Dynamic ST-segment Research Articles

Abnormal ST-segment changes in anterior and inferior leads during acute inferior myocardial infarction

Anterior and inferior ST elevation on electrocardiography (ECG) in patients with acute myocardial infarction is uncommon. ST-segment elevation due to right ventricular infarction induced by right coronary occlusion may extend from V1 to V3/V4, resembling the pattern of transmural ischemia of the anterior wall of the left ventricle. In addition, a wraparound left anterior descending (LAD) artery can produce ischemia manifesting as ST-segment elevation in the anterior and inferior leads. Our case report reveals dynamic ST-segment changes in acute inferior myocardial infarction, including the appearance of the shark fin ECG pattern, unlike what has been reported before.

Abstract 16361: Atypical Presentation of Myocardial Ischemia Provoked by Food Ingestion

Introduction: A type 2 myocardial infarction typically occurs due to demand ischemia from a blood supply mismatch. Significant blockage can trigger coronary steal syndrome and worsen perfusion in areas with severe coronary artery disease (CAD). In this case, we highlight a patient who experienced a dynamic elevation in troponin levels after food consumption, ultimately necessitating coronary artery bypass graft surgery (CABG), shedding light on the diverse presentations of cardiac ischemia. Case Presentation: A 49-year-old male with a history of hypertension, type 2 diabetes mellitus, obesity, recent stroke on dual antiplatelets, and non-obstructive CAD presented with chest discomfort over a period of two months. The patient denied associated symptoms and physical examination was unremarkable. Interestingly, the chest pain occurred specifically after meals. Extensive workup, including an EGD and CTA Abdomen, were negative. The symptoms were refractory to proton pump inhibitors (PPI). An EKG revealed dynamic precordial ST segment depressions, and troponin levels were elevated after meals on multiple occasions, gradually decreasing between meals. A left heart catheterization revealed severe five-vessel blockages; thepatient consequently required a quadrupleCABG. Following surgery, the patient reported a resolution of chest pain. Discussion: Our patient developed chest pain and demonstrated elevated troponin levels after each meal. With an extensive negative workup, further evaluation was necessary. Theoretically, circulatory flow in the splanchnic circulation during food digestion can mimic physical activity. Additionally, a full stomach may irritate the diaphragm and lead to arrhythmias. This case highlights the potential role of meals as triggers for coronary artery disease in patients with critical coronary blockage. Demand cardiac ischemia can manifest with atypical presentations that may pose diagnostic challenges. It is essential to recognize the atypical presentations of myocardial infarction to aid in the timely diagnosis and treatment of this potentially life-threatening condition.

P320 AN UNUSUAL CASE SYNCOPE DUE TO SILENT CORONARY VASOSPASM

Abstract Background Variant angina is a condition due to a transient vasospasm of the epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. A non–negligible subset of patients can also experience silent myocardial ischemia, defined as objective documentation of myocardial ischemia in the absence of angina or equivalents. This condition is associated with increased cardiac mortality and incidence of acute cardiac events. Description of the case. A 65–years–old man was admitted to our Emergency Department for syncope. He reported palpitations before the event without chest pain. ECG showed biphasic T waves in V2–V6 (Fig 1A), troponin values were normal. Immediately after admission in our coronary care unit for monitoring, he developed dynamic ST segment elevation with signs of inferior and posterior transmural ischemia (Fig 1B) and non–sustained polymorphic ventricular tachycardias (Fig 2), being symptomatic only for palpitations. ECG abnormalities and symptoms quickly resolved after intra–venous nitrates administration. Coronary angiography was performed showing a critical non–occlusive (85%) fixed stenosis at the proximal right coronary artery (Fig 3 A). The lesion was treated by angioplasty and stenting (Fig 3 B) and the patients was discharged on dual anti–platelet therapy, statins and oral high–dose calcium–channel antagonist. Discussion This case underlines first the importance of searching for high–risk features in patients with syncope of non–obvious origin: our patient reported palpitations and ECG changes consistent with myocardial ischemia (even with normal troponin values and echocardiographic findings). A peculiarity of our case is that the patient did not complaint any chest pain despite the presence of ST elevation, a condition known as silent ischemia. The transient nature of ECG modification and ventricular arrhythmias, their dramatic response to nitrates and coronary angiography findings were suggestive of silent vasospasm. Coronary vasospasm induces transient myocardial ischemia and may cause ventricular arrhythmias which in turn can cause syncope due to transient cerebral hypoperfusion or, when sustained, even cardiac arrest and sudden death. We did not perform provocative test with acetylcholine or ergonovine due to the likely vasospastic origin of myocardial ischemia and to their potential risks, especially in the presence of non–sustained plymorphic ventricular tachycardias.

Abstract 10178: Concurrent Left Ventricular and Left Anterior Coronary Artery Thrombus; Is Covid-19 an Innocent Bystander?

Case presentation: A 36-year-old male was admitted to a local hospital with respiratory failure secondary to COVID-19 pneumonia. Initial management included oxygen, dexamethasone and baricitinib. On day 14 of illness the patient developed severe chest pain associated with widespread dynamic ST segment elevation and an elevated high sensitivity troponin I (17516 ng/L). He was transferred to a tertiary center for cardiac evaluation. Cardiovascular risk factors included treated hypertension and obesity (BMI 34). Physical exam revealed a blood pressure of 145/95 mmHg, regular heart rate at 90 bpm and coarse crepitations in bilateral lower lungs with a 3L oxygen requirement. Differentials included myopericarditis however, clinical suspicion for an acute coronary syndrome remained high. Urgent coronary angiogram revealed a large filling defect (figure 1A) at the mid-vessel of the LAD at the 1st diagonal bifurcation, likely a thrombus. Dual antiplatelet therapy, heparin and tirofiban infusion were commenced. Furthermore, echocardiography performed the same day revealed a reduced LVEF secondary to LAD territory hypokinesis and an associated apical left ventricular thrombus measuring 2.2x1.3 cm (figure 1B). Once established on anticoagulation the patient experienced no further chest pain and was discharged home on warfarin.The left ventricular thrombus was monitored for resolution in the community with serial transthoracic echocardiograms. Discussion: Raised highly sensitive troponin in the vicinity of severe COVID-19 infection is common, however, when associated with chest pain and or dynamic ECG changes myocarditis must be considered. The cytokine storm triggered by a SARS-CoV-2 infection can be thrombogenic, resulting from increased platelet activation and decreased fibrinolysis. This process may further complicate the evaluation and acute coronary syndrome does need consideration, even in those patients at a younger age with minimal risk factors.

Electrical Storm in a Patient with Brugada Syndrome and Coronavirus Disease 2019

Brugada syndrome (BrS) is an inherited arrhythmia syndrome characterized by right bundle branch block and dynamic ST-segment changes in precordial leads V1–V3. In patients with BrS, fever is a known trigger that may induce arrhythmia. For patients with BrS who contract coronavirus disease 2019 (COVID-19), the inflammatory response poses the risk of causing ventricular arrhythmias. The following case discusses the management of a patient with BrS presenting with electrical storm after contracting COVID-19. Treatment should be focused on aggressive anti-pyretic management along with concomitant pharmacological therapy.

Chest pain caused by left coronary artery spasm in a patient with anomalous origin of right coronary artery.

Anomalous origin of coronary artery is rare and important reason of chest pain, syncope, and sudden death in young and middle-aged patients. This case reported a patient with interarterial anomalous right coronary artery and chest pain, which was confirmed to be the result of severe vasospasm of the proximal left anterior descending artery. The patient had reoccurred spontaneous chest pain and the dynamic ST segment and T wave changes at anterior walls. Coronary angiography confirmed left coronary artery spasm. Chest pain was controlled by diltiazem and isosorbide mononitrate. During 3 months of follow-up after discharge, the patient did not have chest pain anymore.

Unusual syncope due to silent coronary vasospasm: a case description and an overview of coronary vasospasm

Variant angina is a condition triggered by the transient vasospasm of epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. Among patients with coronary artery vasospasm, a non-negligible subset experiences silent myocardial ischemia, defined as the objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. This condition is associated with the increased cardiac mortality and incidence of acute cardiac events. Herein, we described the case of a 65-year-old man who was admitted to our Emergency Department (ED) for syncope. He reported palpitations before the event but did not complain of chest pain. Baseline electrocardiogram (ECG) showed that troponin values of biphasic T waves in V2-V6 were normal. The patient was admitted to our coronary care unit (CCU) for monitoring. Immediately after hospital admission, he developed dynamic ST segment elevation and non-sustained polymorphic ventricular tachycardia, being symptomatic only for palpitations. Both ECG abnormalities and symptoms quickly resolved after the administration of intravenous nitrates and oral calcium channel blockers. Coronary angiography showed a critical non-occlusive fixed stenosis at the proximal right coronary artery (RCA). The lesion was treated by angioplasty and stenting, and the patient was discharged on dual antiplatelet therapy, statins and oral high-dose calcium-channel antagonist.

SAT-225 A Rare Cause of Cardiogenic Shock

Background: Rare cases of pheochromocytoma are associated with stress induced Takotsubo cardiomyopathy, occurring in approximately 3% of secreting pheoochromocytoma and paraganglioma (PPGL). Case: A 39-year-old female with a history of hypertension and anxiety disorder, re-presented to the ED within 24 hours with headache, vomiting and severe hypertension (BP 205/70 mmHg). She rapidly developed acute pulmonary oedema and cardiogenic shock. ECG revealed dynamic ST-segment abnormalities and troponin rise peaked at 38,000 ng/L (N < 16ng/L). The coronary angiography excluded any coronary artery lesion. Echocardiography revealed severe global hypokinesis with an ejection fraction of 5% and evidence of apical ballooning. A bedside abdominal ultrasound revealed 7cm left adrenal mass confirmed by computed tomography (CT). Investigations revealed a metanephrine level of > 13,760 pmol/L (N < 900 pmol/L) and normetanephrine of > 60,780 pmol/L (N < 500 pmol/L). Her clinical status deteriorated despite on diuretics, inotropes and mechanical ventilation. Extra-corporeal membrane oxygenation (ECMO) was implanted. Alpha adrenergic blockades were initiated followed by beta blockers, during which control of blood pressure was achieved. Her haemodynamic status improved and ECMO removed 8 days post-implantation. Two weeks after discharge from hospital, she underwent uncomplicated open adrenalectomy; histologic examination of the mass confirmed the pheochromocytoma diagnosis. Reference 1. Gagnon N, Mansour S, Bitton Y et al. Takotsubo-like cardiomyopathy in a large cohort of patients with pheoochromocytoma and paraganglioma. Endocrine Practice.2017;10: 1178-1192

P870 The role of transthoracic doppler echocardiography in chronic total occlusion diagnosis in a patient with stable angina and cerebral atherosclerosis

Abstract Introduction The issue of sudden cardiac death (SCD) remains one of the most actual problem in healthcare. Several reports underscores that about 50-80% of SCD is linked to ischemic heart disease (IHD). The usage of contemporary risk-stratification criteria of SCD and implementation of new noninvasive ultrasound methods allow to improve patient’s prognosis through early start of optimal medical therapy and surgical treatment. Material and methods: 63 years-old male with moderate class II stable angina. Patient undergone eversion endarterectomy 2 years prior to initial admittance due to an 80% left internal carotid stenosis and received appropriate optimal medical therapy provided by the modern dyslipidemia guidelines. We’ve used ECG (MAC 1600, GE); transthoracic doppler echocardiography, stress-echo, triplex scanning (VIVID E9, E95, GE); ergometry stress test (eBike, GE), quantitative coronary angiography (Innova 3100, GE). Results ECG (sinus rhythm, 62bpm, left ventricular hypertrophy) and brachiocephalic arteries triplex scan were unremarkable. Patient had dyslipidemia with low HDL. Transthoracic echocardiography revealed no region wall motion abnormalities, concentric remodeling, mild diastolic dysfunction, preserved ejection fraction (57%, Simpson). Transthoracic doppler echocardiography showed retrograde mid-LAD flow and patient was scheduled for noninvasive stress-echocardiography (Level III, 100W 2:00 min). Stress-echo was positive with apical anterior and lateral akinesia, septal and mid-lateral hypokinesia, GLS rest 15 %, GLS peak 13% and dynamic ST-segment changes in V4-V6. Invasive coronary angiography showed LAD CTO and subtotal LCx lesion. Then LAD and LCx PTCA with stenting were performed with good clinical outcome. Conclusion Novel methods of cardiac and coronary visualization are feasible in coronary flow reserve assessment and chronic total occlusions identification, especially in patients with multifocal atherosclerosis.

IMMUNE CHECK POINT INHIBITOR MYOCARDITIS MIMICKING ACS

Myocarditis is a rare but life-threatening complication of immune checkpoint inhibitors (ICI). We report a case of ICI myocarditis which was misdiagnosed as ACS. A 71-year-old gentleman was transferred for acute shortness of breath for 2 days. He had dynamic ST-segment elevation in inferior leads

Diagnosis of Aortic Dissection Presenting as ST-Elevation Myocardial Infarction using Point-Of-Care Ultrasound

BackgroundAortic dissections can present with a broad spectrum of signs and symptoms, making them difficult to diagnose in the emergency department (ED). Aortic dissections can cause occlusion of the coronary arteries, mimicking an acute ST-elevation myocardial infarction (STEMI). Emergency point-of-care ultrasound (POCUS) may be a useful diagnostic tool to help differentiate aortic dissection from a primary myocardial infarction. Case ReportA 69-year-old man with no medical history presented to our ED complaining of chest pain. His electrocardiogram revealed new and dynamic ST-segment elevations consistent with a septal myocardial infarction. While the patient was being prepared for the cardiac catheterization laboratory, the treating emergency physician performed a POCUS study. The scan revealed an echogenic flap in the ascending aorta, significant aortic regurgitation, and intimal flaps in the carotid artery and abdominal aorta. The diagnosis of a type A aortic dissection was confirmed with computed tomography angiography. Why Should an Emergency Physician be Aware of This?Differentiating an acute STEMI from an aortic dissection can be extremely difficult in the ED. It is important not to delay reperfusion therapy for patients with a true STEMI; however, the same treatment can be lethal for patients with aortic dissection. Emergency POCUS is a fast and accessible test that has been shown to have high specificity for the diagnosis of aortic dissection in the ED. POCUS may be a useful tool to help emergency physicians diagnose aortic dissection presenting with STEMI.

CORONARY ANGIOGRAPHY IN OUT OF HOSPITAL CARDIAC ARREST (OHCA): A PRACTICAL GUIDE TO DECISION MAKING

Early coronary angiography remains controversial in patients without ST-segment elevation following OHCA. Observational studies have demonstrated a potential survival benefit, but are potentially confounded by selection bias. Physician decision making is further complicated by the lower incidence of culprit lesions in patients without ST-elevation; and, the difficulty in determination of neurological prognosis at the time of presentation. The Cardiac Arrest Hospital Prognosticator (CAHP) score utilizes seven variables (age, non-shockable rhythm, time from collapse to basic life support, time from basic life support to return of spontaneous circulation, location of cardiac arrest, epinephrine dose, and arterial pH) and has been shown to be a reliable predictor of neurologic outcomes (Maupain et al. 2016). ST-segment deviation and prior history of CAD have been proposed to help identify OHCA survivors without ST-elevation who might benefit from angioplasty in deciding to pursue early angiography (Wong et al. CJC 2017). The aim of this study was to evaluate the ability of the CAHP score to help guide decision making regarding the need for urgent coronary angiography in survivors of OHCA; and, to determine the association between dynamic ST-segment changes, or a history of angina or CAD with the presence of a culprit coronary artery lesion in those patients without ST elevation. Based on these findings, we have developed a decision pathway for the use of angiography in survivors of OHCA. A retrospective chart review of 336 OHCA patients admitted to the Foothills Medical Center Cardiac Intensive Care Unit (CICU) between 2009 and 2016 was conducted. Chi-squared and t-tests were used to assess differences in categorical and continuous variables respectively. Associations were assessed using odds ratios. A CAHP score of >200 demonstrated a specificity for in-hospital death of 93.94% (89.9-96.74%), and was inversely associated with the decision to pursue angiography in patients with and without ST-elevation, but not with early angiography. ST deviation but not prior CAD/angina was predictive of a culprit lesion in patients without ST-elevation (Figure 1). These factors were not found to be associated with the decision to pursue early coronary angiography. Given the paucity of data supporting the benefit of early angiography in patients without ST-elevation, an elevated CAHP score (≥ 200) conferring poor prognosis is a reasonable indication for deferring angiography. We propose that CAHP scores and predictive factors for culprit coronary disease (ST-deviation and prior CAD/angina) be used to guide timing of coronary angiography.

MP028: Dynamic changes of prehospital serial 12-lead electrocardiogram for remote diagnosis of suspected ST-segment elevation myocardial infarction

Introduction: Accurate and efficient interpretation of prehospital 12-lead electrocardiogram (ECG) in patients with suspected ST-segment elevation myocardial infarction (STEMI) can improve outcomes, especially in rural regions. In the Chaudière-Appalaches region, Quebec, a prehospital serial 12-lead ECG monitoring system is used for remote interpretation of ECG abnormalities by emergency physicians via a telemedicine platform, the Unité de Coordination Clinique des Soins Préhospitaliers d'Urgence (UCCSPU). The objective of the study was to evaluate the use of serial monitoring of dynamic ECG changes in patients with suspected STEMI during emergency medical services (EMS) transport. Methods: A retrospective cohort study with suspected STEMI patients monitored with prehospital serial ECGs was performed from August 2006 to December 2013. The data was extracted from UCCSPU clinical databases and verified by an emergency physician supervisor. During EMS transport, the serial ECG monitoring system automatically produced and transmitted every 2 minutes a 12-lead ECG without artefacts. STEMI criteria were based on the Third Universal Definition of Myocardial Infarction. Dynamic ECG change was defined as an ST-segment elevation or depression that meets diagnostic criteria (eg. initial non STEMI (NSTEMI) changing to STEMI and vice versa). Results: Among the 752 patients identified with suspected STEMI, 728 (96.8%) were included in the study due to missing data. The majority (614/728; 84.3%) had a consistent ST segment without significant dynamic changes throughout transport, of which 521 were identified as STEMI and 93 as NSTEMI. The remaining 114 patients (15.7%) had dynamic ECG changes: 41 (36%) evolved from NSTEMI to STEMI, 40 (35.1%) changed from STEMI to NSTEMI, and 33 (28.9%) had more than one dynamic ST-segment change. Overall, 59 patients (8.1%) had a final STEMI ECG diagnosis after an initial NSTEMI ECG interpretation. Conclusion: In this study, the serial ECG system enabled the remote diagnosis of STEMI in 8.1% of patients during EMS transport following an initial NSTEMI diagnosis. Serial monitoring of dynamic changes can allow for more rapid diversion to primary percutaneous coronary intervention facilities, potentially improving patient outcomes. Further studies are needed to evaluate the clinical impact, and costs and benefits of implementing this technology.

Relation of ST-Segment Elevation Before and After Percutaneous Transluminal Coronary Angioplasty to Left Ventricular Area at Risk, Myocardial Infarct Size, and Systolic Function

Electrocardiography is an excellent tool for decision making in patients with ST elevation myocardial infarction (STEMI). However, little is known on the correlation between its dynamic changes during primary percutaneous coronary intervention (PCI) and the anatomic information provided by cardiovascular magnetic resonance. The study aimed to assess the predictive value of dynamic ST-segment changes before and after PCI on myocardial area at risk (AAR), infarct size, and left ventricular function in patients with STEMI. Eighty-five consecutive patients with a first STEMI were included. An electrocardiogram was recorded before and after PCI at 1, 24, 48, 72, and 120 hours. Sum of ST elevation (sumSTE), the number of STE, and STE resolution (resSTE) were determined. Complete resSTE was defined as ≥70% resolution, and patients were classified into 3 groups: group 1 (resSTE 1 hour after PCI) n = 39; group 2 (resSTE 120 hour after PCI) n = 27; and group 3, without resSTE (n = 19). Cardiovascular magnetic resonance was performed during hospitalization and at 6 months. Left ventricular volumes, ejection fraction, AAR, infarct size, myocardial salvage index, and microvascular obstruction were determined. Before PCI, the number of STE and sumSTE were best associated with AAR (p <0.001). After PCI, lack of resSTE (group 3) was associated with larger infarct size, MVO, and lower myocardial salvage index. However, sumSTE at 120 hours after PCI best discriminated patients with larger infarct size, ventricular volumes, and lower ejection fraction during hospitalization and at follow-up. In conclusion, admission sumSTE best correlates with AAR, whereas sumSTE at 120 hours rather than early resSTE best correlates with infarct size and left ventricular volumes during hospitalization and at 6 months.

Telecardiología: pasado, presente y futuro

Technological advances over the past decades have allowed improved diagnosis and monitoring of patients with acute coronary syndromes as well as patients with advanced heart failure. High-quality digital recordings transmitted wirelessly by cellular telephone networks have augmented the prehospital use of transportable electrocardiogram machines as well as implantable devices for arrhythmia monitoring and therapy. The impact of prehospital electrocardiogram recording and interpretation in patients suspected of acute myocardial infarction should not be underestimated. It enables a more widespread access to rapid reperfusion therapy, thereby reducing treatment delay, morbidity and mortality. Further, continuous electrocardiogram monitoring has improved arrhythmia diagnosis and dynamic ST-segment changes have been shown to provide important prognostic information in patients with acute ST-elevation myocardial infarction. Likewise, remote recording or monitoring of arrhythmias and vital signs seem to improve outcome and reduce the necessity of re-admissions or outpatient contacts in patients with heart failure or arrhythmias. In the future telemonitoring and diagnosis is expected to further impact the way we practice cardiology and provide better care for the patient with cardiovascular disease.Full English text available from:www.revespcardiol.org/en.

Telecardiology: Past, Present and Future

Technological advances over the past decades have allowed improved diagnosis and monitoring of patients with acute coronary syndromes as well as patients with advanced heart failure. High-quality digital recordings transmitted wirelessly by cellular telephone networks have augmented the prehospital use of transportable electrocardiogram machines as well as implantable devices for arrhythmia monitoring and therapy. The impact of prehospital electrocardiogram recording and interpretation in patients suspected of acute myocardial infarction should not be underestimated. It enables a more widespread access to rapid reperfusion therapy, thereby reducing treatment delay, morbidity and mortality. Further, continuous electrocardiogram monitoring has improved arrhythmia diagnosis and dynamic ST-segment changes have been shown to provide important prognostic information in patients with acute ST-elevation myocardial infarction. Likewise, remote recording or monitoring of arrhythmias and vital signs seem to improve outcome and reduce the necessity of re-admissions or outpatient contacts in patients with heart failure or arrhythmias. In the future telemonitoring and diagnosis is expected to further impact the way we practice cardiology and provide better care for the patient with cardiovascular disease.

An Iatrogenically Unmasked Life Threatening Disease: Brugada Syndrome

Brugada syndrome is a life threatening disease that is usually overlooked during emergency service admissions. It is characterized by typical electrocardiography resembling right bundle branch block, static or dynamic ST-segment elevation in leads V 1-3. There is familial tendency in some cases. A majority of patients have a structurally normal heart and are likely to remain asymptomatic, however they may present to emergency departments with syncope and various serious arrhythmias. Therefore it is crucially important for emergency medicine physicians not to omit this potential diagnosis. Herein we report a case with Brugada syndrome which was iatrogenically unmasked after propafenone administration for atrial fibrillation.

A Mid-Ventricular Variant of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) was initially recognized in Japan in 1990. The typical patient is a postmenopausal woman with symptoms that mimic an acute coronary syndrome generally following physical or emotional stress. The EKG will typically have dynamic ST segment changes, while the angiogram will usually show normal coronary arteries. In classic TC, the left ventriculogram typically shows akinesis and ballooning of the apex with a normal or hyperdynamic base. Several variants of TC have been described. In this case report, we describe a midventricular variant of TC in a 64-year-old Hispanic female. The patient had chest pain, shortness of breath, elevated cardiac enzymes, and ST-segment elevations in leads II, aVF, and V5-V6. Coronary angiography revealed normal coronary arteries. Left ventriculogram showed hypokinesis of the midventricular segment and hyperdynamic apical and basal regions. Although the exact mechanism of TC is unknown, several theories include loss of estrogen, catecholamine or neurohumoral stimulation, coronary artery spasm, and left ventricular outflow tract (LVOT) obstruction.

Unruptured aneurysms of all sinus of Valsalva causing non-ST-elevation myocardial infarction

A 36-year-old female patient was admitted with 1-hour history of chest pain and short of breath. Electrocardiogram displayed dynamic ST segment depression and T-wave inversion in precordial leads (V1–V6) (Fig. 1, panels A and B), and the serum level of cardiac troponin T was significantly elevated. Coronary angiography showed mild stenosis of left main coronary artery (panel C, arrowed) and normal left anterior descending, circumflex and right arteries (panels C and D). The multislice spiral CT revealed aneurysms of left-, rightand non-coronary sinus of Valsalva (panel E), and the proximal portion of left main coronary artery was displaced superiorly and compressed by the left sinus Valsalva aneurysm (panels F and G, arrowed). The sinus Valsalva aneurysms are generally isolated and are frequently involved in rightor non-coronary sinus of Valsalva [1,2]. There have been extremely rare reports of aneurysms arising from all sinuses of Valsalva, especially accompanied with acute myocardial infarction resulted from left sinus Valsalva aneurysm. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2).

Predictors and Implications of Stent Thrombosis in Non–ST-Segment Elevation Acute Coronary Syndromes

The frequency, predictors, and consequences of stent thrombosis (ST) in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) have been incompletely studied. We sought to investigate the incidence, predictors, and clinical implications of ST occurring within 1 year after percutaneous coronary intervention in patients with NSTE-ACS. The Acute Catheterization and Urgent Intervention Triage StrategY (ACUITY) trial was a large-scale, prospective, randomized trial of antithrombotic regimens in patients with NSTE-ACS. The present analysis includes 7162 patients in whom stents were implanted. At 1 year, definite/probable ST occurred in 146 patients (2.2%), including 94 definite and 52 probable events. There were 100 episodes (1.4%) of early ST (within the first 30 days) and 46 episodes (0.8%) of late ST (between 30 days and 1 year). The incidence of ST within 1 year was similar in patients treated with drug-eluting stents or bare metal stents (hazard ratio, 0.86; 95% confidence interval, 0.62-1.20; P=0.38) and was independent of procedural antithrombotic treatment. Patients with ST compared with those without ST had strikingly higher 1-year rates of cardiac mortality (32.4% versus 2.9%, P<0.0001), myocardial infarction (82.6% versus 7.6%, P<0.0001), and target vessel revascularization (79.6% versus 7.4%, P<0.0001). Independent predictors of 1-year definite/probable ST were insulin-treated diabetes mellitus, number of diseased vessels, and ST-segment deviation ≥1 mm. Compared with elective stent implantation, ST occurs with increased frequency in the first year after stent implantation in patients with NSTE-ACS, especially within the first 30 days, and is associated with marked increases in cardiac mortality and adverse events. Insulin-treated diabetes, number of diseased vessels, and dynamic ST-segment changes were independent predictors of 1-year ST in NSTE-ACS.