Coronary Narrowing Research Articles

Thirty-Day Outcomes After Unrestricted Implantation of Bioresorbable Vascular Scaffold (from the Prospective RAI Registry)

The Absorb biovascular scaffold (BVS) is a bioresorbable, everolimus-eluting scaffold whose data on real-world patients with complex lesions are limited. Short-term follow-up from recent studies point to a higher rate of 30-day thrombosis than observed with drug-eluting stents. We aimed to understand the short-term safety and efficacy of BVS. Registro Absorb Italiano (RAI, ClinicalTrials.gov:NCT02298413) is an Italian, prospective, multicenter registry not funded, whose aim is to investigate BVS performance through a 5-year follow-up of all consecutive patients who have undergone successful implantation of ≥1 BVS in different clinical/lesion subsets. Co-primary end points were target lesion revascularization and definite/probable thrombosis. Secondary end point was the occurrence of device-oriented cardiac events. The registry involved 23 centers, with patient enrollment from October 2012 to December 2015. We here report the 30-day outcomes of the whole population of the registry. We enrolled 1,505 consecutive patients, of which 82% were men and 22.4% diabetic. At presentation, 59.6% of the patients had an acute coronary syndrome, including 21% ST-elevation myocardial infarction. All lesions were pre-dilated and in 96.8% of the cases BVS was post-dilated. At 30days, the co-primary study end point target lesion revascularization occurred in 0.6% of patients and definite/probable BVS thrombosis in 0.8%. There were 2 cases of cardiac and overall death (0.13%). Device-oriented cardiac events occurred in 1% of the patients. In conclusion, our data of consecutive patients suggest that current use of BVS in a wide spectrum of coronary narrowings and clinical settings is associated with good outcome at 30days.

Comparison of Frequency and Characteristics of Patients With Atrial Fibrillation Having Ablation With Versus Without Coronary Narrowing (≥50%) by Angiography

Atrial fibrillation (AF) shares background comorbidities with coronary artery disease (CAD), including hypertension and diabetes mellitus. The aim of the study is to evaluate the prevalence, risk factors, and prognostic significance of CAD among patients who underwent catheter ablation for AF. In 544 consecutive registered patients who underwent catheter ablation for AF (CHADS2 score 1.2 ± 1.1, paroxysmal AF 57%), quantitative coronary angiography was used to detect CAD, defined as luminal narrowing of ≥50% in diameter. Univariate and multiple logistic regression analyses were applied to evaluate the risk factors of CAD. Subsequent clinical events up to 1 year were obtained in all the patients. CAD was found in 70 patients (13%). The factors associated with the presence of CAD in AF patients who underwent catheter ablation were similar to traditional coronary risk factors such as hypertension and diabetes mellitus. AF patients with CAD had a higher CHADS2 score than those without CAD (1.5 ± 1.1 vs 1.1 ± 1.0, p= 0.009). Hence, a CHADS2 score ≥1 may be an alternative risk factor to predict CAD. Previous coronary revascularization (14% with CAD vs 6% without CAD) and paroxysmal AF (69% vs 55%) were also associated with CAD. During follow-up, patients with CAD experienced acute coronary syndrome (n= 2) and coronary revascularization (n= 18); no such events were recorded in those without CAD. In addition to traditional risk factors, CHADS2 score, previous revascularization, and paroxysmal AF may be new risk factors for CAD in AF patients.

Meta-Analysis of Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Narrowing

Patients with unprotected left main coronary artery (ULMCA) disease are increasingly treated with percutaneous coronary intervention (PCI) using new-generation drug-eluting stents (DES); however, the benefits of DES compared with coronary artery bypass grafting (CABG) in ULMCA remain controversial. This meta-analysis evaluated the effects of PCI with DES compared with CABG for the treatment of ULMCA stenosis. Databases were searched through November 30, 2016. Randomized controlled trials (RCTs) comparing DES with PCI versus CABG for ULMCA stenosis were identified. We calculated summary odds ratios (ORs) and 95% CIs with the random-effects model. The primary outcome was major adverse cardiovascular events, defined as a composite of death from any cause, stroke, or myocardial infarction (MI). The analysis included 4,612 patients from 5 RCTs. Compared with CABG, patients assigned to PCI had a similar rate of major adverse cardiovascular events (OR 1.06, 95% CI 0.79 to 1.43), all-cause mortality (OR 1.03, 95% CI 0.79 to 1.35), cardiovascular death (OR 1.03, 95% CI 0.73 to 1.45), stroke (OR 0.81, 95% CI 0.38 to 1.76), and MI (OR 1.47, 95% CI 0.87 to 2.47). The risk of any repeat revascularization was significantly greater in the PCI group than that in the CABG group (OR 1.85, 95% CI 1.53 to 2.24). In conclusion, our meta-analysis of RCTs suggest that PCI with DESresults in comparable mortality, stroke, and MI compared with CABG for revascularization of ULMCA stenosis, with PCI associated with higher rates of repeat revascularization.

Meta-Analysis of Randomized Control Trials Comparing Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Significant Left Main Coronary Narrowing

Previous meta-analyses showed that drug-eluting stent (DES) implantation may serve as an alternative to coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) stenosis, largely driven by data from registries. Hence, we performed a meta-analysis of randomized controlled trials (RCTs) to overcome this limitation. PubMed, the Cochrane Library, and Scopus were systematically searched through October 2016 to identify eligible RCTs. The primary outcomes were major adverse cardiac and cerebrovascular events (MACCE) at 1-year and long-term (≥3years) follow-ups. This meta-analysis included 5 RCTs, totaling 4,595 patients with ULMCA disease. Compared with CABG, DES showed similar 1-year rates of MACCE (risk ratio [RR] 1.14, 95% confidence interval [CI] 0.91-1.42), all-cause death, and myocardial infarction, with a higher incidence of revascularization (RR 1.68, 95% CI 1.24-2.27) and lower incidence of stoke (RR 0.43, 95% CI 0.23-0.78). At long-term follow-up, DES placement was inferior to CABG in terms of MACCE (RR 1.27, 95% CI 1.13-1.43) and revascularization (RR 1.70, 95% CI 1.43-2.01). There was no difference in long-term risk of other outcomes between these 2 strategies. In conclusion, DES stenting and CABG for ULMCA disease yield comparable rates of MACCE at 1-year follow-up; however, CABG is associated with a decreased risk of long-term MACCE compared with DES, exclusively driven by the considerable reduction in revascularization events.

Do we need invasive confirmation of cardiac magnetic resonance results?

IntroductionCoronary artery revascularization is indicated in patients with documented significant obstruction of coronary blood flow associated with a large area of myocardial ischemia and/or untreatable symptoms. There are a few invasive or noninvasive methods that can provide information about the functional results of coronary artery narrowing. The application of more than one method of ischemia detection in one patient to reevaluate the indications for revascularization is used in case of atypical or no symptoms and/or borderline stenosis.AimTo evaluate whether the results of cardiac magnetic resonance need to be reconfirmed by the invasive functional method.Material and methodsThe hospital database revealed 25 consecutive patients with 29 stenoses who underwent cardiac magnetic resonance (CMR) and fractional flow reserve (FFR) between the end of 2010 and the end of 2014. The maximal time interval between CMR and FFR was 6 months. None of the patients experienced any clinical events or underwent procedures on coronary arteries between the studies.ResultsAccording to the analysis, the agreement of CMR perfusion with the FFR method was at the level of 89.7%. Assuming that FFR is the gold standard in assessing the severity of stenoses, the sensitivity of CMR perfusion was 90.9%. The percentage of non-severe lesions which were correctly identified in CMR was 88.9%.ConclusionsThe study shows that CMR perfusion is a highly sensitive method to detect hemodynamically significant CAD and exclude nonsevere lesions. With FFR as the reference standard, the diagnostic accuracy of MR perfusion to detect ischemic CAD is high.

Association between Left Ventricular Global Longitudinal Strain and Functional Capacity Measured with Six-Minutes Walk Test in Patients after Acute Myocardial Infarction

Background: The ischemia resulting from critical coronary narrowing or total occlusion first affects the subendocardialmyofibers. Thus, abnormalities in longitudinal function can be detected before reductions in LVEF and reflects infarct size. The 6MWT provides information that may be a better index of the patients ability to perform daily activities. This study was to assess the relationship between left ventricular (LV) global longitudinal strain (GLS) and functional capacity measured with 6 minute walk test (6MWT) after AMI.Subjects and Method: This is a cross sectional study of patients with STEMI and NSTEMI, at Moewardi Hospital, Surakarta. Eligible patients underwent echocardiography global longitudinal 2D-STE that performed within 48 hour of admission and 6MWT pre- discharge or at the first follow-up visits (day 4-9). Patients were divided into 2 groups according to the LV GLS value, patients with substantial infarction (LV GLS > -13.8%) and non-substantial infarction (LV GLS -13.8% (n=32) were more likely to be older (57.6 y.ovs 55 y.o), less in functional capacity (10.17 1.3 ml/kg/min vs 11.04 0.98 ml/kg/min; p= 0.018) and less in 6 MWT distance (347.97 65.49 m vs392.39 49.44 m; p=0.016). Using ROC curves, the 6 MWT distance cutoff value of 375 m identified patients with LV GLS >-13.8%, sensitivity of 72.2% and specificity 65.6%, respectively with AUC= 0.70 (CI 95%; 0.559-0.852; p= 0.017). However, LV GLS >-13.8% and age >60 y.o remained the independent predictor in a multivariate logistic regression analysis to identify 6 MWT distance -13.8%, (OR =7.967; CI 95%= 1.669-38.030; p=0.009) and age >60 y.o, (OR=10.898; CI95%= 2.201-53.971; p=0.003).Conclusions: In patients after AMI with substantial infarction (LV GLS >-13.8%) had less in functional capacity. The 6 MWT distance cutoff value of 375 m identified patients with LV GLS >-13.8% and could be used in rehabilitation program after AMI.Keywords: Acute Myocardial Infarction, LV Global longitudinal strain, functional capacity, 6 MWT.Correspondence:Trisulo Wasyanto. Department of Cardiology and Vascular Medicine, Faculty of Medicine, Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami No. 36 A, 57126, Surakarta, Central Java.Indonesian Journal of Medicine (2017), 2(3): 192-206https://doi.org/10.26911/theijmed.2017.02.03.07

Outcomes of First- Versus Second-Generation Drug-Eluting Stent Implanted for Right Coronary Artery Ostial Narrowing

Clinical outcome is generally poor when stents are implanted at right coronary artery ostial lesion (RCAos). We compared the clinical outcome between the first-generation drug-eluting stent (first DES) and second-generation drug-eluting stent (second DES) used for RCAos. Consecutive 88 patients who underwent percutaneous coronary interventions of de novo RCAos using the first DES (33 patients) or second DES (55 patients) were analyzed. The incidence of major adverse cardiac events (MACE) defined as the composite of cardiac death, myocardial infarction attributed to right coronary artery, and target lesion revascularization within 2.5years was compared. The incidence of MACE was significantly lower in second DES (11% vs 36%, p= 0.010) than that in the first DES. Multivariate analysis revealed use of second DES (odds ratio 0.24, 95% CI 0.11 to 0.93, p= 0.008) alone was significantly associated with MACE. In conclusion, second DES revealed better clinical outcome than the first DES when used in de novo RCAos.

Prognostic implications of coronary artery calcium in the absence of coronary artery luminal narrowing

Background and aimsCoronary artery calcium (CAC) scoring is a predictor of future adverse clinical events, and a surrogate measure of overall coronary artery plaque burden. Coronary computed tomographic angiography (CCTA) is a contrast-enhanced method that allows for visualization of plaque as well as whether that plaque causes luminal narrowing. To date, the prognosis of individuals with CAC but without stenosis has not been reported. We explored the prevalence of CAC>0 and its prognostic utility for future mortality for patients without luminal narrowing by CCTA. MethodsFrom 17 sites in 9 countries, we identified patients without known coronary artery disease, who underwent CAC scoring and CCTA, and were followed for >3 years. CCTA was graded for % stenosis according to a modified American Heart Association 16-segment model. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) for incident mortality and compared risk of death for patients as a function of presence or absence of CAC and presence or absence of luminal narrowing by CCTA. ResultsAmong 6656 patients who underwent CCTA and CAC scoring, 399 patients (6.0%) had no coronary luminal narrowing but CAC>0. During a median follow-up of 5.1 years (IQR: 3.9–5.9 years), 456 deaths occurred. Compared to individuals without luminal narrowing or CAC, individuals without luminal narrowing but CAC>0 were older, more likely to be male and had higher rates of diabetes, hypertension, and dyslipidemia. Individuals without luminal narrowing but CAC experienced a 2-fold increased risk of mortality, with increasing risk of mortality with higher CAC score. Following adjustment, incident death persisted (HR, 1.8; 95% CI, 1.1–2.9, p = 0.02) among patients without luminal narrowing but with CAC>0 compared with patients whose CACS = 0. Individuals without luminal narrowing but CAC ≥100 had mortality risks similar to individuals with non-obstructive CAD (0 < stenosis<50%) by CCTA [HR 2.5 (95% CI 1.3–4.9) and 2.2 (95% CI 1.6–3.0), respectively]. ConclusionsPatients without luminal narrowing but with CAC experience greater risk of 5-year mortality. Patients with CAC score ≥100 and no coronary luminal narrowing experience death rates similar to those with non-obstructive CAD.

Characteristics, circumstances and pathology of sudden or unnatural deaths of cases with evidence of pathological hoarding

The study aimed to determine the characteristics and circumstances of cases sudden or unnatural death (n = 61) with evidence of pathological hoarding, their major organ pathology and toxicology. The mean age was 65·8 yrs (a mean of 16.1 years of potential life lost), 62·3% were male, and 28·2% were obese. 95·1% lived alone, and 96·7% died in their residence, with no medical intervention. In all cases severe squalor and extensive hoarding were noted. The direct cause of death was attributed to disease in 75·4%, heart disease being a significant factor in 52·5%. Accidents causing death directly related to hoarding occurred in two cases. Autopsy revealed extensive pathology: severe coronary artery narrowing (42·4%), myocardial replacement fibrosis (44·1%), emphysema (39·0%), nephrosclerosis (46·6%). Signs of hypothermia were present in 14·8%, and diabetes was diagnosed in 21·3%. The most commonly detected substance was alcohol (32·1%). Medications for heart disease (5·4%) or diabetes (7·1%) were rare. The overall clinical picture was of an isolated group, with a heavy burden of physical disease and, in all probability, a high level of psychiatric disorders, who died alone in their homes.

Feasibility of omitting provocation test with 50μg of acetylcholine in left coronary artery.

According to the Japanese Circulation Society guideline of vasospastic angina, incremental doses of acetylcholine (ACh) are prescribed for coronary spasm provocation: 20 and 50μg for the right coronary artery (RCA), and 20, 50 and 100μg for the left coronary artery (LCA). However, provocation by low doses of ACh in patients with low vasoreactivity may be less needed, and the requirement of 50μg of ACh for the LCA in these patients has not been evaluated. In the present study, patients who underwent ACh provocation test for both the RCA and LCA were included. The positive diagnosis of intracoronary ACh provocation test was defined as total or subtotal coronary artery narrowing (i.e., angiographic coronary artery spasm) accompanied by chest pain and/or ischemic electrocardiographic changes. Coronary artery constriction was visually evaluated and defined as coronary artery diameter reduction <25 or 25-90% in patients without angiographic coronary artery spasm by 20µg of ACh in the LCA. There were 33 out of 249 patients (13%) with LCA spasm by 20µg of ACh. In subjects without LCA spasm by 20µg of ACh, patients with coronary constriction <25% (n=101) by 20µg of ACh in the LCA rarely showed coronary artery spasm induced by 50μg of ACh in the LCA, in comparison to those with coronary constriction 25-90% (n=115) (2.6 vs. 32.7%, p<0.001). None of the patients with coronary constriction <25% by 20µg of ACh in the LCA had cardiac complications associated with administration of ACh. In conclusion, omission of 50µg of ACh in the LCA may be possible when there is little coronary artery constriction by 20µg of ACh in the LCA during provocation test, leading to less contrast and shortens overall procedure time.

Deaths in triathletes: immersion pulmonary oedema as a possible cause.

Background/aimTo address the question as to whether immersion pulmonary oedema (IPO) may be a common cause of death in triathlons, markers of swimming-induced pulmonary oedema (SIPO) susceptibility were sought in triathletes' postmortem examinations.MethodsDeaths while training for or during triathlon events in the USA and Canada from October 2008 to November 2015 were identified, and postmortem reports requested. We assessed obvious causes of death; the prevalence of left ventricular hypertrophy (LVH); comparison with healthy triathletes.ResultsWe identified 58 deaths during the time period of the review, 42 (72.4%) of which occurred during a swim. Of these, 23 postmortem reports were obtained. Five individuals had significant (≥70%) coronary artery narrowing; one each had coronary stents; retroperitoneal haemorrhage; or aortic dissection. 9 of 20 (45%) with reported heart mass exceeded 95th centile values. LV free wall and septal thickness were reported in 14 and 9 cases, respectively; of these, 6 (42.9%) and 4 (44.4%) cases exceeded normal values. 6 of 15 individuals (40%) without an obvious cause of death had excessive heart mass. The proportion of individuals with LVH exceeded the prevalence in the general triathlete population.ConclusionsLVH—a marker of SIPO susceptibility—was present in a greater than the expected proportion of triathletes who died during the swim portion. We propose that IPO may be a significant aetiology of death during the swimming phase in triathletes. The importance of testing for LVH in triathletes as a predictor of adverse outcomes should be explored further.

Correlation Between Quantitative Angiography–Derived Translesional Pressure and Fractional Flow Reserve

Fractional flow reserve (FFR) is widely used for the assessment of myocardial ischemia. However, it has the disadvantage of cost and invasive complication risks. We investigated the usefulness of quantitative coronary angiography-derived translesional pressure (QCA-TP) for predicting functional myocardial ischemia, using FFR as the gold standard. We retrospectively analyzed 152 coronary narrowings (98 left anterior descending arteries, 28 left circumflex arteries, and 26 right) in 132 patients with mild-severe coronary stenosis who underwent coronary angiography and FFR measurements simultaneously. QCA-TP was calculated using software implemented in the QCA software. Coronary morphology was calculated using both densitometry and lumen edges. Functional myocardial ischemia was defined as an FFR of 0.8 or less. The mean values of diameter stenosis by QCA and FFR were 48.9% ± 14.9 and 0.76 ± 0.14, respectively. QCA-TP was significantly correlated with FFR (r= 0.76, p <0.01). The cut-off values of QCA-TP for predicting functional myocardial ischemia based on FFR were 72.8mm Hg for the left anterior descending arteries (accuracy, 86.7%; area under the curve [AUC], 0.93), 60.5mm Hg for the left circumflex arteries (accuracy, 89.3%; AUC, 0.88), and 64.4mm Hg for the right (accuracy, 88.5%; AUC, 0.94). Therefore, our data suggest that QCA-TP can predict myocardial ischemia with high diagnostic accuracy.

Effect of Fractional Flow Reserve (≤0.90 vs >0.90) on Long-Term Outcome (>10 Years) in Patients With Nonsignificant Coronary Arterial Narrowings

We assessed the long-term (>10years) clinical course of patients with documented coronary lesions deemed nonsignificant according to fractional flow reserve (FFR) assessment and investigated whether the initial FFR value impacted on prognosis. From January 2000 to October 2003, all patients submitted to coronary angiography with FFR measurement were included in a single-center, prospective registry. Patients with an FFR value >0.80 were treated medically without revascularization. Major adverse cardiac events (MACE) (death, acute coronary syndrome (ACS), or coronary revascularization) were compared according to initial FFR value (absolute value and by category, ≤0.90 vs >0.90). Analyses were performed using a multivariable Cox model and propensity score matching. Among 257 patients (332 lesions) treated medically initially, 131 (51%, 143 lesions) had FFR ≤0.90 and 126 (49%, 189 lesions) >0.90. During follow-up (median duration, 11.6years), 82 (31.9%) had a MACE, 38 (14.8%) died, 17 (6.6%) had ACS, 93 (36.2%) had repeat coronary angiography, and 27 (10.5%) had revascularization. There was no clinical, biologic or angiographic difference between patients with initial FFR value ≤0.90 versus >0.90. Adjusted Cox model showed no difference in relative risk of MACE, death, ACS, or revascularization. Coronary angiographies were numerically more frequent in patients with FFR ≤0.90, versus FFR >0.90. These findings were confirmed by propensity score-matched comparison. In patients with coronary narrowings left unrevascularized based on FFR, an FFR value between 0.80 and 0.90 has no impact on long-term outcome compared with those with FFR >0.90. In conclusion, patients with high FFR values should not be considered as having a lower risk of coronary event.

Correlations Between the Gradient of Contrast Density, Evaluated by Cardio CT, and Functional Significance of Coronary Artery Stenosis

Abstract Background: Assessment of the hemodynamic significance of a coronary artery stenosis is a challenging task, being extremely important for the establishment of indication for revascularization in atherosclerotic coronary artery stenosis. The aim of this study was to evaluate the role of a new marker reflecting the functional significance of a coronary artery stenosis, represented by the attenuation degree of contrast density along the stenosis by Coronary CT. Material and Method: We evaluated retrospectively 30 patients with angina and coronary luminal narrowing, who underwent 64-slice Coronary Computed Tomography Angiography. We measured the stenosis degree, intraluminal contrast density (Hounsfield units [HU]) at two levels, proximal and distal to stenosis, and the attenuation gradient was calculated on this basis. Results: The average contrast density was 77,96 UH proximal to the stenosis and 67,6 UH distal to the stenosis. The average transluminal gradient was 10,36. The average length of the coronary lesions was 16,93 mm. In those lesions with significant stenosis, expressed by &gt;70% luminal narrowing, we recorded a significantly higher transluminal attenuation gradient as compared to those with &lt;70% luminal narrowing (6.16 +/−3.7, 95%CI 4.3-80 vs 16.6 +/− 8.4, 95% CI 11.3 – 21.9). The degree of luminal narrowing significantly correlated with the contrast attenuation gradient (r=0.71, p&lt;0.001). Conclusions: The assessment of intraluminal contrast density by Coronary Computed Tomography Angiography may represent a new noninvasive tool to obtain relevant information about the clinical significance of a coronary stenosis. Larger studies are requested to emphasize the benefits brought by CCTA in evaluating coronary lesions.

Selective subepicardial localization of monocyte subsets in response to progressive coronary artery constriction.

Following myocardial infarction and atherosclerotic lesion development, monocytes contribute to myocardial protection and repair, while also partaking in myocardial ischemic injury. The balance of proinflammatory and reparative monocyte subsets is crucial in governing these therapeutic and pathological outcomes. Myocardial ischemic damage displays heterogeneity across the myocardium, whereby the subendocardium shows greatest vulnerability to ischemic damage. In this study we examined the transmural distribution of monocyte subsets in response to gradual coronary artery occlusion. CD14(+) monocytes were isolated from peripheral blood of New Zealand White rabbits and divided into two subgroups based on the expression of CD62L. We employed a rabbit model of progressive coronary artery obstruction to induce chronic myocardial ischemia and reinfused fluorescently labeled autologous monocytes. The distribution of fluorescently labeled autologous monocytes was examined with a high-resolution three-dimensional imaging cryomicrotome. The subepicardial layer contained the largest infiltration of both monocyte subgroups, with a significantly greater proportion of CD14(+)CD62L(+) monocytes at the time when the ischemic area was at a maximum. By targeting CD13(+) angiogenic vessels, we confirmed the presence of angiogenesis in epicardial and midmyocardial regions. These myocardial regions demonstrated the highest level of infiltration of both monocyte subsets. Furthermore, CD14(+)CD62L(+) monocytes showed significantly greater migration towards monocyte chemoattractant protein-1, greater adhesive capacity, and higher expression of C-C chemokine receptor type-2 relative to CD14(+)CD62L(-) monocytes. In conclusion, we note selective subepicardial distribution of monocyte subpopulations, with changes in proportion depending on the time after onset of coronary narrowing. Selective homing is supported by divergent migratory properties of each respective monocyte subgroup.

Short-term Prognosis of Fragmented QRS Complex in Patients with Non-ST Elevated Acute Myocardial Infarction.

Background:There remains significant debate as to the relationship between fragmented QRS (fQRS) complexes on electrocardiogram (ECG) and acute myocardial infarction (AMI). Few studies have reported on this relationship in non-ST elevated AMI (NSTEMI), and thus, we attempt to assess this relationship and its potential short-term prognostic value.Methods:This was a single-center, observational, retrospective cohort study. A total of 513 consecutive patients (399 men, 114 women) with NSTEMI within 24 h who underwent coronary angiography at our department, between January 1, 2014, and December 31, 2014. Patients were divided into 2 groups according to the presence or absence of fQRS complex on the admission ECG. fQRS complexes were defined as the existence of an additional R’ or crochetage wave, notching in the nadir of the S wave, RS fragmentation, or QS complexes on 2 contiguous leads. All patients were followed up for 6 months, and all major adverse cardiac events (MACE) were recorded.Results:In this study, there were 285 patients with fQRS ECG in the 513 patients with NSTEMI. The number of patients with 0–2 coronary arteries narrowed by ≥50% in fQRS group were less while patients with 3 narrowed arteries were more than in the non-fQRS group (P = 0.042). There were fewer Killip Class I patients in the fQRS group (P = 0.019), while Killip Class II, III, and IV patients were more in the fQRS group than in the non-fQRS group (P = 0.019). Left ventricular ejection fraction levels were significantly lower in the fQRS group (P = 0.021). Baseline total cholesterol, low-density lipoprotein, creatinine, creatine kinase, homocysteine, high-sensitivity C-reactive protein (CRP), and red blood cells distribution width levels were significantly higher in the fQRS group. Total MACE (MACE, P = 0.028), revascularization (P = 0.005), and recurrent angina (P = 0.005) were also significantly greater in the fQRS group. On final logistic regression analysis, after adjusting for baseline variables, the following variables were independent predictors of fQRS: Coronary artery narrowing (P = 0.035), Killip classification (P = 0.026), and total cholesterol (P = 0.002). The following variables were found to be independent predictors of preoperative MACE: Hemoglobin (P = 0.000), gender (P = 0.026), fQRS (P = 0.016), and time from myocardial infarction to balloon or coronary artery bypasses grafting (P = 0.013).Conclusions:The fQRS complexes are commonly present in NSTEMI and the fQRS complexes are an independent predictor of MACE in NSTEMI patients. The number of narrowed coronary arteries, Killip classification, and total cholesterol are all independent predictors of the fQRS complexes.

Comparison of Triggering and Nontriggering Factors in ST-Segment Elevation Myocardial Infarction and Extent of Coronary Arterial Narrowing

Various physical, emotional, and extrinsic triggers have been attributed to acute coronary syndrome. Whether a correlation can be drawn between identifiable ischemic triggers and the nature of coronary artery disease (CAD) still remains unclear. In the present study, we evaluated the correlation between triggered versus nontriggered ischemic symptoms and the extent of CAD in patients with ST-segment elevation myocardial infarction (STEMI). We conducted a retrospective, single-center observational study including 1,345 consecutive patients with STEMI, treated with primary percutaneous coronary intervention. Acute physical and emotional triggers were identified in patients' historical data. Independent predictors of multivessel CAD were determined using a logistic regression model. A potential trigger was identified in 37% of patients. Physical exertion was found to be the most dominant trigger (65%) followed by psychological stress (16%) and acute illness (12%). Patients with nontriggered STEMI tended to be older and more likely to have co-morbidities. Patients with nontriggered STEMI showed a higher rate of multivessel CAD (73% vs 30%, p <0.001). In a multivariate regression model, nontriggered symptoms emerged as an independent predictor of multivessel CAD (odds ratio 8.33, 95% CI 5.74 to 12.5, p= 0.001). No specific trigger was found to predict independently the extent of CAD. In conclusion, symptoms onset without a recognizable trigger is associated with multivessel CAD in STEMI. Further studies will be required to elucidate the putative mechanisms underlying ischemic triggering.

The Relationship between P & QT Dispersions and Presence & Severity of Stable Coronary Artery Disease.

Background and ObjectivesThe study aimed to evaluate the correlation between electrocardiographic (ECG) parameters and presence and extent of coronary artery disease (CAD) to indicate the usefulness of these parameters as predictors of severity in patients with stable CAD.Subjects and MethodsTwo hundred fifty patients, without a history of any cardiovascular event were included in the study. The ECG parameters were measured manually by a cardiologist before coronary angiography. The patients were allocated into five groups: those with normal coronary arteries (Group 1), non-critical coronary lesions (Group 2), one, two and three vessel disease (Group 3, Group 4 and Group 5, respectively.ResultsGroup 1 had the lowest P wave dispersion (PWD) and P wave (Pmax), QT interval (QTmax), QT dispersion (QTd), corrected QT dispersion (QTcd) and QT dispersion ratio (QTdR), while the patients in group 5 had the highest values of these parameters. Gensini score and QTmax, QTd, QTcmax, QTcd, QTdR, Pmax, and PWD were positively correlated. QTdR was the best ECG parameter to differentiate group 1 and 2 from groups with significant stenosis (groups 3, 4, and 5) (area under curve [AUC] 0.846). QTdR was the best ECG parameter to detect coronary arterial narrowing lesser than 50% and greater than 50%, respectively (AUC 0.858).ConclusionPresence and severity of CAD can be determined by using ECG in patients with stable CAD and normal left ventricular function.

Gastropericardial Fistula as a Delayed Complication of a Nissen Fundoplication

A 41-year-old man presented to the emergency department with sub-sternal chest pain and was found to have ST elevations in the inferior leads on his electrocardiogram. An emergent cardiac catheterization did not identify significant coronary narrowing. Computed tomography of the thorax demonstrated a pneumopericardium and a hiatal hernia. The patient had a complicated past surgical history, including a Nissen fundoplication and three additional surgeries for postoperative complications. An esophagram later revealed an ulcer and possible fistula, and the patient underwent gastropericardial fistula resection after the fistula failed to close with fibrin sealant application. Enteropericardial fistulas occur infrequently but have high morbidity and mortality rates. This possibility is much more likely in patients with prior gastroesophageal surgery, including laparoscopic Nissen fundoplication.

A case of Werner's syndrome with cardiac syndrome X and heart failure with preserved ejection fraction

We herein report a case of Werner's syndrome (WS) with cardiac syndrome X (CSX) and heart failure with preserved ejection fraction (HFpEF), receiving nicorandil treatment.A 58-year-old woman with chest discomfort on exercise was suspected of having effort-angina pectoris because of broad ST-depression in electrocardiogram of exercise test and reversible defect in the posterior-wall portion of left ventricle in exercise thallium201 myocardial scintigraphy. This patient also exhibited HFpEF, diagnosed by increased ratio of early-transmitral-flow-velocity to tissue-Doppler early-diastolic mitral annular velocity (E/e′) in echocardiography and plasma B-type natriuretic peptide (BNP) levels. However, coronary angiography revealed no organic stenosis in epicardial coronary arteries, and coronary physiological measurements by PressureWire™ (St. Jude Medical, St Paul, MN, USA) demonstrated that coronary flow reserve (CFR) was greatly decreased. Because impaired CFR represents coronary microvascular dysfunction in the absence of obstructive coronary narrowing, we diagnosed CSX, and initiated the administration of nicorandil to improve coronary microcirculation. After three-month-treatment of nicorandil, the patient's symptoms were diminished, and reversible defect in exercise myocardial scintigraphy was improved. Furthermore, both E/e′ and BNP were decreased, indicating the improvement of HFpEF via the restoration of microvascular dysfunction.Thus, nicorandil administration could bring beneficial effects in WS with CSX and HFpEF, accompanied by coronary microcirculation dysfunction.<Learning objective: Contrary to previous case reports regarding Werner's syndrome (WS) with obstructive coronary artery disease (CAD), we herein report a case of WS with cardiac syndrome X (CSX) without obstructive CAD, complicated with heart failure with preserved ejection fraction (HFpEF). Because impaired coronary microcirculation is known to be associated with left ventricular hypertrophy and HFpEF, nicorandil could improve not only CSX but HFpEF via the restoration of coronary microvascular dysfunction.>