular events (cardiovascular death or non-fatal myocardial infarction) was evaluated using Cox proportional hazards models adjusted for age and sex. ResultsThe mean follow-up duration was 11.3±2.7years. Only 11 patients (1.5%) were lost to follow-up, resulting in an analyzed population of 707 patients. Patients with SVD (HR: 4.9, 95% CI: 1.1–22.4, P=0.040) and VSD (HR: 4.8, 95% CI: 1.0–23.4, P=0.050) had an increased risk of suffering cardiovascular events compared to patients with non-cardiac problems. Among SVD patients, those with the presence of endothelial dysfunction had a particularly high risk (HR: 7.3, 95% CI: 1.5–35.5, P=0.015). Among patients with SVD or VSD, those having persisting or worsening angina during follow-up had a higher risk than patients in whom angina improved (HR: 4.8, 95% CI: 1.9–12.3, P=0.001). ConclusionsOur study shows that patients with SVD or VSD have an increased risk of cardiovascular events. This particularly applies to SVD patients with endothelial dysfunction. Symptoms should be taken seriously in SVD and VSD patients.Trial registration: ClinicalTrials.gov Identifier: NCT01318629.

Quantitative CMR perfusion imaging identifies reduced flow reserve in microvascular coronary artery disease

Background Patients with angina without obstructive coronary artery disease are increasingly recognized and microvascular disease (MVD) is thought to play a significant role. An abnormal myocardial perfusion reserve (MPR) by positron emission tomography is predictive of increased cardiovascular events, particularly in women, diabetics, and those with metabolic syndrome. We hypothesized that MPR as measured by CMR would be reduced in patients with angina or anginal equivalent symptoms and nonobstructive CAD/normal coronaries compared with asymptomatic controls.

Characteristics and Risk Factors of Out-of-Hospital Cardiac Arrest Within 72 Hours After Discharge

ObjectiveTo determine the characteristics and risk factors for patients who developed out-of-hospital cardiac arrest (OHCA) within 72 hours after emergency department (ED) discharge. MethodsA nested case-control study (1:4 ratio) was conducted in 5 EDs from January 2002 to December 2011. The study group consisted of adults experiencing nontraumatic OHCA who revisited ED within 72 hours after discharge. Patients matched in sex, age group and chief complaints were selected for the control group. Demographic data, discharge diagnosis, discharge vital signs and laboratory result were collected. Etiologies of cardiac arrest and whether the events were expected or related to the 1st ED visit were reviewed. ResultsIn all, 1,657,870 patients were discharged during the study period; 109 developed OHCA within 72 hours of ED discharge (6.6/100,000 per year). The mean age was 64.7 years and 67.9% were men. After comparison with the control group, a higher heart rate (88.5± versus 81.7± beat per minutes, P = 0.003) and higher serum creatinine level (2.2± versus 1.4± mg/dL, P = 0.002) remain the statistical significant characteristics of study group by conditional logistic regression. Approximately 60% events were expected or unrelated to the 1st ED visit. Among patients whose OHCA were unexpected and related to the 1st ED visit, 71.4% had a cardiac cause. Of these, 20% had chest pain, but 40% had angina-equivalent symptoms during 1st presentation. ConclusionsA higher discharge heart rate and higher creatinine level are risk factors in these patients.

The association of paraoxonase 1 gene L55M polymorphism with the extent and severity of coronary artery disease in the Turkish population and its dependence on gender.

Objective:Coronary artery disease (CAD) is a common, complex, and progressive disorder characterized by the accumulation of lipids and fibrous elements in the arteries. It is one of the leading causes of death in industrialized nations. Oxidative modification of low-density lipoprotein (LDL) in the arterial wall plays an important role in the initiation and progression of atherosclerosis. Paraoxonase1 (PON1) is involved in lipid metabolism and is believed to protect LDL oxidation. In our study, we aimed to clarify the relationship between PON1 gene L55M polymorphism and the extent and severity of CAD.Methods:In total, 114 patients (54 males, mean age: 56.7±12.0 years; 60 females, mean age: 55.7±13.2 years) with stable angina or angina equivalent symptoms were enrolled in this prospective study. Cardiological evaluation was performed with electrocardiogram and transthoracic echocardiogram. The presence of hypertension, dyslipidemia, diabetes, and smoking status were ascertained. The patients were grouped according to their Gensini scores and gender. Genetic analysis of the PON1 gene L55M polymorphism was performed by polymerase chain reaction-restriction fragment length polymorphism.Results:We determined that the LL genotype was more prevalent in patients with Gensini score higher than or equal to 20 (p=0.026) and that this correlated with severe atherosclerotic coronary artery lesions in both gender groups, reaching a statistical significance in the female subjects (p=0.038).Conclusion:It was thought that the PON1 gene L55M polymorphism plays a significant role in CAD progression, especially in females.