Etiology Of Acute Coronary Syndrome Research Articles

Two case reports of spontaneous coronary dissection

Spontaneous coronary artery dissection (SCAD) has nowadays been described as a non-negligible etiology of acute coronary syndromes (ACS). Its prevalence approximates 3% in most cohorts. It mainly affects women in the young to middle-aged range. Individuals with SCAD typically exhibit fewer conventional cardiovascular risk factors associated with ischemic heart disease compared to those with atherosclerotic coronary artery disease. Nevertheless, some SCAD patients may present with risk factors such as hypertension, smoking, and dyslipidemia, although their direct contribution to SCAD risk remains uncertain. We present two cases of spontaneous coronary dissection to explore its pathogenesis, diagnosis, and treatment options. Learning objectives · Recognize spontaneous coronary artery dissection as the possible cause of ACS in females even with cardiovascular risk factors. Learn the importance of angiographic control after a conservative therapy that may lead to a more invasive approach.

Abstract 17708: Cardiac Nut-Cracker: Paroxysmal Left Main Coronary Compression by Inducible Pulmonary Trunk Dilatation in Pulmonary Hypertension

Case Presentation: A 56yo woman with a 12-year history of idiopathic pHTN and severe RV dysfunction presented with worsening exertional angina (CCS III). Perfusion imaging demonstrated a large apical-septal defect, corresponding to an 80% eccentric stenosis of the LMCA on angiography ( Fig 1AB ) due to compression on ostium and shaft by a severely dilated pulmonary trunk ( Fig 1C ). Right heart catheterization revealed pulmonary artery pressures (PAPs) of 90/40/68mmHg. Operative risk for CABG was deemed prohibitive, thus the patient underwent high-risk PCI of the LMCA under IV conscious sedation. Initial angiography confirmed a patent LMCA with minimal longitudinal compression. Opening PAPs (102/37/64mmHg) with supplemental oxygen (FiO 2 /PaO 2 0.76/168mmHg) were similar to preop findings ( Fig 1D ). To replicate her symptomatology, supplemental oxygen was discontinued, resulting in rapid worsening of LMCA compression with severe reduction in LMCA cross-sectional area at room air conditions (FiO 2 /PaO 2 0.21/70mmHg), with corresponding suprasystemic PAP (122/44/73mmHg) ( Fig 1E) . Under IVUS guidance, a preselected stent was deployed producing complete LMCA patency without evidence of dynamic compression; minimal stent areas were unchanged at supraphysiologic and physiologic conditions: 19 vs 20mm 2 , FiO 2 0.73 vs 0.21 ( Fig 1F ). Discussion: LMCA stenosis from extrinsic compression of the vessel by an enlarged pulmonary artery is a rare etiology of acute coronary syndromes. Treatment options include PCI, CABG, reimplantation, or PA reduction plasty. While preop imaging clearly demonstrated LMCA compression by a dilated PA, during PCI true and dynamic severity of LMCA compression was revealed only under “normoxic conditions” (FiO 2 0.21). This paroxysmal “nut-cracker” phenomenon from inadvertent reversal of dynamic LMCA compression highlights the importance of normoxia in making the diagnosis of such anomalies in susceptible individuals with pHTN.

Novel Diagnostic Imaging Approach for Patients With Spontaneous Coronary Artery Dissection: The Utility of 18 F-FDG PET Imaging.

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed etiology of acute coronary syndrome in women. Accurate diagnosis remains challenging but is imperative for treatment and prevention. We show here the utility of 18 F-FDG PET imaging in SCAD diagnosis. We present 1 representative case of 4 women with suspected SCAD on coronary angiography from the EVACS (Evolocumab in Acute Coronary Syndromes) clinical trial. 18 F-FDG PET imaging showed acute inflammation in the distribution of the suspected dissected coronary artery identified on angiography. Localized myocardial inflammation identified on 18 F-FDG PET imaging can aid in diagnosing SCAD suspected on coronary angiography.

Frequency Of CRP Levels In Patients Presenting With Acute Coronary Syndrome

Myocardial necrosis is thought to be the etiology of acute coronary syndrome (ACS) and elevated CRP levels in the first 12 hours after an intervention is linked to a higher risk of cardiovascular recurrence and death. Objectives: To evaluate if CRP has any predictive value in predicting cardiovascular outcomes in ACS patients. Methods: We conducted a cross-sectional study at Jinnah Post Graduate Medical Centre from Oct 2021 to March 2022. 117 patients of both gender aged between 40 to 80 years, presenting with chest pain were included in the study. Data were analyzed on SPSS Version 25. Chi-square was used to compare the outcomes of both groups. The age and gender were stratified to control the effect modifiers. The p-value of <0.05 was considered significant. Results: There were a total of 117 patients enrolled in this study. Among them, there were 63 (53.85%) males, and 79 (67.52%) were above 60 years of age. There were 90(76.92%) patients who had a raised CRP level, and 78 (66.67%) had a duration of ACS > 12 hours. Differences between the duration of elevated CRP and non-elevated CRP were statistically significant (p-value = 0.013). Conclusions: CRP levels may be indicative of suspected acute coronary syndrome. Physicians can identify such patients and provide them with more intensive health care and cardiac management. Resources are scarce in the developing world. Having such tools that are more economical can help with the diagnosis and provide better care.

Abstract 11658: Acute Coronary Syndrome After Insect Bite: A Systematic Review

Arthropod and insect bites/stings have been associated with the development of Acute Coronary Syndrome (ACS) in prior case reports. In this systematic analysis, we review 57 reported cases of ACS in patients that were exposed to arthropods, bee stings or insect bites, and provide a summary of these findings in Table 1. We then discuss Kounis Syndrome Type 1 or Type 2 as the proposed mechanism by which myocardial ischemia develops in this subset of patients, and the implications of this diagnosis on management. Kounis Syndrome Type 1 develops due to mast cell activation and histamine release provoking vasospasms and inducing myocardia injury in the absence of underlying coronary artery disease, as demonstrated in Figure 1A. Kounis Syndrome Type 2 develops due to inflammation induced plaque rupture and subsequent thrombus formation, as demonstrated in Figure 1B. In general, Kounis Syndrome should be suspected in patient’s presenting with the appropriate exposure, an allergic or anaphylactic response and/or unremarkable coronary angiogram (specific to Type 1). Once suspected, the use of coronary artery vasodilators, antihistamines, steroids and possibly Epinephrine should be considered in management. In this review, it was discovered that approximately 50% of cases received management consistent with Kounis Syndrome (targeted to allergic/anaphylactic symptoms) with appropriate clinical response, yet only 12% received the formal diagnosis, indicating this condition is underdiagnosed. Furthermore, 40% of patients that underwent coronary angiogram did not have CAD, indicating a possible Type 1 (vasospastic) etiology of ACS that may benefit from more targeted therapy.

Abstract 15639: Infected Thrombus - An Unusual Etiology of Acute Coronary Syndrome in a Patient With New Onset Atrial Fibrillation

Background: Coronary embolism (CE) is an uncommon (3%) cause of acute coronary syndromes (ACS) and is often missed. Case Presentation: A 68-year-old woman with a h/o hypertension & breast cancer post lumpectomy 10 yrs ago, presented with generalized weakness, fever (101F), & vomiting without chest pain, dyspnea, or palpitations. She was afebrile, tachycardic (158 beats/min), tachypneic (26 breaths/min) with BP of 98/64 mmHg. Cardiac exam revealed irregularly irregular rhythm, 5 cm jugular venous distension & 3+ bilateral pretibial edema. Labs revealed thrombocytopenia, lactic acidosis, & hyponatremia. High sensitivity-Troponin was 1023 & NT-pro-BNP 19854. EKG showed atrial fibrillation (AF), diffuse ST elevations in the precordial leads & aVR, poor R wave progression & inferior Q waves. Her cardiac cath revealed a large thrombus from mid-left main extending into the LAD with minimal atherosclerotic burden. Intraoperative transesophageal echocardiogram for emergent surgical resection of the thrombus revealed a highly mobile thrombus 2.32x0.6 cm on the aortic aspect originating between L and R coronary cusps and a left atrial appendage thrombus (1.1 cm) with marked spontaneous contrast in LA appendage & LA which was surgically resected. Blood cultures & of coronary thrombus grew Methicillin sensitive Staphylococcus Aureus (MSSA) . Anticoagulation & appropriate antibiotics were initiated. but after a protracted, complicated ICU stay, patient was made comfort care. Discussion/Conclusion: CE should be considered in cases of recurrent coronary thrombus or in the setting of heavy thrombus burden despite a relatively normal coronary vessel. AF is the most common underlying cause of CE causing ACS. Aspiration or surgical thrombectomy should be performed with a high thrombus burden. Thrombus should be sent for pathology to further delineate the source of thrombus.

Younger Age Impacts Perceptions of Care Received in the Emergency Department Among Women with Spontaneous Coronary Artery Dissection.

Background: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic etiology of acute coronary syndrome (ACS) that primarily affects younger women with few traditional cardiovascular disease risk factors. The primary objective of this study was to evaluate how younger age impacts the perception of care women receive in the emergency department (ED) at the time of their first or only SCAD. Methods: SCAD survivors were recruited using SCAD Alliance social media platforms to complete a one-time online survey regarding their experiences of seeking treatment for SCAD in the ED and their post-SCAD recovery. A total of 409 participants consented to participate in the parent study and data collected from the 367 participants who reported female gender were further analyzed. Results: Fewer participants <50 years old than would be expected under the null hypothesis (i.e., 65.5% observed vs. 71.2% expected, p = 0.009) reported perceived serious treatment by ED staff, more participants <50 years than would be expected under the null hypothesis (i.e., 12.0% observed vs. 9.3% expected, p = 0.049) reported perceived dismissive treatment by ED staff, and more participants <50 years than would be expected under the null hypothesis (i.e., 13.3% observed vs. 10.8% expected, p = 0.02) reported discharge from the ED without a diagnosis. Conclusions: Results of this study highlight the different experiences of younger SCAD survivors' engaging with providers in the ED. Further research regarding strategies for increasing ED providers' clinical interrogation of SCAD when treating and evaluating younger female patients presenting with ACS symptoms is indicated.

Myocardial bridging presenting as an acute coronary syndrome with mitral valve stenosis and paroxysmal atrial fibrillation: A case report

We report a 33-year-old man presented to the emergency department with a chief complaint of typical angina three days before admission. An electrocardiogram showed arrowhead T-waves inversion in leads V1-V4, and the cardiac enzyme marker was increased. The initial diagnosis was non-ST-elevation acute coronary syndrome. On subsequent examinations, he had severe mitral stenosis, paroxysmal atrial fibrillation, and a history of intracranial hemorrhage. Diagnostic coronary angiography examination revealed myocardial bridging in the middle segment of left anterior descending coronary arteries. The patient was given dual antiplatelets (DAPT), beta-blocker, atorvastatin, and anticoagulant. Beta-blocker is the first-line therapy for myocardial bridging, whereas DAPT, anticoagulant, and high-dose statin therapy are used to treat acute coronary syndrome (ACS). The atherosclerotic process is commonly found in the proximal segment of myocardial bridging that can lead to ACS. In addition, mitral stenosis is one of the main causes of systemic embolism, including coronary embolism, while atrial fibrillation is known to increase the risk of embolism. Herein, we discuss the possible etiology of ACS, the management of myocardial bridging and comorbidity of this patient, and the rationale for selecting antithrombotic therapy.

Spontane Koronararteriendissektion

Spontaneous coronary artery dissection Abstract. Spontaneous coronary artery dissection (SCAD) is an increasingly recognized etiology of acute coronary syndrome (ACS) and an important cause of myocardial infarction in women. First described in 1931, SCAD is defined as a spontaneous tear in a coronary artery that is not associated with atherosclerosis, trauma or medical intervention. SCAD predominantly affects younger women, who often lack atherosclerotic risk factors. Some risk factors that have been identified include female sex, pregnancy, severe emotional or physical stress, underlying blood vessel diseases such as fibromuscular dysplasia, and connective tissue diseases such as Ehlers-Danlos syndrome or Marfan syndrome. Previously believed to be rare, a chiefly fatal condition, recent epidemiological data suggests SCAD is accountable for up to 4 % of all ACS cases and up to 35 % of ACS cases in women < 50 years of age. There is a lack of awareness of SCAD among physicians, which probably results in underreporting and underdiagnosing of this disorder. The clinical presentation of SCAD is often similar to that of ACS making differentiation at first presentation difficult. Cardiac enzymes are elevated like in ACS and there are no biomarkers that are specific for the diagnosis of SCAD. Coronary angiography is the gold standard method to distinguish both entities, however correct diagnosis by cath is challenging and SCAD can be truly missed and misdiagnosed as classic ACS. Still there are no randomized controlled trials about the optimal treatment of these patients. But it is suggested that management should be different to atherosclerotic myocardial infarction. Conservative medical treatment is favored in the majority of cases, with percutaneous coronary intervention (PCI) being reserved for high risk patients due to poor interventional outcomes and higher failure rates. However, there is still a lack of data on this poorly understood condition and the optimal management has yet to be determined.

AMPHETAMINE-RELATED CORONARY ARTERY DISSECTION LEADING TO CARDIAC ARREST

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized etiology of acute coronary syndrome (ACS) in young adults. Amphetamine use has been linked to aortic, carotid and renal artery dissections. We present a rare case of SCAD attributed to amphetamine abuse and presented as

RAISE THE ROOF: IFR-GUIDED INTERVENTION OF A MYOCARDIAL BRIDGE

A myocardial bridge is a segment of an epicardial coronary artery tunneled within the myocardium, which clinically ranges from an incidental finding to an etiology of acute coronary syndrome. Determining the hemodynamic significance with instantaneous wave-free ratio (iFR) can guide medical vs.

Spontaneous Coronary Artery Dissection: Report on 20 Cases at Multiple Centers and a Review of the Literature

Spontaneous coronary artery dissection (SCAD) is an uncommon etiology of Acute Coronary Syndrome (ACS); however, appropriate treatment based on early diagnosis can improve outcomes. We screened medical records of all ACS patients who were admitted to one of 8 different centers (Cardiovascular Research Consortium-8 Universities) and underwent emergent coronary angiography from January 2001 to December 2014. From these ACS patients, we selected the patients with SCAD based on a review of the results of coronary angiography. Patient demographics, treatment, and in-hospital and long-term outcomes were determined from a review of medical records and angiographic findings. Of the 9377 ACS patients, 20 (0.21%) were diagnosed with SCAD. In these 20 SCAD patients, the mean age was 48.6 ± 12.0 years old, and 19 patients were female (95.0%). In 3 patients (15%), SCAD was associated with pregnancy. Coronary spasm was associated with SCAD in 2 patients (10%). Two patients (10%) were treated conservatively, and percutaneous coronary intervention was performed in 18 patients (90%). Two patients (10.0%) received target lesion revascularization, and one patient (5%) received coronary artery bypass grafting (CABG). SCAD recurred in one patient (5%), and there was in-hospital death in one patient (5%) after CABG. The patient demographics and outcomes in this study were compatible with recent reports of SCAD, except for the trigger of coronary spasm. SCAD should be suspected in middle-aged female ACS patients, and conservative treatment is recommended when there is no ongoing ischemia or left main trunk dissection. In addition, close follow-up is important.

Etiology of Acute Coronary Syndrome after Noncardiac Surgery.

The objective of this investigation was to determine the etiology of perioperative acute coronary syndrome with a particular emphasis on thrombosis versus demand ischemia. In this retrospective cohort study, adult patients were identified who underwent coronary angiography for acute coronary syndrome within 30 days of noncardiac surgery at a major tertiary hospital between January 2008 and July 2015. Angiograms were independently reviewed by two interventional cardiologists who were blinded to clinical data and outcomes. Acute coronary syndrome was classified as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or unstable angina; myocardial infarctions were adjudicated as type 1 (plaque rupture), type 2 (demand ischemia), or type 4b (stent thrombosis). Among 215,077 patients screened, 146 patients were identified who developed acute coronary syndrome: 117 were classified as non-ST-elevation myocardial infarction (80.1%); 21 (14.4%) were classified as ST-elevation myocardial infarction, and 8 (5.5%) were classified as unstable angina. After coronary angiography, most events were adjudicated as demand ischemia (type 2 myocardial infarction, n = 106, 72.6%) compared to acute coronary thrombosis (type 1 myocardial infarction, n = 37, 25.3%) and stent thrombosis (type 4B, n = 3, 2.1%). Absent or only mild, nonobstructive coronary artery disease was found in 39 patients (26.7%). In 14 patients (9.6%), acute coronary syndrome was likely due to stress-induced cardiomyopathy. Aggregate 30-day and 1-yr mortality rates were 7 and 14%, respectively. The dominant mechanism of perioperative acute coronary syndrome in our cohort was demand ischemia. A subset of patients had no evidence of obstructive coronary artery disease, but findings were consistent with stress-induced cardiomyopathy.

The Effects of Dabigatran and Rivaroxaban on Markers of Polymorphonuclear Leukocyte Activation

Dabigatran is an oral direct thrombin inhibitor, and rivaroxaban, a factor Xa inhibitor. Dabigatran has been implicated in the etiology of acute coronary syndromes and as these occur following inflammatory changes in the endothelium, we investigated the inflammatory potential of these agents in vitro. In order to do so, polymorphonuclear leukocytes (PMNL) were isolated from heparinized venous blood from non-smoking, healthy adults and exposed to dabigatran or rivaroxaban (0.5–10 µM). Generation of reactive oxygen species (ROS), elastase release, cytosolic Ca2+ fluxes, neutrophil extracellular trap (NET) formation and cell viability were measured using chemiluminescence, spectrophotometric and flow cytometric procedures respectively. However, with the exception of modest inhibitory effects on elastase release, neither agent at concentrations of up to 10 µM affected these markers of PMNL activation. Although no pro-inflammatory effects of dabigatran nor any difference between the two test agents were detected in vitro, the existence of a pro-inflammatory mechanism involving the generation of thrombin during dabigatran therapy cannot be fully excluded.

Spontaneous coronary artery dissection in women: What is known and what is yet to be understood.

Spontaneous coronary artery dissection is a nonatherosclerotic etiology of acute coronary syndrome, including sudden cardiac death, which frequently affects younger women. This review highlights contemporary knowledge regarding spontaneous coronary artery dissection demographics, prevalence, diagnosis, presentation, and associated conditions and risks, inpatient treatment, major adverse clinical events, and outpatient management decisions.

Assessment of the association between the personality traits of young patients with acute coronary syndrome and the severity of coronary artery disease.

The role of psychosocial risk factors is becoming increasingly important in the etiology of acute coronary syndrome (ACS). The purpose of this study was to assess an association between the personality types of young patients with ACS and the prevalence and severity of coronary artery disease (CAD). Patients younger than 45 years of age who presented with ACS and who underwent coronary angiography in the period from 2012 to 2016 were included in the study. The coronary angiography records of the patients were examined and their Gensini score (GS) was calculated; GS ≥20 was considered to be severe CAD. The Eysenck Personality Questionnaire-Revised Short Form scales were used to measure psychoticism, extraversion, lying, and neuroticism. A total of 139 patients were included in the study. The median psychoticism score of patients with GS <20 was found to be significantly higher than that of patients with GS ≥20 [1.0 (25th and 75th percentile: 0.0-2.0) vs. 1.0 (25th and 75th percentile: 0.0-1.0); p=0.015]. The median psychoticism score was 1.0 (25th and 75th percentile: 1.0-2.0) in the unstable angina pectoris group, 0.5 (25th and 75th percentile: 0.0-1.0) in the ST segment elevation myocardial infarction group, and 1.0 (25th and 75th percentile: 0.0-1.0) in the non-ST segment elevation myocardial infarction group (p=0.004). The presence of psychoticism characteristics in patients who present with ACS is associated with less severe CAD.

Abstract 15573: Impact of Coronary Calcification on Different Culprit Lesion Morphology in Acute Coronary Syndrome

Background: Previous studies have reported plaque rupture and erosion were the most common causes of acute coronary syndrome (ACS) and spotty calcifications was identified as a marker of plaque rupture. Optical coherence tomography (OCT) offers a high-resolution imaging to assess the plaque morphology and coronary calcification. Purpose: The aim of this study was to evaluate the relationship between the distribution of coronary calcification and the culprit lesion morphology in patients with ACS. Methods: We enrolled consecutive 183 patients with ACS (mean age: 68 ± 11 years, 148 males). Culprit lesion was assessed by OCT and patients were divided into the rupture and non-rupture group according to the OCT findings. Maximum radial thickness, cross-sectional area of calcification and radial depth from the lumen and longitudinal length of calcification were compared between 2 groups. Results: Plaque rupture was detected at culprit site in 105 patients and coronary calcification was identified in 58 patients. There were no significant differences in age and gender between 2 groups. Maximum thickness, area and longitudinal length of calcification were smaller in rupture group (457.4 ± 284.9 μm vs. 722.1 ± 384.1 μm, p &lt; 0.01, 0.7 ± 0.4 mm 2 vs. 1.8 ± 1.4 mm 2 , p &lt; 0.01, 2.2 ± 1.1 mm vs. 5.6 ± 5.3 mm, p[[Unsupported Character - Codename &amp;shy;]] &lt; 0.01, respectively). Radial depth of calcification from the lumen was significantly geater in rupture group (150.0 ± 65.3 μm vs. 83.1 ± 63.3 μm, p&lt;0.001). Conclusions: Distribution of coronary calcification could be associated with morphological etiology of ACS.

Acute coronary syndrome vs. myopericarditis – not always a straightforward diagnosis

Patient: Male, 58Final Diagnosis: MyopericarditisSymptoms: Retrosternal thoracic painMedication: —Clinical Procedure: MRISpecialty: CardiologyObjective:Challenging differential diagnosisBackground:Patients with acute cardiac symptoms, elevated cardiac troponin, and culprit-free angiograms are a consistent proportion of patients admitted with presumed acute coronary syndromes (ACS). Current literature on this population of patients justifies the diagnostic importance of cardiovascular magnetic resonance (CMR) imaging.Case Report:This report describes the case of a 58-year-old cyclist in which CMR allowed us to perform a diagnosis of myopericarditis mimicking acute STEMI against other evidence. There are several such reports in literature because the clinical presentation of myocarditis is quite variable.Conclusions:This case report emphasizes the importance of cardiovascular magnetic resonance imaging in the differential diagnosis of the etiology of acute coronary syndromes. This is especially important because the signs and symptoms presented are ambiguous and equivalent to those of other diseases, such as myopericarditis, which affects mainly young athletes but also middle-aged athletes.

Spontaneous Dissection of All 3 Coronary Arteries in a Postpartum Woman

Forty-one thousand people aged 29 to 44 years are diagnosed with acute myocardial infarction each year in the United States. The etiology of acute coronary syndrome among patients younger than 45 years can be atheromatous or nonatheromatous coronary heart disease, hypercoagulable states, or related to substance abuse. Spontaneous coronary artery dissection (SCAD) falls under the nonatheromatous category, and unfortunately the diagnosis is often made at autopsy.

Clinical Predictors of Culprit Plaque Rupture Assessed on Intravascular Ultrasound in Acute Coronary Syndrome

Acute coronary syndrome (ACS) commonly results from vulnerable plaque rupture, and occasionally results from thrombus formation in lesions without plaque rupture. The aim of the present study was to clarify the clinical features of different etiology of ACS and clinical predictors of culprit plaque rupture assessed on intravascular ultrasound (IVUS). One hundred and ten ACS patients with emergent coronary angiography were classified into 2 groups based on the presence or absence of culprit plaque rupture assessed on IVUS. Clinical characteristics were compared between the 2 groups. Culprit coronary plaque rupture was observed in 60 patients (55%). Patients with plaque rupture were younger and were more likely to be male (P<0.03 and P<0.02, respectively). In the rupture group, the prevalence of metabolic syndrome was higher (P<0.002), and among the components of metabolic syndrome, waist circumference was greater and serum high-density lipoprotein cholesterol level was lower (P<0.0001 and P=0.0004, respectively). IVUS-assessed lesion remodeling index was greater in the rupture group (P<0.0001). On multivariate analysis metabolic syndrome was an independent predictor of culprit plaque rupture (odds ratio =5.26, 95% confidence interval =1.49-21.40, P<0.02). Abdominal obesity and low high-density lipoprotein-cholesterol level are the characteristics of metabolic syndrome that seem to be the key factors for vulnerable plaque rupture with coronary compensatory enlargement.