Acute Coronary Syndrome Cases Research Articles

High Risk Non-ST Elevation Myocardial Infarction - A Case Report

Coronary artery disease (CAD) is the leading cause of cardiovascular mortality worldwide. Electrocardiogram (ECG) remains an important tool in the diagnosis of acute myocardial infarction (MI) and further risk stratification. ST segment elevation myocardial infarction (STEMI) is a medical emergency requiring early diagnosis and prompt reperfusion of occluded coronary artery to prevent morbidity and mortality. Recent studies have shown that a subset of patients with acute MI in the absence of ST segment elevation (non-ST elevation myocardial infarction [NSTEMI]) have an acute occlusion of the culprit artery on coronary angiography. The Aslanger’s pattern is a specific ECG finding in acute inferior myocardial infarction with multivessel disease. It allows identification of inferior wall myocardial infarction that does not show ST elevation in contiguous leads but needs rapid evaluation by coronary angiogram and revascularization. We presented a case of acute coronary syndrome whose ECG showed Aslanger’s pattern and was confirmed to have significant stenosis of the left main coronary artery and right coronary artery (RCA) by coronary angiogram. STEMI criteria of ST elevation involving two contiguous leads may not be sufficient in diagnosing critical coronary artery occlusions in clinical practice. Keywords: Acute Myocardial Infarction; Aslanger’s Pattern; ST-Elevation; NSTEMI

CARDIAC REHABILITATION AND PSYCHOLOGICAL TREATMENT: CONTRASTS IN ANXIETY, DEPRESSION AND ILLNESS PERCEPTION LEVELS

Abstract Background Investigating the relationship between psychological factors and cardiovascular diseases (CVD) has long been a focal point of previous research. Researchers have primarily focused on identifying possible predictive factors for CVD’s development and examining patients’ responses during acute or chronic phases, but less is known about the role of cardiac rehabilitation and the types of psychological treatments on patients’ psychological status. Aims The aim of this study is to compare anxiety, depression, and illness perception levels of patients affected by different cardiovascular diseases at the beginning (t0), at the end (t1), and three months after a cardiac rehabilitation program (t2) in which patients were involved in three different types of psychological treatments: psychoeducational intervention group, progressive muscle relaxation training integrated with Jacobson‘s technique and imaginative stabilization techniques, individual counseling. Methods In this study were involved patients with recent episodes of Acute Coronary Syndrome (ACS), heart failure (HF) or cardiac surgery undergoing cardiac rehabilitation between January 2023 and August 2023 at ASST Bergamo Est. To assess anxiety, depression and illness perception levels of participants we used self–report questionnaires that included the Hospital Anxiety and Depression Scale (HADS) and the Brief Illness Perception Questionnaire (Brief–IPQ). Patients could be assigned to different psychological treatments based on their clinical condition. Results The study involved 181 participants, namely N=36 ACS cases (19.9%), N=25 CHF (13.8%), and N=120 cardiac surgery (66.3%). As shown in Table 1, males were 71.3% (N=129) and the average age was 65.96 years old (SD=11.904). One hundred–sixty einght patients participated in psychoeducational intervention group, 120 in relaxation training, and 35 in individual counseling. Statistically significant differences in anxiety, depression, and illness perception levels were observed at the program‘s initiation (t0) and upon completion (t1 and t2) in relation to the psychological treatments: individual counseling had a better impact on levels of anxiety and depression and on the development of a more adequate perception of illness. Conclusions The type of psychological treatment during cardiac rehabilitation appears to give different results in terms of psychological status, self–care and disease management of patients.

Impact of Climate on the Incidence of Acute Coronary Syndrome - Differences Between Japan and Thailand.

Background: Although there are many reports of temperature being associated with the onset of acute coronary syndrome (ACS), few studies have examined differences in ACS due to climatic differences between Japan and Thailand. The aim of this joint Japan-Thailand study was to compare patients with myocardial infarction in Japanese and Thai hospitals in different climates. Methods and Results: We estimated the climate data in 2021 for the Wakayama Prefecture and Chonburi Province, two medium-sized cities in Japan and Thailand, respectively, and ACS patients who were treated at the Wakayama Medical University (WMU) and Burapha University Hospital (BUH), the two main hospitals in these provinces (ACS patient numbers: WMU, n=177; BUH, n=93), respectively. In the Chonburi Province, although the average temperature was above 25℃, the number of ACS cases in BUH varied up to threefold between months (minimum: July, 4 cases; maximum: October, 14 cases). In Japan and Thailand, there was a mild to moderate negative correlation between temperature-atmospheric pressure at the onset of ACS, but different patterns for temperature-humidity (temperature-atmospheric pressure, temperature-humidity, and atmospheric pressure-humidity: correlation index; r=-0.561, 0.196, and -0.296 in WMU vs. r=-0.356, -0.606, and -0.502 in BUH). Conclusions: The present study suggests that other climatic conditions and factors, not just temperature, might be involved in the mechanism of ACS.

Exploring the Role of Non-HDL Cholesterol in Acute Coronary Syndrome: A Case-Control Study

Objectives: This case-control study aimed to investigate the association between non-high-density lipoprotein (non-HDL) cholesterol levels and acute coronary syndrome (ACS) among individuals not recently treated with statins. Methodology: A total of 100 participants with ACS, who had not received recent statin therapy, were selected from the Coronary Care Unit (CCU) at Al-Kadhimiyah Hospital in Baghdad, Iraq. Controls, matching the eligibility criteria of cases except for ACS symptoms, were randomly chosen from the same hospital. Both groups met criteria including age over 40, and a history of diabetes mellitus, hypertension, smoking, and obesity. Statistical significance was set at p < 0.05. Results: The study found a significant independent association between elevated non-HDL cholesterol levels and ACS, with an average non-HDL level of 154.2 mg/dl (normal: 130 mg/dl) among ACS cases (p < 0.001), compared to 120 mg/dl in controls. Elevated non-HDL levels were also correlated with increased BMI (p = 0.01, r = 0.3) and various lipid markers (p < 0.05), except HDL. Conclusion: Elevated non-HDL cholesterol levels upon admission may serve as a potential indicator of ACS risk. These findings underscore the importance of non-HDL cholesterol assessment in ACS risk stratification and management.

Exploring the Spectrum of Acute Coronary Syndromes:

Abstract
 Objective: To present a case series highlighting the diverse clinical presentations and management approaches in patients with Acute Coronary Syndromes (ACS).
 Methods: We conducted a retrospective analysis of four ACS cases, focusing on clinical history, examination findings, diagnostic tests, and treatment strategies.
 Results: The case series includes patients with unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI) with acute decompensated heart failure, and ST-elevation myocardial infarction (STEMI). Each case illustrates the importance of early recognition and individualized management.
 Discussion: ACS encompasses a broad spectrum of clinical presentations, requiring prompt diagnosis and risk stratification for appropriate intervention. These cases emphasize the critical role of tailored management in improving patient outcomes.
 Conclusion: ACS management should consider the heterogeneity of clinical presentations and prioritize accurate diagnosis and risk assessment.

Cardiovascular Outcomes after Paclitaxel-Coated Balloon Angioplasty versus Drug-Eluting Stent Placement for Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

Background: We conducted a systematic review and meta-analysis to examine the feasibility of paclitaxel-coated balloon (PCB) angioplasty for de novo lesions in patients with acute coronary syndrome (ACS) by comparing with drug-eluting stent (DES) placement. Methods: By a systematic literature search, nine (five randomized controlled, two retrospective propensity-score matched, and two retrospective baseline-balanced) studies comparing the midterm clinical and angiographic outcomes after PCB angioplasty and DES placement were included, yielding 974 and 1130 ACS cases in PCB and DES groups, respectively. Major adverse cardiac event (MACE) was defined as a composite of cardiac mortality (CM), all-cause mortality (ACM), myocardial infarction (MI), target vessel revascularization (TVR), and target lesion revascularization (TLR). Late luminal loss (LLL) and bleeding events (BLD) were also estimated. Results: The frequencies of MACE in PCB and DES groups were 8.42% and 10.62%, respectively. PCB angioplasty had no significant impacts on all of MACE (risk ratio: 0.90, 95%CI: 0.68-1.18, p = 0.44), CM, ACM, MI, TVR, TLR, BLD, and LLL, compared to DES placement in random-effects model. Conclusions: The present systematic review and meta-analysis showed the feasibility of PCB angioplasty for the de novo lesions in patients with ACS in comparison with DES placement by the emergent procedures.

Impact of inflammatory bowel disease on the risk of acute coronary syndrome: A Swedish Nationwide Cohort Study.

There are conflicting data on the risk of acute coronary syndrome (ACS) in patients with inflammatory bowel disease (IBD). Only a few previous reports include patients diagnosed during the last decade. To assess and compare the risk of ACS between patients with IBD and the general population. In this cohort study, we used nationwide registers to identify patients diagnosed with IBD in Sweden 2003-2021. Every patient was matched by birth year, sex, calendar year and area of residence with up to 10 general population comparators. The primary outcome was incident ACS. We used semi-parametric Cox proportional hazard models to estimate hazard ratios (HRs). We identified 76,517 patients with IBD (Crohn's disease [CD], N = 22,732; ulcerative colitis [UC], N = 42,194 and IBD-unclassified, N = 11,591) and 757,141 comparators. During a median follow-up of 8 years, 2546 patients with IBD (37.5/10,000 person-years) were diagnosed with ACS compared with 19,598 (28.0/10,000 person-years) among comparators (HR 1.30; 95% confidence interval 1.24-1.35) after adjustments for confounding factors, and approximately one extra case of ACS in 100 IBD patients followed for 10 years. The highest HRs for ACS were in patients with elderly onset IBD (≥60 years) and among patients with CD or UC with extra-intestinal manifestations. No increased HRs were observed in patients diagnosed with IBD before the age of 40. In this contemporary cohort of patients with IBD, exposed to modern IBD care, there was an increased risk for ACS compared with individuals from the general population.

Histological and functional assessment of a Takotsubo cardiomyopathy model established by immobilization stress.

Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, resembles acute heart failure syndrome but lacks disease-specific diagnosis and treatment strategies. TTC accounts for approximately 5-6% of all suspected cases of acute coronary syndrome in women. At present, animal models of TTC are often created by large amounts of exogenous catecholamines such as isoproterenol. However, isoproterenol injection cannot fully simulate the onset of stress-induced cardiomyopathy in humans since stress is not an instantaneous event. Rats were immobilized for 6h per day for 1-14 days. To examine whether the TTC model was successful, echocardiography was employed; Elisa detected serum sympathetic activation markers; and the Open-Field test (OFT) was used to analyze behavioral changes in rats after stress. Western blot and histology were used to assess sympathetic remodeling, inflammation levels, and fibrosis; qRT-PCR was used to explore the levels of fibrosis and myocardial hypertrophy. The electrical stability of ventricular was determined by electrophysiological testing. The rats showed severe stress behavior and local sympathetic remodeling of the heart after only 1 day of stress. After 3 days of stress, the induction of ventricular tachyarrhythmia increased prominently. The highest incidence of TTC in rats was at 5 days of immobilization stress. The pathological left ventricular remodeling caused by immobilization (IMO) stress includes inflammatory infiltration, fibrosis, and myocardial hypertrophy. Our study confirms the hypothesis that IMO stress can mimic Takotsubo cardiomyopathy, and the various effects on the heart depending on the duration of IMO stress. We observed the highest incidence of TTC occurred after 5 days of stress. Furthermore, there is a gradual occurrence of electrical and structural remodeling as the stress duration prolongs.

Interactions Between Depression, Alcohol Intake, and Smoking on the Risk of Acute Coronary Syndrome.

Our study hypothesizes that the interaction between depression, alcohol intake, and smoking status can significantly influence the risk of acute coronary syndrome (ACS). We aim to investigate the magnitude of the association between depression and ACS risk and explore how alcohol intake and smoking status affect this association. We used data from the Korean Genome and Epidemiology Study. The primary exposure of interest was the presence of depression, as measured using the Beck Depression Inventory score at baseline. The primary outcome was the occurrence of ACS observed in the biennial follow-up surveys. We used Cox proportional regression analysis to estimate the effect of depression on ACS incidence. We conducted interaction and joint effect analyses to explore the interactions between depression and health-related habits including alcohol intake and smoking with regard to ACS incidence. During 16 years of follow-up among 3,254 individuals, we documented 88 cases of new-onset ACS (2.2 cases per 1,000 personyears). We found no association between depression and ACS risk; furthermore, the effect of depression on ACS risk by alcohol intake and smoking status did not differ significantly. In the analysis to observe the joint effect of smoking and depression, the multivariate hazard ratios of ACS were 1.26 (95% confidence interval [CI], 0.67-2.36) for non-smoking and depression, 1.52 (95% CI, 0.83-2.82) for smoking and non-depression, and 2.79 (95% CI, 1.21-6.41) for smoking and depression compared with non-smoking and non-depression. Our study reveals the combined effect of depression and smoking on ACS risk, highlighting the potential benefits of concurrent interventions for both depression and smoking for cardiovascular health.

Correlation of Serum Neutrophil Gelatinaseassociated Lipocalin with Clinical Severity Score in Patients with Acute Coronary Syndrome: A Cross-sectional Study

Introduction: Acute Coronary Syndrome (ACS) is a term that encompasses various clinical presentations such as ST-Segment Elevation Myocardial Infarction (STEMI), Non STEMI (NSTEMI), or unstable angina. Neutrophil Gelatinase-associated Lipocalin (NGAL), also known as lipocalin-2, belongs to the lipocalin category of extracellular proteins. Recent research indicates that NGAL levels are increased in different cardiac situations, regardless of the presence of acute renal injury. Aim: To compare the levels of serum NGAL and Global Registry of Acute Coronary Events (GRACE) scores between cases with ACS and Angio-negative cases, and to study the correlation of serum NGAL with the GRACE score (clinical severity score) in ACS patients. Materials and Methods: A cross-sectional study was conducted with 128 patients at the Department of Biochemistry, MKCG Medical College and Hospital, Berhampur, Odisha, India, presenting to the Cardiac Emergency Department from November 2020 to August 2021. Coronary Angiograms (CAG) were done to confirm the presence of Coronary Artery Disease (CAD), and patients were grouped accordingly as Group-1 with ACS patients and Group-2 with angiogram-negative cases. Apart from the routine work-up, including serum urea and creatinine, serum electrolytes, fasting blood sugar, lipid profile, and management, all patients underwent determination of serum NGAL levels and GRACE score at admission. The data were analysis using student’s t-test and Pearson’s correlation test. Results: Among the 128 participants (64 cases in Group-1 and 64 cases in Group-2), Group-1 comprised 37 cases of STEMI, 26 cases of NSTEMI, and one case of unstable angina. Serum NGAL levels were significantly elevated in patients with CAGproven ACS (140.89±56.47 ng/mL) without any renal dysfunction, sepsis, or overt infection compared to patients without CAD on CAG (52.01±18.39 ng/mL) (p<0.0001). The serum NGAL level exhibited a positive correlation of 0.359 (p=0.004) with the severity of ACS, as measured by the GRACE score. Conclusion: The present study suggests that serum NGAL in patients with ACS may serve as a potential novel biomarker for risk stratification and predicting the severity of the disease.

Rapid Plaque Progression in a Patient with Non-ST-Segment Elevation Acute Coronary Syndrome: A Case Report

Acute coronary syndrome (ACS), diagnosed by optical coherence tomography (OCT), is caused primarily by plaque rupture, plaque erosion, and calcified nodules. Plaque erosion is more common in patients with non-ST-segment elevation myocardial infarction than ST-segment elevation myocardial infarction. This study reports the details of a case of ACS caused by massive thrombus formation due to plaque erosion. The factors associated with plaque erosion and thrombosis could not be confirmed on the basis of clinical examination findings and the physicians’ experience; therefore, the initial diagnosis of an ischemic event was replaced by a diagnosis of rapid plaque progression, as microscopically confirmed by OCT. Therefore, OCT examination must be performed for blurred or “rapidly progressing” lesions identified through angiography.

Assessing the Role of MAPH Score in Predicting Acute Coronary Syndrome: A Cross-sectional Study

Introduction: Incorporating the concepts of hyperviscosity, platelet hyperactivity, and age-related risk of Acute Coronary Syndrome (ACS), a new score has been put forward-the Mean platelet volume-Age-total Protein-Haematocrit (MAPH) score, which can determine the increased thrombotic tendency associated with ST-Segment Elevation Myocardial Infarction (STEMI). The MAPH score includes parameters such as Mean Platelet Volume (MPV), age, total protein, and haematocrit. Researchers have found that a high MAPH score is associated with a high thrombus burden in cases with STEMI and Non ST-Elevation Myocardial Infarction (NSTEMI). However, the association between MAPH score and ACS is undefined. Aim: To assess the role of MAPH score in predicting ACS. Materials and Methods: This cross-sectional study was conducted in the Department of Pathology, Srinivas Institute of Medical Sciences and Research Centre Mangalore, Karnataka, India for six months. The study included 100 clinically diagnosed cases of ACS and 100 healthy controls. The demographic data, MPV, total protein, and haematocrit values of all cases and controls were collected and tabulated, and statistical analysis was performed. Receiver Operating Characteristic (ROC) curve analysis was performed on each MAPH score parameter, and cutoff values for each parameter were obtained based on the Youden index. After calculating the MAPH score of cases and controls, multivariate logistic regression analysis was performed to evaluate the role of the MAPH score as an independent predictor of ACS. Results: A statistically significant increase in MPV (p-value =0.017) and total protein (p-value<0.001) was noted among the cases. The calculated cut-off values for MPV, age, total protein, and haematocrit were 8.4 fL, 54 years, 6.8 g/dL, and 49.1%, respectively. A statistically significant increase in the MAPH score was noted among the cases compared to the controls. Finally, multivariate logistic regression analysis identified the MAPH score as an independent predictor of ACS. Conclusion: This was the first study investigating the association between MAPH scores in patients with ACS. The MAPH score was identified as an independent predictor of ACS and can be used as a screening tool to predict and diagnose the condition in primary healthcare settings. This helps to ensure early coronary revascularisation and reduce Coronary Artery Disease (CAD)- related mortality and morbidity to a greater extent.

Comparison of Acute Coronary Syndromes in the Earthquake Zone before and in the First Month after the Earthquake: A Single-center and Retrospective Analysis.

Earthquakes can significantly impact both the occurrence and the management of acute coronary syndromes (ACS). This study aimed to investigate the effects of an earthquake on patients with ACS by comparing their clinical and angiographic features before and after the event. We utilized a retrospective observational cohort design, involving 260 ACS patients who underwent coronary angiography. Data on patient characteristics, clinical variables, and procedural details were extracted from medical records. Statistical analyses were conducted to compare the ACS groups pre- and post-earthquake and to assess outcomes, which included in-hospital mortality and complications. After the earthquake, the ACS patients were older and predominantly male. The distribution of ACS subtypes remained similar between the groups. The use of anticoagulation before the procedure decreased after the earthquake, while the usage of other medications remained stable. The incidence of non-critical coronary arteries decreased post-earthquake, and there was a higher frequency of non-intervention in this group. Intervention in the left anterior descending coronary artery was more common after the earthquake. In-hospital mortality was associated with post-earthquake ACS, certain ACS subtypes, shock at admission, bifurcation stenting, and the no-reflow phenomenon. Complete revascularization was found to reduce mortality. The duration of intensive care unit stays was longer before the earthquake, while in-hospital mortality was higher after the earthquake. Gender differences were observed in coronary ectasia, with females being more affected post-earthquake. Earthquakes significantly influence the clinical and angiographic features of ACS cases, thereby affecting mortality rates and revascularization outcomes.

A CASE OF ACUTE CORONARY SYNDROME UNDER IMMUNSUPRESSION WHO IS THE CRIMINAL NEUTROPHILS OR T CELLS?

Chronic granulomatous disease (CGD) is a primary immunodeficiency characterized by recurrent, life-threatening bacterial and fungal infections of the skin, airways, lymph nodes, liver, brain, and bones. These infections most commonly occur in organs in contact with the outside world (lungs, gastrointestinal tract, and skin), as well as in lymph nodes that drain these structures. While involvement can be seen in many organs, there is no known cardiovascular involvement. Our case is an ACS case that has a different place in the literature because acute coronary syndrome (ACS) was seen in a 20-year-old male patient with a diagnosis of chronic granulomatous disease.

A review of the risk and precipitating factors for spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) accounts for 1%-4% of cases of acute coronary syndrome (ACS). SCAD is caused by separation occurring within or between any of the three tunics of the coronary artery wall. This leads to intramural hematoma and/or formation of false lumen in the artery, which leads to ischemic changes or infarction of the myocardium. The incidence of SCAD is higher in women than in men, with a ratio of approximately 9:1. It is estimated that SCAD is responsible for 35% of ACS cases in women under the age of 60. The high frequency is particularly observed during pregnancy and in the peripartum period (first week). Traditional risk factors are rare in patients with SCAD, except for hypertension. Patients diagnosed with SCAD have different combinations of risk factors compared with patients who have atherosclerotic changes in their coronary arteries. We presented the most common so-called "non-traditional" risk factors associated with SCAD patients. In the literature, there are few diseases frequently associated with SCAD, and they are identified as predisposing factors. The predominant cause is fibromuscular dysplasia, followed by inherited connective tissue disorders, systemic inflammatory diseases, pregnancy, use of sex hormones or steroids, use of cocaine or amphetamines, thyroid disorders, migraine, and tinnitus. In recent years, the genetic predisposition for SCAD is also recognized as a predisposing factor. The precipitating factors are also different in women (emotional stress) compared with those in men (physical stress). Women experiencing SCAD frequently describe symptoms of anxiety and depression. These conditions could increase shear stress on the arterial wall and dissection of the coronary artery wall. Despite the advancement of SCAD, we can find significant differences in the clinical presentation between women and men. When evaluating patients with chest pain or other ACS symptoms who have a low cardiovascular risk, particularly female patients, it is important to consider the possibility of ACS due to SCAD, particularly in conditions often associated with SCAD. This will increase the recognition of SCAD and the timely treatment of affected patients.

Acute coronary syndrome with single‑lead ST segment elevation: A rare presentation of multivessel coronary artery disease

We report the case of a 73-year-old male admitted for epigastric pain and syncope with increased troponin level and a rare electrocardiogram (a single‑lead ST-elevation). Coronary angiography showed multi-vessel coronary artery disease. The patient underwent coronary angioplasty with drug-eluting stenting on left anterior descending coronary artery and drug eluting ballooning on first diagonal ostium. Coronary revascularization was completed with a staged stenting on left circumflex artery and right coronary artery.In rare cases of acute coronary syndrome, even isolated ST single lead anomalies may underlie multivessel coronary disease.

Pharmacogenomic evaluation of CYP2C19 alleles linking low clopidogrel response and the risk of acute coronary syndrome in Indians.

Clopidogrel is an antiplatelet drug widely prescribed to prevent atherothrombotic events in coronary artery disease patients. However, there is evidence to suggest that the effectiveness of clopidogrel varies owing to genetic diversity in CYP2C19. This heterogeneity in South Asians, who are also known to have high risk of cardiac events than other population groups, highlights the importance of investigating CYP2C19 variants to estimate the risk proportion in the groups. Given the high prevalence and genetic heterogeneity, the population-based case control was conducted in a cohort of 1191 subjects comprising 645 acute coronary syndrome (ACS) cases (unstable angina, ST-elevation myocardial infarction, and non-ST-elevation myocardial infarction) and 546 healthy controls of South Asian Indian origin. The metabolization status of CYP2C19 was assessed using *2, *3 and *17 variants in the stated cohorts to determine the prevalence of metabolization and its association with phenotypes. The results suggest a possible genetic association between studied CYP2C19 polymorphisms and ACS, since there was a higher proportion of intermediate and poor metabolizers present in the studied cohorts. The association analyses revealed that the *2 allele of CYP2C19 confers a significant risk for ACS, while the *17 allele provides protection. These findings contribute to the understanding of CYP2C19 genetic variants and their impact on clopidogrel response in South Asian Indians. Additionally, they underline the significance of assessing CYP2C19 variations in patients receiving clopidogrel therapy in order to improve therapeutic outcomes.

Abstract 16199: Postsurgical Takotsubos Complicated by Clot Burden in the Setting of Heterozygous Prothrombin Gene Mutation

Introduction: Postsurgical Takotsubo cardiomyopathy (TCM) is associated with acute stress secondary to catecholamine release causing reversible left ventricular (LV) failure. We present a diagnostically challenging presentation of postsurgical TCM with underlying prothrombin gene mutation. Case Presentation: A 53 year old female underwent laparoscopic hysterectomy 2 days prior to presentation with chest pain and shortness of breath. Vitals were unremarkable, labs showed elevated troponin and EKG consistent with NSTEMI. CTA chest demonstrated significant clot burden to the ascending and descending aorta. Echocardiogram revealed a reduced ejection fraction (EF) of 25-30% with apical ballooning and thrombus. She was admitted on heparin drip and completed an infusion of eptifibatide for 24 hours. Repeat CTA chest demonstrated mildly reduced clot burden. Left heart catheterization (LHC) was precluded due to aortic arch clot. Coronary CTA revealed no CAD with a calcium score of 0. Coagulopathy workup showed heterozygous prothrombin G20210A variant. She was discharged on warfarin. Repeat echocardiography 1 month later showed improved EF to 40-45%. Discussion: TCM accounts for 1-3% of cases of acute coronary syndromes (ACS) and affects women at a rate of 90%. Studies have shown that TCM with apical ballooning is minimally associated with LV thrombus . The presence of heterozygous prothrombin gene mutation increases risk of clot formation by 2 to 3 times. Surgery can cause this risk to dramatically increase. Coronary CTA was the best noninvasive approach to make the diagnosis as the risk of LHC was too great given the anatomic challenge of the aortic arch clot. We advocate for hypercoagulable workups to inform management of anticoagulation in patients with clotting events without known risk factors for thrombus formation.

Twenty-five-year trends in incidence, angiographic appearance, and management of spontaneous coronary artery dissection

BackgroundSpontaneous coronary artery dissection (SCAD) has been described as an infrequent cause of acute coronary syndrome (ACS). Knowledge about the disease is still limited and SCAD might still be underdiagnosed. ObjectivesTrends in incidence, presentation, angiographic appearance, management, and outcomes of SCAD over 25 years were analyzed. MethodsPatients with SCAD between 1997 and 2021 at the University Hospital Zurich, Switzerland, were included. Incidences were assessed as total numbers and proportions of ACS cases. Clinical data were collected from medical records and angiographic findings were reviewed. Major adverse cardiac events (MACE) were defined as the composite of all-cause death, cardiac arrest, SCAD recurrence or progression, other myocardial infarction, and stroke. ResultsOne hundred fifty-six SCAD cases were included in this study. The incidence increased significantly in total (p < 0.001) and relative to ACS cases (p < 0.001). This was based on an increase of shorter lesions (p = 0.004), SCAD type 2 (p < 0.001), and lesions in side branches (p = 0.014), whereas lesions in the left main coronary artery and proximal segments were decreasing (p-values 0.029 and < 0.001, respectively). There was an increase in conservative therapy (p < 0.001). The rate of MACE (24%) was stable, however, there was a reduced proportion of patients with a need for intensive care treatment (p = 0.017). ConclusionsSCAD represents an important entity of ACS that still might be underappreciated. The increasing incidence of SCAD is likely based on better awareness and familiarity with the disease. A lower need for intensive care treatment suggests positive effects of the increasing implementation of conservative management.

Risk factor profile and outcomes of premature acute coronary syndrome after percutaneous coronary intervention: A 1-year prospective design.

The prevalence of acute coronary syndrome (ACS) among young adults (premature ACS) has dramatically increased in recent years, especially in developing countries. Yet, the data on these patients' attributed risk factors and outcomes are inconsistent. In this study, we aimed to investigate these data in a cohort of premature ACS cases who underwent percutaneous coronary intervention (PCI) compared to older patients. We hypothesize that premature ACS patients undergoing PCI will exhibit different risk factor profiles and outcomes compared to non-premature patients. specifically, we anticipate that premature patients do not necessarily have better outcomes than non-premature. Overall, 3142 and 10 399 patients were included in premature and non-premature groups, respectively. Patients' pre-operative, post-operative, and follow-up data were retrieved retrospectively from the Tehran Heart Center PCI databank. The mean age of premature and non-premature cohorts was 48.39 and 67 years, respectively. Patients were predominantly male in both groups. Family history of coronary artery disease (CAD), dyslipidemia, smoking, and opium addiction were more prevalent among the younger cohort. After adjustment, in-hospital mortality in younger patients was considerably higher, with all-cause mortality and major cardiovascular and cerebrovascular events (MACCE) exhibiting no noticeable difference among the two groups. Risk factor profile is different in young patients, and traditional cardiovascular risk factors, such as hypertension and diabetes mellitus, are more prevalent among older adults. Younger age is not equivalent to a better prognosis; hence, similar or even more caution should be taken into consideration regarding secondary prevention for these patients.