Evidence Of Coronary Artery Disease Research Articles

Acute myocarditis revealing autoimmune and inflammatory disorders: Clinical presentation and outcome

BackgroundAcute myocarditis (AM) may be the heralding manifestation of autoimmune and inflammatory disorders (AIID). We aimed to describe the clinical presentation and outcome of patients with AM revealing AIID. MethodsAll consecutive adult patients with AM admitted in a department of Cardiology (Bichat Hospital, Paris, France) from January 2011 to January 2019 were included. Diagnosis of AM was based on clinical manifestations, elevated Troponin, myocardial inflammation on CMR and no evidence for coronary artery disease. AIID were classified using international criteria. ResultsTwo-hundred and eighteen (35.3 [26.4–47.1] years, 75.2% males) patients with AM were included. Overall, AM revealed AIID in 15 (6.9%), including systemic lupus erythematosus (n = 3), adult onset Still's disease (n = 3), sarcoidosis (n = 2), mixed connective tissue disease (n = 1), anti-Jo1 syndrome (n = 1), eosinophilic granulomatosis with polyangiitis (n = 1), antiphospholipid syndrome (n = 1), reactive arthritis (n = 1), Graves' disease (n = 1) and Crohn's colitis (n = 1). Left ventricular ejection fraction (LVEF) at onset was <30% in 5 (33.3%) patients with AIID. All but 2 patients with AIID were treated with steroids, immunosuppressive and/or immunomodulatory drugs and LVEF normalized in all by the end of follow-up. By comparing patients with AIID to patients with idiopathic AM (n = 203), multivariable analysis showed that pericardial effusion, lack of chest pain and high CRP level at onset were independently associated with AIID. ConclusionAcute myocarditis revealing AIID may be life-threatening at the acute phase but has an overall good prognosis under specific treatment. Pericardial effusion and CRP level at admission suggest an AIID as the cause for AM.

Angiographic profile and outcomes in persistent non-valvular atrial fibrillation: A study from tertiary care center in North India

BackgroundThe relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients. MethodsThe study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded. ResultsA total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005). ConclusionsMajority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.

Evaluating the correlation of serum leptin levels with evidence of coronary artery disease on myocardial perfusion single-photon emission computed tomography in suspected coronary artery disease patients.

Cardiovascular disease is currently the most common cause of death worldwide. Several risk factors have been identified for cardiovascular diseases, including hypertension, hyperlipidemia and diabetes. Leptin is a peptide hormone that acts as a proinflammatory cytokine and has a variety of effects in hemostasis and metabolism such as lipid metabolism, production of glucocorticoid, angiogenesis, etc. The aim of this study was to determine the relationship between the concentrations of leptin with evidence of coronary artery disease in the myocardial perfusion scan. A one year retrospective cross-sectional study was conducted on patients who are suspected of coronary artery disease that referred to the nuclear medicine department for performing myocardial perfusion scan. The patients were classified based on the results of the myocardial perfusion scan. Serum leptin was measured with ELISA assay. The correlation of serum leptin with these parameters and also with different groups of age, sex and coronary artery disease risk factors was also compared. The mean serum level of leptin was 290.44 ng/ml (82.9-1600 ng/ml). There is no meaningful relation between serum leptin and coronary artery disease risk factors, age and sex; also, none of the quantitative myocardial perfusion scan parameters have a significant correlation with serum leptin. Based on our findings, there was no significant correlation between myocardial perfusion scan parameters and leptin levels. Serum leptin and different groups of age, sex and coronary artery risk factors were not correlated as well.

Prevalence and Angiographic Characteristics of Coronary Ectasia in Adults: A Retrospective Study in a Tertiary Cardiac Centre of Nepal

Background and Aims: Coronary artery Ectasia is a relatively uncommon problem encountered during coronary angiography with the prevalence ranging from 1.2% to 4.9%. Coronary artery Ectasia and aneurysm both denote an arterial segment the dimension of which is larger than normal arterial segment, both have diameter greater than 1.5 times of normal. The length of dilate segment is greater than its width in Ectasia while less in aneurysm. There is an overlap between risk factors of coronary artery Ectasia and atherosclerosis. The clinical relevance in general, and the appropriate medical management of coronary artery Ectasia specifically, is ill defined, as no randomised prospective studies exists. The study was conducted with an aim to estimate the prevalence of coronary artery Ectasia and aneurysm as well as to study the angiographic characteristics of coronary artery Ectasia and aneurysm undergoing in adult patients’ coronary angiography in tertiary cardiac centre of Nepal.&#x0D; Methods: A retrospective study was conducted in Shahid Gangalal national heart centre, Nepal analysing the angiographic records from cardiac catheterization lab. A total of 447 patients who underwent coronary angiography and meet the inclusion criteria from July, 2019 to December, 2019 were included in the study. Any angiographic evidence of coronary Ectasia and aneurysm, coronary artery involved and it’s extent were analysed and recorded in the proforma. In addition, any associated evidence of coronary artery disease was analysed and recorded in the proforma.&#x0D; Results: The findings of our study revealed the overall prevalence of coronary artery Ectasia (CAE) and Coronary artery Aneurysm as 2.6%. Coronary ectasia was most prevalent in left anterior descending (LAD) artery (83.3%), followed by RCA and left main in 66.7% and 16.7% respectively. In contrast, Coronary aneurysm was mostly seen in RCA (66.7%) followed by LCX (33.3%). In addition, the study also showed the frequency of localised Ectasia as 50 % and the association of significant coronary artery disease with coronary artery Ectasia in 66.67%.&#x0D; Conclusion: CAE and aneurysm are rare phenomenon encountered in routine coronary angiography, with LAD and RCA being most commonly involved in CAE and coronary aneurysm respectively. CAE and aneurysm have significant association with the coronary artery disease.

Mannose as a biomarker of coronary artery disease: Angiographic evidence and clinical significance

BackgroundHigh mannose has previously associated with insulin resistance and cardiovascular disease (CVD). Our objective is to establish whether mannose is associated with anatomical evidence of coronary artery disease (CAD). MethodsPlasma mannose concentrations were measured by liquid chromatography/tandem mass spectrometry in a discovery cohort (n = 513) and a validation cohort (n = 221) of carefully phenotyped individuals. In both cohorts CAD was quantitated using state-of-the-art imaging techniques (coronary computed coronary tomography angiography (CCTA), invasive coronary angiography and optical coherence tomography). Information on subsequent CVD events/death was collected. Associations of mannose with angiographic variables and biomarkers were tested using univariate and multivariate regression models. Survival analysis was performed using the Kaplan-Meier estimator. ResultsMannose was related to indices of CAD and features of plaque vulnerability. In the discovery cohort, mannose was a marker of quantity and quality of CCTA-proven CAD and subjects with a mannose level in the top quartile had a significantly higher risk of CVD events/death (p = 3.6e-5). In the validation cohort, mannose was significantly associated with fibrous cap thickness < 65 μm (odds ratio = 1.32 per each 10 μmol/L mannose change [95% confidence interval, 1.05–1.65]) and was an independent predictor of death (hazard ratio for mannose≥vs < 84.6 μmol/L: 4.0(95%CI, 1.4–11.3), p = 0.006). ConclusionThe current data add novel evidence that high mannose is a signature of CAD with a vulnerable plaque phenotype, consistently across measures of severity of vessel involvement and independent of the traditional correlates of CVD, and that it is an independent predictor of incident adverse outcomes.

Abstract 11910: Prevalence and Variation in Malnutrition in Non-Obstructive Coronary Artery Disease

Introduction: Prior work demonstrates up to 50% of patients with acute coronary syndrome are malnourished, as evaluated by the Controlling Nutritional Status (CONUT) score. We investigated the prevalence of malnutrition in stable nonobstructive coronary artery disease (CAD) detected by coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA). Methods: In a single-center, retrospective cohort, we examined the electronic health records of 429 patients with normal coronary arteries (NCA) without evidence of atherosclerosis on CCTA (n=144), nonobstructive CAD (&lt;70% stenosis) by CCTA (n=143), or ICA (n=142) on clinically ordered studies for chest pain or exertional dyspnea. CONUT scores, an aggregate of albumin, lymphocyte count, and total cholesterol, were calculated at time of CCTA or ICA in patients with available lab values. Patients within each group were stratified by severity of malnutrition defined as none (0-1), mild (2-4), moderate (5-7), or severe (8-12). Diabetic patients were excluded. Number of risk factors including history of hypertension, hyperlipidemia, or smoking were compared. Results: Among all patients with complete data (n=332), 33% overall had malnutrition, including 31% with mild, 2% with moderate, and none with severe malnutrition. In patients with NCA, 24% had malnutrition, compared to 31% in nonobstructive CAD by CCTA and 45% in ICA. There was a direct positive relationship between malnutrition presence and severity with age, cardiac risk factors and the presence of nonobstructive CAD ( Table ). Conclusions: Malnutrition is present in over one-third of stable patients with no obstructive CAD and directly associated with age, risk factor burden, and nonobstructive CAD. Future prospective studies are needed to understand whether malnutrition directly contributes to development of CAD or if age and cardiac risk factors associated with CAD lead to progression of malnutrition, or both.

A CASE OF ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS WITH INFILTRATING EOSINOPHILIC MYOCARDITIS

TOPIC: Allergy and Airway TYPE: Medical Student/Resident Case Reports INTRODUCTION: Eosinophilic myocarditis (EM) is associated with myriad clinical presentations. With both chronic and acute forms, there exists a wide range of cardiac dysfunction and etiologies, including hyper-eosinophilia, hypersensitivity reaction, and parasitic or fungal infections. Chronic EM is associated with congestive heart failure, a lower mortality rate when compared to acute EM, and clinical response to corticosteroids. Here we present a case of a 57-year-old male with suspected long standing undiagnosed allergic bronchopulmonary aspergillosis, presenting as asthma, leading to infiltrative eosinophilic myocarditis. CASE PRESENTATION: Our patient was diagnosed with asthma at age 45 and he had pansinusitis with recurrent polypectomies. He presented with 10 days of dyspnea, chest tightness, palpitations, and orthopnea. He had no history of cardiac disease. CXR on admission showed bilateral patchy opacities and pleural effusions. CT of the chest demonstrated upper lobe bronchiectasis and pulmonary edema. His EKG was significant for a right axis deviation and new Q waves in V1-V4, consistent with myocardial scarring. An ejection fraction of 30-34% with global hypokinesis was seen on transthoracic echocardiogram.Based on the clinical presentation, he was thought to have allergic bronchopulmonary aspergillosis. When his previous laboratory was reviewed, he had significant eosinophilia that had been persistent over time. Since he had persistent eosinophilia and new cardiomyopathy with possible myocarditis, the diagnosis of eosinophilic myocarditis was suspected. He had no evidence of coronary artery disease on left heart catheterization and cardiac MRI showed scarring of the septal and infero-septal walls, and bilateral atria, consistent with chronic EM. Prednisone therapy was begun and his eosinophil count returned to normal in 5 days and improved to discharge with prednisone therapy. Two weeks later, he had an endomyocardial biopsy (EMB), which showed fibrosis, but no eosinophilic infiltration. He was asymptomatic at his last clinic appointment. DISCUSSION: EM can result in irreversible and fatal myocardial dysfunction. For diagnosis, EMB is considered the gold standard, for which serum eosinophil concentration, echocardiography, and cardiac MRI may assist. Though biopsy in this case showed fibrosis without eosinophilic infiltration, this can be attributed to previous corticosteroid treatment, in addition to variation with tissue sampling. CONCLUSIONS: Our patient had a misdiagnosis of asthma, associated with recurrent nasal polyps, persistent eosinophilia, positive aspergillus IgE and bronchiectasis, consistent with allergic bronchopulmonary aspergillosis. In this case, corticosteroid administration resolved his respiratory and cardiac symptoms. To date, there is no gold standard for treatment; however, regimens typically include corticosteroids, cytotoxic agents, and immunosuppressive therapy. REFERENCE #1: Barry, J.; Gadre, A.; Akuthota, P.; Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases. Current Opinion in Immunology, 2020, 66:129–135. https://doi.org/10.1016/j.coi.2020.10.005 REFERENCE #2: Ralapanawa et al. A young female presenting with heart failure secondary to eosinophilic myocarditis: a case report and review of the literature. BMC Res Notes, 2018, 11(168). https://doi.org/10.1186/s13104-018-3273-1 REFERENCE #3: Sheikh, H.; Siddiqui, M.; Uddin, S. et al. The Clinicopathological Profile of Eosinophilic Myocarditis. Cureus, 2018, 10(12): e3677. doi:10.7759/cureus.3677 DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Navkiran Randhawa, source=Web Response No relevant relationships by Sabrina Siddiqui, source=Web Response No relevant relationships by Victor Test, source=Web Response

Efficacy of a family-based cardiovascular risk reduction intervention in individuals with a family history of premature coronary heart disease in India (PROLIFIC): an open-label, single-centre, cluster randomised controlled trial

Coronary heart disease, a leading cause of death globally, is amenable to lifestyle interventions. The family environment can affect the ability or willingness of individuals to make lifestyle changes. We aimed to investigate the efficacy of a targeted family-based intervention for reduction of total cardiovascular risk in individuals with a family history of premature coronary heart disease. We did an open-label, cluster randomised controlled trial (PROLIFIC) in the families (first-degree relatives and spouses, older than age 18 years) of individuals with coronary heart disease who had been diagnosed before age 55 years. Patients with coronary heart disease diagnosed within the past year were selected from a tertiary care speciality hospital that provides care for patients from Kerala, India. Family members of selected patients who were bedridden or terminally ill, and individuals with a history of established cardiovascular heart disease and stroke were excluded, as were families with fewer than two eligible family members. Simple randomisation with computer-generated random numbers was used to randomly assign families to intervention and usual care groups (1:1). Participants in the intervention group received a comprehensive package of interventions facilitated by non-physician health workers, consisting of: screening for cardiovascular risk factors; structured lifestyle interventions; linkage to a primary health-care facility for individuals with established chronic disease risk factors or conditions; and active follow-up for adherence. The usual care group received one-time counselling and annual screening for risk factors. We obtained data on lifestyle, clinical, and biochemical characteristics at baseline and annually during the 2-year follow-up. The primary outcome was achievement or maintenance of any three of the following: blood pressure lower than 140/90 mm Hg, fasting plasma glucose lower than 110 mg/dL, low-density lipoprotein cholesterol lower than 100 mg/dL, and abstinence from tobacco. The primary outcome was analysed in all participants available for follow-up at the relevant timepoint. This trial is registered with Clinicaltrials.gov, NCT02771873. From Jan 1, 2015, to April 30, 2017, 980 patients with coronary heart disease were assessed for eligibility and 230 were excluded primarily due to lack of evidence of coronary artery disease (n=199), or a diagnosis of coronary heart disease more than 1 year previously (n=29). Of the 750 remaining families, 368 (with 825 participants) were assigned to the intervention group and 382 (with 846 participants) were assigned to the usual care group. At the 2-year follow-up, data from 803 (97%) of 825 participants in the intervention group and 819 (97%) of 846 participants in the usual care group were available. Of the 1671 participants, 1111 (66·5%) were women, and 560 (33·5%) were men. The mean age of the study population was 40·8 years (SD 14·2). At the 2-year follow-up, the primary outcome was achieved by 514 (64%) of 803 participants in the intervention group and 379 (46%) of 819 in the usual care group. After adjustment for clustering and baseline risk factors, the odds of achieving the primary outcome at the 2-year timepoint was two times higher in the intervention group than in the usual care group (odds ratio 2·2, 95% CI 1·7-2·7; p<0·0001). The reduction of total cardiovascular risk observed after the intervention could have a substantial public health impact by preventing future cardiovascular events. The Wellcome Trust and Department of Biotechnology, Government of India, and India Alliance.

PPARγ as an indicator of vascular function in an experimental model of metabolic syndrome in rabbits

Background and aimsUnderlying mechanisms associated with vascular dysfunction in metabolic syndrome (MetS) remain unclear and can even vary from one vascular bed to another. MethodsIn this study, MetS was induced by a high-fat, high-sucrose diet, and after 28 weeks, aorta and renal arteries were removed and used for isometric recording of tension in organ baths, protein expression by Western blot, and histological analysis to assess the presence of atherosclerosis. ResultsMetS induced a mild hypertension, pre-diabetes, central obesity and dyslipidaemia. Our results indicated that MetS did not change the contractile response in either the aorta or renal artery. Conversely, vasodilation was affected in both arteries in a different way. The aorta from MetS showed vascular dysfunction, including lower response to acetylcholine and sodium nitroprusside, while the renal artery from MetS presented a preserved relaxation to acetylcholine and an increased sensitivity to sodium nitroprusside. We did not find vascular oxidative stress in the aorta from MetS, but we found a significant decrease in PPARγ, phospho-Akt (p-Akt) and phospho-eNOS (p-eNOS) protein expression. On the other hand, we found oxidative stress in the renal artery from MetS, and PPARγ, Akt and p-Akt were overexpressed. No evidence of atherosclerosis was found in arteries from MetS. ConclusionsMetS affects vascular function differently depending on the vessel. In the aorta, it decreases both the vasodilation and the expression of the PPARγ/Akt/eNOS pathway, while in the renal artery, it increases the expression of PPARγ/Akt signalling pathway without decreasing the vasodilation.

A STUDY OF HYPERURICACIDEMIA AND THE PRESENCE AND SEVERITY OF ACUTE CORONARY SYNDROME IN INDEX MEDICAL COLLEGE, HOSPITAL AND RESEARCH CENTER, INDORE ( M.P.)

Background: Few studies have assessed the relation of hyperuricacidemia with the acute coronary syndrome (ACS). This study investigated the association between high uric acid levels with the presence and severity of ACS.&#x0D; Methods: Three hundred and seventy patients having angiographic evidence of atherosclerosis (CAD + case group) compared to 170 patients with no luminal stenosis (n=110) or with &lt;50% luminal stenosis (n=60) at coronary angiography (CAD – control group).&#x0D; Results: The mean age of the patients was 60 ± 10 years (317 men, 58.7%). Hyperuricacidemia was more likely associated with a trend toward higher vessel scores, indicating a more severe CAD (adjusted OR=1.51, 95% CI=1.09-2.09; P=0.005) in the whole population. A comparison of sex-specific values showed a significant association existed only in men.&#x0D; Conclusions: Asymptomatic hyperuricacidemia may be associated with the presence and severity of ACS.&#x0D; Keywords: Hyperuricacidemia, Severity &amp; Acute Coronary Syndrome.

Risk of Silent Myocardial Infarction in Prediabetic Patients: A Case-Control Study in a Veteran Population.

In the management of cardiovascular disease, it is important to identify patients at risk early on, to provide interventions to prevent the disease and its complications. The goal of our study was to investigate the association between glucose levels and silent myocardial infarction (SMI) among patients, who consisted of veterans within the Veterans Affairs clinical system. Among the group of patients with an initially normal electrocardiogram, a cohort of patients with a subsequent diagnosis of SMI was selected as the case cohort, whereas 4 patients for each study subject, without evidence of coronary artery disease and normal electrocardiogram within the previous 6 months, were identified and constituted the control cohort. We conducted an adjusted logistic regression model using the stepwise function to assess the association between glucose level and SMI. Of the 540 patients included in the study, 108 (20.0%) with an SMI diagnosis made up the case cohort. We observed that as compared with those who had normal levels of glucose, those who were prediabetic were 3.99 times as likely (95% confidence interval 1.48-12.85) to have SMI, whereas the diabetic patients were 3.80 times as likely (95% confidence interval 1.39-12.38) to experience SMI. SMIs have been shown to be predictive of subsequent cardiovascular events, including another MI and death, and that indicates the importance of identifying a group at high risk for a SMI. As such, our findings could be extremely beneficial for targeted intervention toward prediabetics and to improve health outcomes in the entire population.

Urgent Percutaneous Coronary Artery Intervention and Coronary Artery Bypass Grafting in STEMI Patients with Confirmed COVID-19.

Our aim of this study was to evaluate the cardiac symptoms, coronary angiographic results, and clinical outcomes of patients with confirmed COVID-19 and ST-segment elevation with myocardial infarction (STEMI) or myocardial ischemia. Thirty-seven patients, who already were confirmed with COVID-19 using reverse transcriptase-polymerase chain reaction (RT-PCR), were admitted to our hospital due to chest pain with STEMI. The median patient age was 66 years (range: 27-84 years). Female/male ratio was 22/15. We performed a second RT-PCR test in all patients. We investigated myocardial enzymes (creatine kinase myocardial band (CK-MB), cardiac troponin-I (c-TnI), and C-reactive protein (CRP), and liver enzymes (alanine amino transferase (ALT) and aspartate amino transferase (AST) also were measured. Blood d-dimer, thromboplastin time (PT), partial thromboplastin time (PTT), and fibrinogen were investigated. Transcutaneous oxygen saturation was monitored for each patient in the emergency department (ED). To evaluate myocardial wall abnormalities, transthoracic echocardiography was performed. Coronary artery disorders requiring revascularization were detected in 25 patients (67.5%). There was no evidence of coronary artery disease in the remaining 12 patients. Out of 25, nine coronary artery disease patients had a history of coronary intervention (24.3%). All patients had high levels of myocardial enzyme release. Percutaneous coronary interventions (PCI) were performed in patients with culprit lesion(s). Success rate of PCI was 87.5% (N = 21). The median number of stent use was 2.9±0.7 (range: 1-4). Because PCI failed in four patients, we suggested elective coronary artery bypass grafting (CABG) surgery after medical treatment. Six patients required re-intervention owing to early stent thrombosis (30%). Seven patients died after PCI (33.3%). For patients with negative or positive RT-PCR test results, we performed thoracic computed tomography (CT), which is a sensitive diagnostic method for COVID-19. Interlobular septal and pleural thickening with patchy bronchiectasis in the bilateral or unilaterally lower and/or middle lobe(s) were the main pathologies in 24 patients. D-dimer, fibrinogen, and CRP levels were high in 11 PCI patients with bilaterally pulmonary involvement by COVID-19 (52.3%), while fibrin degradation products did not significantly change. For three patients with normal coronary arteries with a transient hypokinesia or hypokinesia as result of myocarditis, we decided to perform atypical Takotsubo cardiomyopathy. We medically treated using inodilator (levosimendan), diuretic, angiotensin-converting enzyme inhibitors and beta-blockers. To prevent the risk of thromboembolism, we also administered a heparin drip. The myocardial contractility of the apex did improve, and patients were discharged from the hospital, with the exception of one young female patient. She is following in the ICU with stabil hemodynamics. Chest pain with STEMI can develop in patients with confirmed COVID-19. Nearly one-third of patients had COVID-19 with chest pain and concomitant STEMI and normal coronary angiography (32.4%). Urgent PCI may be performed in hemodynamically unstable patients with high mortality. Complications, including sudden cardiac arrest, severe ventricular arrhythmia, and Takotsubo cardiomyopathy, related to COVID-19 patients with normal coronary arteries.

Clinical presentation and prognosis of non valvular mitral regurgitation-A single institution experience

BackgroundNon valvular, ischemic regurgitation (MR) occurs secondary to myocardial infarction or acute ischemia. The presence of ischaemic MR is associated with increased morbidity and mortality. The severity of ischaemic MR is directly proportional to the severity of the LV dysfunction causing the MR. The present study was carried out to estimate the burden, clinical presentation and prognosis of non valvular MR among patients with coronary artery disease. MethodsThis cohort study was carried out among 75 adults aged over 25 years with electrocardiographic evidence of coronary artery disease. Clinical examination and periodic electrocardiography was done for evaluating the ischemic status and echocardiogram was done to assess the status of mitral regurgitation. Ejection fraction was measured by Simpsons method and regional wall motion abnormality was qualitatively evaluated. ResultsIn this study, 60% of the participants had mild MR while 22.9% had moderate MR. In correlation with STEMI, inferior/posterior wall MI with right ventricular extension showed presence of MR in 100% of the cases. There was a statistically significant difference in the incidence of congestive cardiac failure among the patients with severe MR (66.7%) and mild MR (25%) compared to those without CCF (p < 0.01). ConclusionIschemic MR is characteristically dynamic and can change substantially with changes in loading conditions. This study has laid down the basis for evaluating future role of new adjunctive surgical techniques and of percutaneous interventions.

AB0398 CASE SERIES OF PATIENTS WITH CHOLESTEROL CRYSTAL EMBOLISM SYNDROME THAT MIMICS SYSTEMIC VASCULITIS

Background:Cholesterol crystal embolism (CCE) syndrome is a multisystemic disorder caused by small arteries cholesterol crystal emboli subsequent to small pieces of atheromatous plaques from the aorta or other major arteries break off. CCE is often overlooked because it mimics symptoms of systemic vasculitis due to its clinical characteristics such as ulceration and gangrene of toes, livedo reticularis, renal insufficiency. Acute inflammatory reactants such as ESR, CRP may elevate in CCE patients since the cholesterol crystals trigger a foreign-body inflammatory reaction around the arterioles.Objectives:This study aimed to explore the clinical characteristics of CCE patients, to make rheumatologists learn more about this disease.Methods:Peer-reviewed articles in the electronic databases Medline, PubMed, Science Citation Index, China Biomedical Literature Database (CBM), China Journal Full Text Database (CNKI), and WANFANG Data were searched using the terms “cholesterol crystal embolism syndrome”, “cholesterol embolism”, “atherosclerotic embolism”, “atherosclerotic nephropathy”, or “CCE”. Only articles or case reports containing detailed medical records of CCE patients were included. We also included CCE patients in our department.Results:A 66-year-old male CCE patient presented with multiple ulceration and gangrene of toes and heels (Figure 1), subacute renal insufficiency, and elevated CRP and ESR. This patient had been considered as “suspected systemic vasculitis” and was referred to our rheumatology department. Another 39 Chinese CCE patients from the above databases were qualified for analysis. Among these 40 patients, 87.5% (35/40) were male and the mean age was 68±6 years. The most common involved was kidney and 90% (36/40) of patients presenting with renal insufficiency including the progressive increase of serum creatinine, hematuria, proteinuria, or sudden (or sharp) aggravation of hypertension. Next common involved was skin that occurred in 87.5% (35/40) of patients, especially in the toes and heels. For skin manifestations, blue toe syndrome occurred in 82.5% (33/40) of patients, ulceration or gangrene in 25% (10/40), and livedo reticularis in 15% (6/40). Additionally, 12.5% (5/40) showed ocular involvement such as visual impairment and visual field defect. In 2 patients, embolized cholesterol crystal in retinal arteries that is called Hollenhorst plaques was detected by fundoscopy. There were 62.5% (25/40) of patients having elevated CRP or ESR. The positive rate for skin or subcutaneous biopsies was 58% (11/19) and for kidney biopsies was 100% (6/6). The precipitating factors preceding the occurrence of classical symptoms such as blue toe syndrome, livedo reticularis and/or subacute renal insufficiency is important for CCE diagnosis especially for patients who had contraindications or were intolerant to biopsy. The precipitating factors include endovascular intervention (80%), vascular surgery (5%), and anticoagulant or thrombolytic therapy (2.5%). Only 12.5% (5/40) of patients were spontaneous and didn’t have any predisposing factors. General interventions of CCE included statins (82.5%), antiplatelets (32.5%), and dialysis (32.5%). Twelve patients (30%) received glucocorticoids and 75% (9/12) of them renal function improved and ulceration healed (Figure 1). Among 36 patients who presented with renal insufficiency, the renal function returned to normal after treatment in 2 patients (5.6%), but 27 patients (75%) still showed abnormal renal function even though somewhat improved, and 7 patients (19.4%) needed renal replacement therapy or dialysis for maintenance.Conclusion:This study reported CCE patients had high prevalence of renal insufficiency, blue toe syndrome, and ulceration or gangrene of toes, as well as elevated CRP or ESR, thus rheumatologists should be alert to this disease as one of the differential diagnosis of systemic vasculitis, especially for elderly patients with evidence of atherosclerosis who undergo a recent cardiovascular procedure.Disclosure of Interests:None declared

Prevalence, Incidence and Prognostic Implications of Left Bundle Branch Block in Patients with Chronic Coronary Syndromes (From the CLARIFY Registry)

Left Bundle Branch Block (LBBB) is a frequently encountered electrical abnormality in patients with chronic (more than 3 months after myocardial infarction, or evidence of coronary artery disease with ischemia) coronary syndromes (CCS), but its prognostic significance remains unclear. We aimed to describe the prevalence, incidence and five-year outcomes of LBBB in outpatients with CCS using the CLARIFY registry. Main outcome was a composite of CV death, MI or stroke. Secondary outcomes included all cause death, hospitalization for heart failure (HF) and permanent pacemaker implantation. Among 23.544 patients with available information regarding LBBB status at baseline, 1.041 (4.4%) had LBBB at baseline and 1.015 (4.5%) patients developed a new LBBB during 5-year follow-up. In multivariate analysis, LBBB at baseline was not associated with the composite outcome of CV death, MI or stroke (HR 1.06, 95% CI [0.86 - 1.31], p = 0.67) or the risk of all-cause death (HR 1.07, 95% CI [0.87 - 1.32], p = 0.52) but was significantly associated with a higher risk of hospitalization for HF (HR 1.50, 95% CI [1.21 - 1.88], p < 0.001) and permanent pacemaker implantation (HR 2.11, 95% CI [1.45 - 3.07], p < 0.001). The main factors associated with new-onset LBBB were male sex (HR 0.8 [0.66-0.98], p = 0.028) history of atrial fibrillation (HR 1.29, 95% CI [1.01 - 1.64], p = 0.04), CABG (HR 1.27, [1.08 - 1.51], p = 0.004) and MI (HR 1.19, 95% CI [1.01 - 1.40], p = 0.034). In conclusion, in a contemporary registry of outpatients with CCS, the prevalence of LBBB was 4.4% and the additional 5-years incidence 6.2%. LBBB, in itself, was not associated with a higher risk of major adverse cardiovascular events or all cause mortality. It was however an independent predictor of risk of hospitalization for heart failure and permanent pacemaker implantation.

Impact of Lower Versus Higher LDL Cholesterol Targets on Cardiovascular Events After Ischemic Stroke in Patients With Diabetes.

After an ischemic stroke with evidence of atherosclerosis, lipid-lowering treatment with a target LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL reduced the risk of subsequent cardiovascular events. In this analysis, we explored the effect in the subgroup of patients with diabetes compared with the subgroup without, as well as in those with newly diagnosed diabetes. Patients with ischemic stroke in the previous 3 months or transient ischemic attack within the previous 15 days and evidence of cerebrovascular or coronary artery atherosclerosis were randomly assigned at a 1:1 ratio to a target LDL cholesterol of <70 mg/dL or 100 ± 10 mg/dL using statin or ezetimibe. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization, and death resulting from vascular disease. We performed a prespecified analysis to evaluate the effect in patients with diabetes. Of 2,860 patients enrolled, 643 had diabetes at baseline, with a mean age of 66.2 years and baseline LDL cholesterol of 127 mg/dL, and were followed for a median of 3 years. The primary composite end point occurred in 27 (8.2%) of 328 patients in the lower-target group and in 44 (14.0%) of 315 patients in the higher-target group (adjusted hazard ratio [HR] 0.56; 95% CI 0.34-0.89; P = 0.016). In patients without diabetes, the HR was 0.87 (95% CI 0.66-1.14; P = 0.31; interaction P = 0.15). In those with diabetes, there were three intracranial hemorrhages in both randomization groups (0.9% vs. 1.0%, respectively). Newly diagnosed diabetes occurred in 98 (9.2%) of 1,070 and in 80 (7.4%) of 1,085 patients in the lower- and higher-target groups, respectively (HR 1.27; 95% CI 0.94-1.71; P = 0.11), and baseline higher HbA1c was the unique multivariable predictor. In conclusion, after an ischemic stroke with evidence of atherosclerosis, targeting an LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL consistently reduced the risk of subsequent stroke and other major vascular events in patients with and without diabetes, but the higher risk in those with diabetes yielded a higher absolute risk reduction, with number needed to treat of 17.

Coronary Thrombosis after Rabbit-ATG in LTx Recipient

Introduction Rabbit anti-thymocyte globulin (rATG) is a polyclonal antibody that targets human T lymphocytes; it can be used as an induction agent at the time of lung transplant (LTx) or as treatment for steroid refractory allograft rejection. rATG-induced platelet activation and hypercoagulability has been reported. Herein, we report a case of acute thrombotic myocardial infarction (MI) after the first dose of rATG in an LTx recipient with steroid refractory rejection. Case Report The patient is a 60-year-old man with COPD who underwent a bilateral LTx in May 2018. He had an uneventful post-LTx course, but presented 18 months later with dyspnea and a 600-cc decline in FEV1. A CT scan of the chest showed diffuse bronchial thickening and a bronchoscopy with bronchoalveolar lavage and transbronchial biopsies showed rhinovirus, but no evidence of acute cellular rejection. Donor specific antibodies were absent. The patient was empirically treated with high-dose corticosteroids, but presented a month later with another 400-cc decline in FEV1, prompting admission and treatment with rATG for presumed steroid refractory rejection. During admission, his labs were remarkable for mild anemia and thrombocytosis (781 K/µL). Thirty minutes into his rATG infusion, the patient complained of shortness of breath, chest discomfort, diaphoresis, and right-arm numbness. The infusion was stopped. His labs revealed elevated troponin (0.382 ng/mL), and his EKG showed an ST elevation in leads II, III and aVF along with ST depression in leads I and aVL suggestive of inferior wall MI. Emergent cardiac catheterization and ventriculogram showed 100% occlusion of the mid-distal right coronary artery with heavy clot burden, inferior wall hypokinesis, and a mildly reduced ejection fraction. A drug-eluting stent was placed, which resulted in near resolution of ST elevation. Of note, his prior pre-LTx cardiac catheterization had no angiographic evidence of coronary artery disease (CAD). Summary rATG activates platelets and establishes a link between complement and coagulation cascades, which may explain the clinically observed phenomenon of rATG-induced hypercoagulability. To the best of our knowledge, this is the first report of rATG-induced coronary arterial thrombosis in an LTx recipient with no prior CAD, but with thrombocytosis at the time of rATG infusion.

148 Lipid Targeting Post-Stroke—Targeting Who?

Abstract Introduction Frailer patients are at high risk of complications from drugs like statins. Other less frail patients may be undertreated. The Treat Stroke to Target trial showed that high risk patients with atherosclerosis and/or ischaemic heart disease (IHD) who were treated to an LDL level of less than 1.8 mmol/L had a 22% relative risk reduction in major cardiovascular events compared to those with a higher target. In our Quality Improvement. Project We estimated the numbers of post-stroke cases who might safely benefit from a targeted, pharmacist led intensive lipid management program. Methods 500 consecutive ischaemic stroke cases with a modified Rankin score (mRS) of 0–3 were identified from the Scottish Stroke Care Audit Database. Those discharged to long term care or dead at the time of data collection were excluded. Data collected was age, evidence of atherosclerosis on vascular imaging, co-morbid IHD, LDL at index admission and between 1 month to 1 year post-stroke, anti-lipid treatment at discharge and up to 1 year post-stroke. Atrial fibrillation patients were included if other risk criteria were met. Results The mean age of the 500 cases was 70. From this group, 297 (60%) met the entry criteria for “Treat to Stroke Target”. 190 (64%) cases had LDL checked post-discharge. 87 cases failed to reach the RCP Stroke Guidance of a 40% reduction in LDL Cholesterol. 66 (22%) of cases had LDL &amp;gt;1.8 mmol/L on most recent check and potentially should have been treated to target. Of the 83 cases excluded due to mRS &amp;gt;3 or significant dependency, 70 cases (84%) were discharged on a statin and importantly 34 (48%) of these died within 1 year of their stroke. Conclusions Based on annual stroke admissions in our health board, around 86–117 high risk patients could benefit from a virtual lipid treatment intensification clinic.

Factors Affecting the Patency of Radiocephalic Arteriovenous Fistulas Based on Clinico-Radiological Parameters.

Arteriovenous fistulas are an important means of vascular access for long-term haemodialysis in patients with end-stage renal disease (ESRD). We evaluated the outcome of radiocephalic arteriovenous fistulas (RCAVFs) in 55 patients operated upon in our hospital in southern India. We studied the outcome of RCAVF surgery with the demographic factors, duration of diabetes, the diameter of the radial artery and cephalic vein, and any signs of atherosclerosis in the radial artery. We found that a small cephalic vein size of ≤ 2 mm, a negative cephalic vein tap test, a thickened, non-compressible, calcified radial artery on palpation, and evidence of atherosclerosis on radiological investigations were associated with a significant chance of RCAVF failure. A clinico-radiological grading of atherosclerosis for peripheral arteries is also proposed. Any patient presenting to the microsurgeon with a small cephalic vein size, a negative cephalic vein tap test, a thickened, non-compressible, calcified vessel on palpation, and tram-track calcification or whole vessel calcification or severely atherosclerotic vessel on radiological evaluation must be approached with caution regarding RCAVF creation and must be prepared for an arteriovenous fistula (AVF) creation at a higher level.

Incremental value of feature-tracking cardiac magnetic resonance imaging in detecting myocardial dysfunction in patients with idiopathic ventricular arrhythmias

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac magnetic resonance (CMR) imaging can identify the underlying substrate in patients with ventricular arrhythmias (VAs) and normal echocardiography. Myocardial strain has emerged as a superior index of systolic performance compared to ejection fraction (EF), with an incremental prognostic value in many cardiac diseases. Purpose To assess myocardial deformation using 2-D feature-tracking CMR strain imaging (CMR-FT) in patients with frequent VAs (≥500 ventricular premature contractions (VPC)/24 hours; and/or non-sustained ventricular tachycardia), and structurally normal hearts on echocardiography without evidence of coronary artery disease. Methods Sixty-eight consecutive patients (mean age 46 ± 16 years; 54% female) and 72 healthy controls matched for age and body surface area were included in the study. CMR imaging was performed on a 1.5T Magnetom Avanto (Siemens, Erlangen, Germany) scanner using a standard cardiac protocol. Results CMR showed normal findings in 30 patients (44%), while 16 (24%) had previous myocarditis, 6 (9%) had a diagnosis of non-ischaemic cardiomyopathy (NICM), 15 (22%) were diagnosed with VPC-related cardiomyopathy, and 1 patient had subendocardial infarction [excluded from strain analysis]. Mean left ventricular EF (LVEF) in patients was 62% ± 6% and right ventricular EF 64% ± 6% (vs. 65% ± 3% and 66% ± 4% in controls, respectively). Compared to control subjects, patients with VAs had impaired peak LV global radial strain (GRS) (28.88% [IQR: 25.87% to 33.97%] vs. 36.65% [IQR:33.19% to 40.2%], p &amp;lt; 0.001) and global circumferential strain (GCS) (-17.73% [IQR: -19.8% to -16.33%] vs. -20.66% [IQR: -21.72% to -19.6%], p &amp;lt; 0.001, Panel A). Peak LV GRS could differentiate patients with previous myocarditis from patients with NICM and those with VPC-related cardiomyopathy (Panel B). Peak LV GCS could differentiate patients with previous myocarditis from patients with NICM (Panel C). Peak LV GRS showed excellent diagnostic accuracy in detecting patients from control subjects (Panel D). In a multivariable regression model, subjects with a low GRS (&amp;lt;29.91%-determined by the Youden’s index) had 5-fold higher odds of having VAs (OR:4.99 [95%CI: 1.2-21.95]), after adjusting for LVEF, LV end-diastolic volume index, age, sex, BMI, smoking, hypertension, and dyslipidaemia. Peak LV global longitudinal strain (GLS) and RV strain indices were not statistically different between patients and controls. Conclusion Peak LV GRS and GCS are impaired in patients with frequent idiopathic VAs and can detect myocardial contractile dysfunction in patients with different underlying substrates. Our findings suggest that LV strain indices on CMR-FT constitute independent markers of myocardial dysfunction on top and independently of EF. Abstract Figure.