Angiography For Acute Myocardial Infarction Research Articles

Multivessel Giant Coronary Artery Aneurysms Incidentally Demonstrated During Angiography for Acute Myocardial Infarction

Giant coronary artery aneurysms are a rare manifestation of coronary artery disease and are defined by an aneurysmal diameter of >20 mm. Multimodal invasive and noninvasive imaging is required for accurate assessment We describe a case of multivessel giant coronary artery aneurysms noted during angiography for myocardial infarction. (Level of Difficulty: Intermediate.)

Double Trouble: Ductal Origin of Right Pulmonary Artery With Contralateral Embolism.

A 60-year-old male patient underwent coronary angiography for acute myocardial infarction. Angiograms revealed significant multivessel disease and an abnormal branch arising from the proximal right coronary artery and extending backwards, likely to the right lung (Fig. 1A). Both internal thoracic arteries were patent; notably, the calibre of the right one was markedly larger than the left. Although chest radiograph showed anomalies such as right-lung hypoplasia and ipsilateral mediastinal shift (Fig. 1B), further investigation was skipped as the patient underwent urgent coronary artery bypass grafting.

Myocardial infarction with non-obstructive coronary artery disease.

As a result of the increased use of coronary angiography in acute myocardial infarction in the last two decades, myocardial infarction with non-obstructive coronary arteries (MINOCA) has received growing attention in everyday clinical practice. At the same time, research interest in MINOCA has increased significantly. MINOCA is a heterogeneous disease entity seen in 5-10% of all patients with myocardial infarction, especially in women. Clinically, MINOCA may be difficult to distinguish from other non-ischaemic conditions that can cause similar symptoms and myocardial injury. There is still some confusion around the diagnosis, investigation and management of patients with MINOCA. The present review summarises the current knowledge of MINOCA regarding epidemiology, pathophysiology, investigation, and treatment, with a special focus on imaging modalities. In addition, remaining important knowledge gaps are highlighted.

Abstract 14143: Percutaneous Coronary Intervention in Very Elderly Patients With Prior Coronary Artery Bypass Grafts Presenting With Acute Myocardial Infarction

Introduction: There is limited data on the benefits of percutaneous coronary intervention (PCI) in very elderly patients with prior coronary artery bypass grafts (CABG). Therefore, we sought to evaluate the outcomes of PCI versus medical therapy alone in very elderly patients with prior CABG who present with acute myocardial infarction (AMI). Methods: Retrospective study of patients ≥ 80 years old with prior CABG who underwent invasive coronary angiography for AMI at Kaiser Permanente Los Angeles Medical Center between June 2009 and February 2019. Patients were treated with PCI or medical therapy alone. Inverse Probability Treatment of Weighting (IPTW) was used to balance baseline characteristics between treatment groups and cox proportional hazard regression analysis was utilized. Outcomes evaluated were all-cause mortality and non-fatal MI. Results: There were 347 patients (average age 83.6±3.2 years, 18% female) analyzed. Of these 167 (48%) underwent PCI. Compared to medical therapy alone, the PCI group was more likely to have left main disease (15% vs 2.8%, p<0.01) and higher ejection fraction (48.0± vs 44.4± %, p=0.02); but less likely to have history of atrial fibrillation (31.7% vs 45.6%, p<0.01). To adjust for significant differences between groups, IPTW was utilized to balance covariates (all p>0.05). At a median follow-up of 27.6 months (interquartile range 9.7-52 months), there were no significant differences in all-cause mortality (Hazard Ratio [HR] 0.93, 95% Confidence Interval [CI] 0.88-1.32, p=0.5), and non-fatal MI (HR 0.95, 95% CI 0.72-1.26, p=0.7). Conclusion: PCI did not improve clinical outcomes over medical therapy alone in very elderly patients ≥ 80 years of age with prior CABG presenting with AMI. Further studies are needed to delineate the role of PCI in this high-risk unique population.

Abstract 14142: Revascularization in Very Elderly Patients With Left Ventricular Dysfunction Suffering From Acute Myocardial Infarction

Introduction: There is limited data on the benefits of revascularization in very elderly patients with left ventricular (LV) dysfunction and coronary artery disease (CAD). Hence, we sought to evaluate the role of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in very elderly patients with LV dysfunction who present with acute myocardial infarction (AMI). Methods: Retrospective study of patients ≥ 80 years old with LV ejection fraction (LVEF) ≤ 40% referred for invasive coronary angiography for AMI at Kaiser Permanente Los Angeles Medical Center between June 2009 and February 2019. Patients were grouped by treatment: PCI, CABG, or medical therapy. Inverse Probability Treatment of Weighting (IPTW) was utilized. Results: A total of 480 patients (average age 84.1±3.3years, 30% female) were analyzed. Of these, 206 (42.9%) underwent PCI and 46 (9.6%) underwent CABG. Compared to medical therapy, those revascularized were less likely to have any chronic total occlusion, prior strokes, diabetes, CAD, peripheral vascular disease, atrial fibrillation, and prior CABG; and more likely to have had prior PCI and higher LVEF. Median follow-up was 24.9 months (interquartile range 7.7-48.7months), After IPTW adjustment, revascularization was associated with a reduction in mortality (Hazard Ratio [HR] 0.72, 95% Confidence Interval [CI] 0.61-0.85) and non-fatal MI (HR 0.58, 95% CI 0.44-0.76). Both PCI and CABG were associated with reduced mortality (PCI: HR 0.75, 95% CI 0.63-0.90; CABG: HR 0.51, 95% CI 0.40-0.66) and non-fatal MI (PCI: HR 0.65, 95% CI 0.49-0.85; CABG: HR 0.28, 95% CI 0.16-0.48). Compared to CABG, there were no differences in mortality (HR 1.27, 95% CI 0.96-1.67), but increased non-fatal MI events (HR 3.81, 95% CI 1.82-8.0) with PCI. Conclusion: In very elderly patients with LV dysfunction, revascularization is superior to medical therapy. There were no differences in mortality between PCI and CABG, but PCI was associated with increased non-fatal MI events.

Acute Kidney Injury Among Older Patients Undergoing Coronary Angiography for Acute Myocardial Infarction: The SILVER-AMI Study

BackgroundAmong older adults (age ≥75 years) hospitalized for acute myocardial infarction, acute kidney injury after coronary angiography is common. Aging-related conditions may independently predict acute kidney injury, but have not yet been analyzed in large acute myocardial infarction cohorts. MethodsWe analyzed data from 2212 participants age ≥75 years in the Comprehensive Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study who underwent coronary angiography. Acute kidney injury was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria (serum Cr increase ≥0.3 mg/dL from baseline or ≥1.5 times baseline). We analyzed the associations of traditional acute kidney injury risk factors and aging-related conditions (activities of daily living impairment, prior falls, cachexia, low physical activity) with acute kidney injury, and then performed logistic regression to identify independent predictors. ResultsParticipants’ mean age was 81.3 years, 45.2% were female, and 9.5% were nonwhite; 421 (19.0%) experienced acute kidney injury. Comorbid diseases and aging-related conditions were both more common among individuals experiencing acute kidney injury. However, after multivariable adjustment, no aging-related conditions were retained. There were 11 risk factors in the final model; the strongest were heart failure on presentation (odds ratio [OR] 1.91; 95% confidence interval [CI], 1.41-2.59), body mass index [BMI] >30 (vs BMI 18-25: OR 1.75; 95% CI, 1.27-2.42), and nonwhite race (OR 1.65; 95% CI, 1.16-2.33). The final model achieved an area under the receiver operating characteristic curve of 0.72 and was well calibrated (Hosmer-Lemeshow P = .50). Acute kidney injury was independently associated with 6-month mortality (OR 1.98; 95% CI, 1.36-2.88) but not readmission (OR 1.26; 95% CI, 0.98-1.61). ConclusionsAcute kidney injury is common among older adults with acute myocardial infarction undergoing coronary angiography. Predictors largely mirrored those in previous studies of younger individuals, which suggests that geriatric conditions mediate their influence through other risk factors.

Asymptomatic abdominal aortic stenosis detected by unenhanced computed tomography before angiography in acute myocardial infarction.

Key Clinical MessageAlthough rapid treatment is important, unenhanced computed tomography before angiography is quick and can detect myocardial infarction induced by aortic dissection and also asymptomatic abdominal aortic stenosis in acute myocardial infarction cases.

Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA)

Article, see p 1481 Myocardial infarction with nonobstructive coronary arteries (MINOCA) is clinically defined by the presence of the universal acute myocardial infarction (AMI) criteria, absence of obstructive coronary artery disease (≥50% stenosis), and no overt cause for the clinical presentation at the time of angiography (eg, classic features for takotsubo cardiomyopathy).1 With the more frequent contemporary use of coronary angiography in AMI, clinicians have been regularly confronted with this puzzling problem and seeking guidance in its management. An article by Lindahl et al2 in this issue of Circulation represents a major step forward in MINOCA and thereby warrants taking stock of the past, present, and future management strategies of this intriguing condition. The pioneering early angiography studies of DeWood et al demonstrated that ST-segment–elevation myocardial infarction was often associated with an occluded epicardial artery, but this occurred less frequently in non–ST-segment–elevation myocardial infarction, although in both conditions obstructive coronary artery disease was evident in >95% of patients.3 These findings underscored the importance of the underlying atherothrombotic process and provided the impetus for major advances in AMI management over the next 35 years. However, when angiography failed to reveal the presence of obstructive atheroma or thrombosis in patients with clinical criteria for ST-segment–elevation myocardial infarction, some clinicians labeled these patients as having a false-positive ST-segment–elevation myocardial infarction diagnosis.4 Such a label implies that an AMI has not occurred (despite the clinical presentation) and therefore no further diagnostic investigation or cardiac therapy is required. To avoid such diagnostic complacency, the diagnosis of MINOCA was coined5 with an emphasis on investigating these patients to identify the underlying cause of their AMI presentation. Providing a label for this clinical syndrome was the first …

Abstract 129: Chest Pain Characteristics of Myocardial Infarction With Non-Obstructive Coronary Arteries (MINOCA) in Comparison to Myocardial Infarction With Coronary Artery Disease (MI-CAD)

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI); yet there is little evaluation of these patients in the literature. The current study is a prospective, contemporary analysis of clinical features and chest pain characteristics between patients with MINOCA and Myocardial Infarction with coronary artery disease (MI-CAD). Methods: All consecutive patients undergoing coronary angiography for AMI (as per the Third Universal AMI Definition) in South Australian public hospitals from January 2012 - December 2013 were included. Data was captured by Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR ® CathPCI ® Registry. The AMI patients were classified as MI-CAD or MINOCA on the basis of the presence or absence of a significant stenosis (≥50%) on angiography. Results: From 3,431 angiography procedures undertaken for AMI, 359 (11%) were classified as MINOCA. MINOCA patients were younger (59 ± 15 vs. 64 ± 13, p <0.01) and more likely to be female (60% vs. 26%, p<0.01), with age adjusted analysis revealing less cardiovascular risk factors in MINOCA compared to MICAD: current smoker (21% vs. 35%, p< 0.01), hypertension (56% vs. 65%, p<0.01), dyslipidaemia (46% vs. 61%, p<0.01), and diabetes (20% vs. 32%, p<0.01). Analysis of presenting chest pain characteristics showed no significant differences between MICAD and MINOCA for the presence of retrosternal pain (81% vs. 82%, p>0.05,) or shoulder pain (27% vs. 26%, p>0.05) respectively, however MINOCA patients were less likely to experience arm pain (33% vs. 40%, p<0.01). In regards to precipitating factors, emotional stress was more common (14% vs. 5%, p<0.001) and exertion related chest pain was less common (27% vs. 40%, p<0.001) in MINOCA patients. Quality of pain for MINOCA and MICAD was similar with the most frequent descriptors being burning (11% vs. 9%, p>0.05), sharp 21% vs. 23%, p>0.05) and tightness (41% vs. 44%, p>0.05). In addition, there were no significant differences observed between groups in relieving factors and duration of chest pain Conclusions: In contemporary cardiology practice, MINOCA presentation is more common than previously appreciated, with younger women frequently implicated. Delineating a MINOCA patient from MICAD on the basis of chest pain characteristics is not feasible.

Abstract 214: Determinants of Cardiac Rehabilitation Referral Following Acute Myocardial Infarction In Australia

Background: Despite the known benefits of cardiac rehabilitation (CR) and widespread endorsement of its use, CR is vastly underutilised, with less than 30% of eligible patients participating in a CR program after a cardiac event. The current study assessed the factors independently associated with referral to CR following acute myocardial infarction (AMI). Methods: The CR referral rate and factors associated with referral were assessed among all consecutive patients undergoing coronary angiography for AMI and surviving to hospital discharge, attending South Australian public hospitals from January 2012 [[Unable to Display Character: –]] December 2013. Data was maintained by the Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR ® CathPCI ® Registry. Results: Among 3,212 patients undergoing angiography for AMI, CR referral occurred in 1,530 patients (48%). Compared to patients without CR referral, these patients were younger (62±13 vs. 64±14, p<0.01) and less likely to be female (25% vs. 34%, p<0.01). Following age-adjusted analysis, the cardiovascular risk factors were similar between CR referral and non-CR referral patients including: diabetes (29% vs. 30%, p>0.5), hypertension (61% vs. 64%, p>0.5), and dyslipidaemia (59% vs. 60%, p>0.5), but CR referral patients were more likely to be active smokers (40% vs. 33%, p<0.01). CR referral patients were less likely to have additional comorbidities including current dialysis (0.9% vs. 2.2%, p<0.01) and cerebrovascular disease (6.0% vs. 8.8%, p<0.01). In multivariable analyses, factors associated with increased CR referral were (c statistic 0.68): presentation with ST-elevation MI (STEMI) (1.4, 1.2-1.7, p<0.01), undergoing percutaneous coronary intervention (PCI) following angiography (1.6, 1.4-1.9, p<0.01) and younger age (1.0, 0.98-1.0, p<0.01). Prior CABG (0.6, 0.5-0.8, p<0.01) and absence of significant coronary artery disease, defined by stenosis <50%, (0.2, 0.1-0.3, p<0.01) were associated with decreased referral. Lastly, secondary prevention therapies were more often prescribed at discharge in patients with CR referral compared to patients without referral including: aspirin (93% vs. 82%, p<0.01), beta-blockers (64% vs. 61%, p<0.05), statin (92% vs. 78%, p<0.01), and ACE-inhibitor/angiotensin receptor blocker (84% vs. 74%, p<0.01). Conclusion: This study highlights a significant disparity in cardiovascular care with approximately half of AMI patients not referred to CR, despite it being a key performance measure. STEMI presentation, younger age and undergoing PCI are associated with increased referral. Alarmingly, AMI patients not referred to CR are also less likely to receive other guideline-based therapies. Increased physician awareness about the benefits of CR is required and initiatives to overcome barriers to referral may improve the delivery of evidence-based care.

Abstract 273: Myocardial Infarction with Non Obstructive Coronary Artery Disease: Prevalence, Clinical Features and Outcomes

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an enigma that is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI). The current study is a prospective, contemporary analysis of MINOCA vs. Myocardial Infarction with obstructive coronary artery disease (MI-CAD) in regards to prevalence, clinical features, and in-hospital outcomes. Methods: All consecutive patients undergoing coronary angiography for AMI (as per the Third Universal AMI Definition) in South Australian public hospitals from January 2012 - December 2013 were included. Data was captured by Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR® CathPCI® Registry. The AMI patients were classified as MI-CAD or MINOCA on the basis of the presence or absence of a significant stenosis (≥50%) on angiography. Results: From 4,189 angiography procedures undertaken for AMI, 468 (11%) were classified as MINOCA. Patients with MINOCA were younger (59±15 vs. 64±13 years, p <0.01) and more likely to be female (53% vs. 26%, p <0.01), compared to those with MI-CAD. Age-adjusted analysis comparing patients with MINOCA to MI-CAD revealed differences in: (1) cardiovascular risk factors including hypertension (52% vs. 66%, p<0.01), diabetes (19% vs. 32%, p<0.01), dyslipidemia (46% vs. 62%, p<0.01), and current smoker status (27% vs. 37% p<0.01); (2) AMI type and size with fewer ST elevation myocardial infarcts (27% vs. 41%, p<0.01) and lower peak troponin values (180 ng/L, IQR 353 vs. 264 ng/L, IQR 680, p<0.01) amongst MINOCA patients. Furthermore, the GRACE Score for acute coronary syndrome risk stratification was lower for the MINOCA patients compared to MICAD (150±34 versus 160±35, p <0.01). Despite fewer cardiovascular risk factors, the absence of obstructive coronary artery disease, smaller infarcts, and a lower GRACE score, the in-hospital mortality was similar for MINOCA and MI-CAD patients (2.2% vs. 3.0%, p=0.22). Moreover, MINOCA patients were less likely to receive secondary prevention therapies at discharge including antiplatelet therapy (60% vs. 92%, p<0.01) beta-blockers (41% vs. 65%, p<0.01), statin (55% vs. 88%, p<0.01), ACE-inhibitor/angiotensin receptor blocker (59% versus 81%, p<0.01), or referral to cardiac rehabilitation (15% versus 52%, p<0.01). Conclusions: In contemporary cardiology practice, MINOCA may be more frequent than previously appreciated and has a guarded prognosis despite its apparent lower risk profile. Improving the use of secondary prevention therapies in these patients may improve their prognosis.

Abstract 178: Acute Myocardial Infarction: Clinical Features and Performance Measures in Indigenous and Non-indigenous Australians

Background: Ischemic heart disease is a major contributing factor to the significant mortality and disease burden gap for Indigenous Australians. The current study is a contemporary analysis of Indigenous and non-Indigenous acute myocardial infarction (AMI) patients in regards to clinical features, in-hospital outcomes and performance measures. Methods: All consecutive patients undergoing coronary angiography for AMI in South Australian public hospitals from January 2012 [[Unable to Display Character: –]] December 2013 were captured. AMI patients (as per Third Universal AMI Definition) were analyzed according to ethnicity (Indigenous/Non-Indigenous). Data was maintained by the Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR ® CathPCI ® Registry. Results: From 10,469 coronary angiograms performed, the prevalence of Indigenous patients was 4%. The frequency of AMI was higher in Indigenous (n=212) vs. Non-Indigenous (n=3636) patients (50% vs. 36%, p <0.01), despite Indigenous patients being younger by 15 years (50±12 vs. 65±13, p<0.01) and also more likely to be female (41% vs. 29%, p<0.01). Age adjusted analyses revealed a higher prevalence of comorbidities in Indigenous patients including: smoker (66% vs. 34%, p<0.01), hypertension (70% vs. 64%, p<0.01), dyslipidaemia (71% vs. 59%, p<0.01), diabetes (58% vs. 29%, p<0.01), and prior AMI (26% vs. 20%, p<0.01). There were fewer ST elevation myocardial infarcts (STEMI) (33% vs. 39%, p<0.01) but higher rates of hospital transfers (43% 25%, p<0.01) amongst Indigenous patients. Percutaneous coronary intervention (PCI) was less frequently utilized in Indigenous patients (46% vs. 51%, p<0.01), including few Indigenous STEMI patients undergoing primary PCI (18% vs. 53%, <0.01). In-hospital outcomes were similar between Indigenous and non-Indigenous patients, including bleeding complications (0.9% vs. 1.5%, p>0.05) and mortality (2.5% vs. 2.9%, p>0.05), although the relative risk of death adjusted for comorbidities was higher among Indigenous patients (2.7, (0.8-8.0) vs. 0.4, (0.1-1.3,) p>0.05). Discharge therapies were mostly similar in Indigenous vs. non-Indigenous patients including aspirin (91% vs. 84%, p>0.05), beta-blockers (75% vs. 62%, p<0.01), statin (90% vs. 83%, p<0.01), ACE-inhibitor/angiotensin receptor blocker (81% vs. 78%, p>0.05), or referral to cardiac rehab (44% vs. 48%, p>0.05). Conclusion: Indigenous Australians present for angiography with AMI 15 years earlier than non-Indigenous Australians. Despite this, they have a greater incidence of comorbidities, are more often transferred but PCI is less often utilised. Although in-hospital complications do not differ, there is room for improvement given a higher risk of death. Furthermore, evaluation of medication compliance and access to medications post discharge may provide further insight into disease burden.

Abstract 8816: Comparison of Prognostic Values of Contemporary Contrast-Induced Nephropathy Definitions in Patients with Acute Myocardial Infarction Undergoing Emergency Coronary Angiography

Background: Previous studies have shown that contrast-induced nephropathy (CIN) defined in several ways is associated with poor outcomes. However, there is no consensus on the optimal definition of CIN. Objective: We examined the prognostic significance of 3 contemporary definitions of CIN with respect to long-term major adverse cardiac and cerebrovascular event (MACCE) and mortality after emergency coronary angiography for acute myocardial infarction (AMI). Methods: We measured serum creatinine (SCr) at admission and each day for the following 3 days in 733 patients with AMI who underwent emergency coronary angiography within 12 h after symptom onset. CIN was defined as SCr increase ≥0.5 mg/dl, SCr increase ≥25%, or estimated glomerular filtration rate (eGFR) decrease ≥25%. Results: Of 733 patients (age 64 ± 12 years), 47% were anterior AMI, 31% had renal dysfunction defined as admission eGFR <60 ml/min/1.73m2, and 81% underwent primary percutaneous coronary intervention. The mean volume of contrast medium used was 155 ± 57 ml. The incidence of CIN ranged widely depending on the definition used; 7.8% (SCr increase ≥0.5 mg/dl), 37.4% (SCr increase ≥ 25%), and 29.2% (eGFR decrease ≥ 25%). There were significant differences of 5-year MACCE (all-cause death, non-fatal myocardial infarction, or stroke) and all-cause mortality between patients with and without CIN by the 3 definitions (especially SCr increase ≥0.5 mg/dl). In multivariate analysis, only SCr increase ≥0.5 mg/dl was independently and significantly associated with 5-year MACCE and all-cause mortality; but the other 2 definitions were not. Conclusions: In patients with AMI undergoing emergency coronary angiography, of the 3 contemporary definitions of CIN, only SCr increase ≥0.5 mg/dl strongly predicts 5-year adverse outcomes, suggesting the prognostic importance of this definition.

One scan for all: extended role of cardiac CT angiography in acute myocardial infarction

Cardiac computed-tomographic angiography (CTA) has gained widespread acceptance as a useful non-invasive technique in the assessment of coronary artery disease. Although most interest has focused on coronary vessels, analysis of myocardial perfusion, left ventricular wall motion, ejection fraction and left ventricular structure can easily be performed at the same time allowing comprehensive assessment of anatomy and function in a single examination. We present a case of acute ST elevation myocardial infarction where cardiac catheterization was deferred, but assessment by CTA permitted a management plan to be constructed using rest perfusion and blood pool inversion analyses of the dataset obtained during the coronary artery study. Coronary CT angiography can provide a comprehensive assessment of coronary arteries, myocardial perfusion and structural features in those not suitable for coronary angiography after myocardial infarction.

Should All Patients With Asymptomatic but Significant (>50%) Left Main Coronary Artery Stenosis Undergo Surgical Revascularization?

The incidental detection of asymptomatic but significant (>50%) left main coronary artery disease (LMCAD) has become more frequent with the increased use of coronary angiography for acute myocardial infarction. Most would agree that such LMCAD cannot be ignored. Yet, clarity is somewhat lacking as to the best approach to managing such patients. The long-running debate of the best revascularization method of LMCAD has flared up again. However, medical management also may be a viable option for some of these patients. A 64-year-old nondiabetic man without a history of cardiovascular disease is admitted with an acute inferior ST-elevation myocardial infarction. He undergoes successful primary angioplasty of a dominant right coronary artery. Left ventriculography reveals inferior hypokinesis with an estimated ejection fraction of 45% to 50%. However, the patient also has a smooth mid-to-distal 60% LMCAD without any significant lesions in the left anterior descending or left circumflex artery. A month later, a stress echocardiogram reveals no new wall motion abnormalities. On the basis of this presentation, should he be referred for coronary artery bypass graft (CABG) surgery? The American College of Cardiology/American Heart Association (ACC/AHA) 2002 guidelines for stable angina1 discuss the indications for CABG surgery separately for symptomatic and asymptomatic LMCAD, but the recommendations are the same for both: Revascularization with CABG is a class I recommendation with level of evidence B. (Class I recommendations indicate situations for which evidence or general agreement exists that a given procedure or treatment is beneficial, useful, and effective.) An abbreviated version of these same guidelines was published in 2003.2 These guidelines acknowledged that the evidence behind the recommendation for asymptomatic patients is weak, yet the class IB recommendation was not changed. The ACC/AHA 2004 guidelines for use of CABG surgery also separate symptomatic and asymptomatic LMCAD recommendations and propose that CABG …

Simultaneous Multivessel Coronary Spasm Causing Acute Myocardial Infarction

Spontaneous simultaneous multivessel coronary artery spasm in patients with acute myocardial infarction (AMI) is uncommon. A 79-year-old Japanese man was transferred to this hospital because of severe prolonged chest pain and faintness. Left coronary angiography revealed total occlusion of the left anterior descending and the left circumflex coronary arteries. Moreover, right coronary angiography revealed 99% stenosis of the right coronary artery. After intracoronary administration of nicorandil, left coronary artery and right coronary artery angiography revealed no organic stenosis or thrombus. This is the first report in which simultaneous 3-vessel spasm was documented by emergency angiography in AMI.

Characteristics and outcomes of patients with acute myocardial infarction and angiographically normal coronary arteries

This study on patients undergoing coronary angiography for acute myocardial infarction demonstrated that 2.8% of patients had angiographically normal coronary arteries and that these patients have a better prognosis than patients with angiographically verified coronary artery disease. The trend toward a higher prevalence of malignancy in this unique patient group raises the possibility of malignancy-induced hypercoagulability or inflammation as an underlying etiologic factor.

Rescue percutaneous coronary intervention for failed thrombolysis in a patient with anomalous coronary arteries

Coronary artery anomalies (CAA) often render technically difficult the completion of coronary angiography and intervention. Their presence in patients undergoing emergency angiography for acute myocardial infarction (AMI) is particularly challenging for interventional cardiologists. In this article, we report, for the first time in the literature, a case of rescue percutaneous coronary intervention for failed thrombolysis in a patient with AMI due to occlusion of a left circumflex coronary artery with anomalous origin from right sinus of Valsalva (in an anomalous left coronary system also including an anomalous origin of the left anterior descending artery from the right sinus). In particular, the present clinical vignette emphasizes the importance of a thorough search for the culprit vessel during cardiac catheterization. Especially in the emergency setting, non-invasive methods of ischemia localization, such as ST-segment elevation at the ECG and wall motion abnormalities at echocardiography, are of pivotal usefulness to guide the interventional cardiologist in identifying and treating the diseased coronary vessel in a timely and effective fashion.

Multislice spiral CT myocardial perfusion and coronary angiography in acute myocardial infarction: an experimental study

Objective To study the myocardial perfusion in acute myocardial infarction by using Multislice spiral CT (MSCT),and to explore the value of MSCT coronary angiography in showing the coronary artery blockage.Methods The left anterior descending artery (LAD) was ligated in nine healthy dogs.Then MSCT perfusion scans were done in several stages (pre-ligation,30 min,1,2,4,6,and 8 h post-ligation).The perfusion peculiarity was analyzed and compared with pathological findings.MSCT coronary angiography was done before and after LAD ligation.Results The mean normal myocardial perfusion was (69.3±13.9) ml·100 g -1· min -1.The mean time to peak (TTP) was (12.8±2.1) s.30 min after LAD was ligated,the myocardial perfusion was (25.2±3.4) ml·100 g -1· min -1 .It became significantly lower than normal,and time-density curve got flat.There was no significant difference between the density of normal myocardium (44.9 ±22.0) HU and that of LAD ligation areas on 10 min delay scan (67.1±11.4)HU (P0.05).But significant enhancement was found after LAD ligation for 4 hours (82.1±15.2) HU.MSCT coronary angiography could show the blockage of LAD in nine dogs.Conclusion MSCT myocardial perfusion combined with coronary angiography could estimate myocardial ischemia and infarction,and show the blockage of the coronary artery.

Effects of intracoronary low-dose enalaprilat as an adjunct to primary percutaneous transluminal coronary angiography in acute myocardial infarction

Bradykinin accumulation is a potent cardioprotective mechanism underlying angiotensin-converting enzyme (ACE) inhibition in ischemia and/or reperfusion injury. There is, however, concern about treatment with ACE inhibitors in the very early phase of acute myocardial infarction (AMI) due to adverse systemic hemodynamic effects. We tested the hypothesis that cardiac bradykinin metabolism can be influenced by very low doses of intracoronary ACE inhibitors without harmful systemic effects in patients with AMI. Twenty-two patients with AMI in Killip classes II to III who underwent primary percutaneous transluminal coronary angiography (PTCA) were randomized to intracoronary enalaprilat (50 μg) or saline, given immediately after reopening of the infarct-related artery. Hemodynamics and electrocardiograms were monitored continuously and samples for determination of ACE activity, angiotensin II, bradykinin, kininogen, and cardiac marker proteins were collected from pulmonary arterial and central venous blood. Enalaprilat had no adverse effects on systemic hemodynamics, but rather stabilized arterial pressure and cardiac rhythm during reperfusion. Enalaprilat induced a 70% reduction of ACE activity and a significant increase of bradykinin in pulmonary arterial blood. Angiotensin II was not significantly affected by enalaprilat either in pulmonary arterial or in central venous blood. Myoglobin release was lower and the duration of reperfusion arrhythmias was significantly reduced in the enalaprilat group (p <0.05). Thus, in this pilot study, intracoronary enalaprilat infusion in the infarct-related artery is feasible in the setting of primary angioplasty and is safe and well tolerated. Effective cardiac ACE inhibition can be achieved by low-dose intracoronary enalaprilat, which primarily causes a potentiation of bradykinin.