High-risk Unstable Angina Research Articles

Wellens Syndrome the Previous Room to A Large Previous Myocardial Infarction. Report of A Case.

Wellens syndrome or also called anterior descending T wave syndrome, described for the first time in 1982 by Wellens and Zwaan, as a subtype of high-risk unstable angina that progresses to myocardial infarction in the anterior face, which can be massive and fatal; Documentation of this pattern on the ECG would be essential to initiate pharmacological treatment and priority referral to the hemodynamics room; A case of a 74-year-old male patient is described who begins symptoms in the early morning with typical chest pain and adrenergic discharge that progressively disappears. The patient is sent to a High Specialty Medical Center for Catheterization, which correlates injury in a rare anatomical site of the middle segment of the anterior descending artery. Knowledge of Wellens Syndrome in the emergency room is of utmost importance to reduce morbidity in patients and avoid its consequences, as well as the importance of primary referral for cardiac catheterization.

13N-Ammonia myocardial blood flow quantitation in patient with aneurismal coronary artery disease

Aneurysmal coronary artery disease includes coronary artery aneurysms and ectasia; this condition has been associated with poor long-term outcomes. Few studies have explored myocardial blood flow 13N-ammonia PET/CT MPI added value. We present a 45-year-old man who came to the emergency department with chest pain. After a physical examination and laboratory studies, he was diagnosed with very high-risk unstable angina and referred to the catheterization laboratory. Coronary angiography showed the culprit lesion in the LCx and was treated by angioplasty and stent. LAD was found with coronary artery ectasia (TIMI 2 flow grade) and the RCA with aneurysmal disease in the proximal and middle segments (TIMI 3 flow grade). Medical treatment was decided for these findings and the patient was discharged. Two weeks later, we performed a 13N-ammonia PET/CT MPI founding apical, inferior, and inferoseptal severe ischemia, and reduced hyperemic coronary blood flow and coronary flow reserve in the RCA territory. Flow was normal in the LAD territory. Although coronary angiography remains the gold standard for evaluating these coronary abnormalities, it does not show the physiological compromise. Therefore 13N-ammonia PET/CT MPI should be performed as a complementary noninvasive imaging approach.

Anomalous origin of the left coronary artery from the right sinus: an interesting and very rare coronary anomaly circulation

Coronary artery anomalies (CAA) are congenital changes in their course, origin and/or structure. Most of them are incidentally discovered during autopsies or angiographic studies. We present the case of a 48-year-old woman with high-risk unstable angina whose coronary angiogram revealed an interesting and extremely rare coronary anomaly circulation pattern.

Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: the Iranian Project for Assessment of Coronary Events 2 (IPACE2)

ObjectivesTo assess contemporary data on characteristics, management and 1-year postdischarge outcomes in Iranian patients hospitalised with acute coronary syndrome (ACS).Setting11 tertiary care hospitals in 5 major cities in the Islamic...

“Vieussens ring” from isolated conus artery

A 56-year-old diabetic man was admitted with high risk unstable angina and after initial medical stabilization, he was taken up for coronary angiogram. Angiogram revealed left main diffuse 80% stenosis, left anterior descending artery (LAD) ostial total occlusion, left circumflex (LCX) ostial 90% stenosis and right coronary artery (RCA) proximal 80% stenosis. Despite multiple angiographic views the rest of LAD could not be visualized. A careful review of angiogram revealed non-visualization of conus branch of RCA. Selective cannulation of conus showed entire LAD filling through collaterals from conus (Fig. 1). The patient was subsequently referred for urgent coronary bypass surgery. Fig. 1 ICA collaterals to LAD. In patients with stenosis or total occlusion of the LAD or RCA, the conus artery often serves as a principal source of collateral circulation.1 This collateral channels form the circle of Vieussens (or ‘Vieussens ring’). In about 40% of population, conus branch can arise separately from right sinus and is called an isolated conus artery (ICA). ICA may be the exclusive source of collaterals to occluded LAD in about 6% of cases.2 Under such circumstances, failure to recognize this normal variant early during angiogram may result in unnecessary prolongation of procedure and additional diagnostic modalities such as CT coronary angiogram in search of non-visualized LAD.

The Prevalence and Prognostic Role of Vitamin D Deficiency in Patients with Acute Coronary Syndrome: A Single Centre Study in South-West of Iran

The objectives of this study were estimating the prevalence of vitamin D deficiency in patients with acute coronary syndrome comparing with normal people and evaluating the relationship between vitamin D deficiency and short-term mortality in these patients. We considered 106 patients with non-ST elevation myocardial infarction and high-risk unstable angina and 110 patients with ST elevation myocardial infarction as group A. The control group (group B) consisted of 120 individuals without any known cardiovascular diseases or systemic disease. We measured serum 25-hydroxyvitamin D in all cases and classified them according to their serum 25-hydroxyvitamin D levels. Sufficient vitamin D level was considered ≥30 ng/ml. We followed the patients for 30 days after index admission. The prevalence of hypovitaminosis D in group A was much higher than group B. In group A, 72% of patients had serum 25-hydroxyvitamin D level of 20 ng/ml or less. This percentage was only 27.4% in control group. We did not find any significant relationship between vitamin D deficiency and short-term mortality in patients with acute coronary syndrome. Our data suggest that vitamin D deficiency was present in most of patients admitted with acute coronary syndrome in Ahvaz.

How Low should the Blood Pressure be reduced in Patients with Hypertension and High Risk for Coronary Artery Disease?

The more aggressive control of blood pressure among patients at high risk for coronary artery disease such as those with coronary artery disease, a 10-year Framingham risk score ≥10%, diabetes mellitus, chronic kidney disease, or other coronary artery risk equivalent with maintenance of the blood pressure below 130/80 mm Hg and below 120/80 mm Hg in patients with left ventricular dysfunction recommended by the American Heart Association (AHA) Task Force scientific statement in 2007 [1] was based upon expert medical opinion at that time, not on prospective, randomized, adequately controlled trial data [2]. The Pravastatin or Atorvastatin Evaluation and Infection TherapyThrombolysis in Myocardial Infarction (PROVE IT-TIMI) 22 trial enrolled 4,162 patients with an acute coronary syndrome (acute myocardial infarction with or without ST-segment elevation or highrisk unstable angina pectoris) [3].The lowest incidence of cardiovascular events occurred with a systolic blood pressure between 130 to 140 mm Hg and a diastolic blood pressure between 80 to 90 mm Hg with a nadir of 136/85 mm. An observational subgroup analysis was performed in 6,400 of the 22, 576 patients in the International Verapamil SR-Trandolapril Study (INVEST) [4]. These patients had diabetes mellitus and coronary artery disease. Patients were considered to have tight control of their blood pressure if they could maintain their systolic blood pressure below 130 mm Hg and their diastolic blood pressure below 85 mm Hg, usual control if they could maintain their systolic blood pressure between 130 to 139 mm Hg, and uncontrolled if their systolic blood pressure was 140 mm Hg or higher. During 16,893 patient-years of follow-up, the incidence of cardiovascular events was 12.6% in patients with usual control of blood pressure versus 19.8% in patients with uncontrolled hypertension, p <0.001 [4]. The incidence of cardiovascular events was 12.6% in patients with usual control of blood pressure versus 12.7% in patients with tight control of blood pressure (p not significant). The all-cause mortality rate was 11.0% with tight control of blood pressure versus 10.2% with usual control of blood pressure (p = 0.06). When extended follow-up was included, the all-cause mortality rate was 22.8% with tight control of blood pressure versus 21.8% with usual control of blood pressure, p = 0.04.

Defining “Appropriateness”

Context: Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. Objective: To assess the appropriateness of PCI in the United States. Design, Setting, and Patients: Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication. Main Outcome Measures: Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures. Results: Of 500 154 PCIs, 355 417 (71.1%) were acute (ST-segment elevation myocardial infarction, 103 245 [20.6%]; non–ST-segment elevation myocardial infarction, 105 708 [21.1%]; high-risk unstable angina, 146 464 [29.3%]), and 144 737 (28.9%) were nonacute. For acute indications, 350 469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72 911 PCIs (50.4%) were classified as appropriate, 54 988 (38.0%) as uncertain, and 16 838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk noninvasive stress test results (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%). Conclusions: In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.

Appropriateness of Percutaneous Coronary Intervention

Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. To assess the appropriateness of PCI in the United States. Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication. Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures. Of 500,154 PCIs, 355,417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103,245 [20.6%]; non-ST-segment elevation myocardial infarction, 105,708 [21.1%]; high-risk unstable angina, 146,464 [29.3%]), and 144,737 (28.9%) for nonacute indications. For acute indications, 350,469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72,911 PCIs (50.4%) were classified as appropriate, 54,988 (38.0%) as uncertain, and 16,838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%). In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.

Editorials Editorial on management of diabetes mellitus with coronary artery disease

Editorials Editorial on management of diabetes mellitus with coronary artery disease

E0440 Pregnancy-associated plasma protein-a polymorphisms and the risks of acute coronary syndrome

BackgroundPregnancy-associated plasma protein-A (PAPP-A) is known to be abundantly expressed in vulnerable plaques in arteriosclerotic disease. Studies have shown PAPP-A to be a sensitive biomarker of plaque instability and cardiovascular...

164: Incremental Value of Magnetocardiograph Over Electrocardiograph in Diagnosing Acute Coronary Syndrome in Patients Presenting to the Emergency Department With High Risk Unstable Angina

164: Incremental Value of Magnetocardiograph Over Electrocardiograph in Diagnosing Acute Coronary Syndrome in Patients Presenting to the Emergency Department With High Risk Unstable Angina

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

TABLE OF CONTENTSPreamble 686Definition of the Problem 688Purpose of These Guidelines 688Methodology and Evidence 689General Approach to the Patient 692History 693Physical Examination and Routine Laboratory Tests 693Multivariable Indices to Predict Preoperative Cardiac Morbidity 694Clinical Assessme

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery WRITING COMMITTEE MEMBERS Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC; Kenneth A. Brown, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA; Elliott Chaikof, MD; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC§; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC ACC/AHA TASK FORCE MEMBERS Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice Chair; Cynthia D. Adams, MSN, PhD, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

To evaluate the prognostic value of stress myocardial perfusion scintigraphy (MPS) applied to patients with suspected acute coronary syndrome (ACS). Retrospective study. Patients with suspected acute coronary syndrome (ACS) admitted into the chest pain unit (CPU) from December 2002 to April 2004, after exclusion of acute myocardial infarction (AMI) and high risk unstable angina they underwent stress MPS. Selected 301 patients, 65.3 +/- 12.5 years and 164 (54.5%) male gender. The test was performed 13 +/- 12 hours after admission. Myocardial ischemia (ISQ) was found in 142 patients (47.2%). Male gender (n=94, p=<0.0001), history of diabetes mellitus (n=31, p=0.033), past of AMI (n=52, p=<0.0001), past of surgical myocardial revascularization (n=46, p=<0.0001) and past of percutaneous revascularization (n=68, p=<0.0001) presented correlation with ISQ. The follow-up was 697.7 +/- 326.6 days. No MPS variable correlated with the occurrence of primary outcome. Abnormal scintigraphy (n=76, p < 0.0001), ISQ (n=73, p < 0.0001) and post-stress left ventricular ejection fraction below 45% (n=21, p=0.006) correlated with secondary outcome. The presence of ISQ was the major variable in the multivariate analysis for the prediction of secondary outcome (RR = 6.5; CI 95% = 0.009). Presence of ISQ was the major independent factor in prediction of adverse events for patients admitted into the CPU.

Intervenção coronariana percutânea em artéria coronariana única em paciente com angina instável de alto risco

In the present case, we report the performance of coronary angioplasty with stent implantation in the right coronary artery of a patient with high-risk unstable angina and single coronary artery originating from the right coronary sinus. The anterior descending and circumflex arteries originated separately from the proximal third of the right coronary artery. This is a rare coronary anomaly and few reports of percutaneous coronary intervention are found in the literature. This case illustrates the need for a detailed anatomical assessment of the course of the coronary arteries prior to the performance of a percutaneous transluminal angioplasty, with the purpose of preventing complications.

A Case of Acute Coronary Syndrome complicated by a Large Rectus Sheath Hematoma

We present a 75-year-old female patient admitted to our clinic with the diagnosis of acute coronary syndrome (ACS) (high risk unstable angina pectoris) who developed a large rectus sheath hematoma one day after low molecular weight heparin (LMWH) (enoxaparin) treatment was started.

Low risk is associated with poorer quality of life than high risk following acute coronary syndrome

Morbidity after acute coronary syndromes includes both physical and mental disorders affecting quality of life. The aim of this investigation was to study quality of life at a 3-month follow-up in patients with acute coronary syndrome, with the main objective of exploring whether unstable angina pectoris and myocardial infarction (MI) patients differ in this respect. This investigation was part of a prospective risk stratification study of consecutive patients with acute coronary syndrome of whom 814 below the age of 75 years (278 diagnosed with unstable angina pectoris and 536 with myocardial infarction) accepted an invitation to a follow-up visit 3 months after discharge. At follow-up, the patients completed the Cardiac Health Profile, a disease-specific quality of life questionnaire, designed to evaluate perceived cognitive, emotional, social and physical function. Quality of life was mainly influenced by patient characteristics and previous history. The Cardiac Health Profile scores in unstable angina pectoris patients were significantly higher (i.e. poorer quality of life) than myocardial infarction patients at the 3-month visit (34, 22, 50; median, 25th, 75th percentile and 30, 19, 44; median, 25th, 75th percentile, respectively, P=0.006). The adjusted odds ratio for a poorer quality of life in unstable angina pectoris patients in relation to myocardial infarction patients was 1.39 (95% confidence interval 1.03, 1.87; P=0.03). The highest Cardiac Health Profile scores were seen in the unstable angina pectoris patients without electrocardiogram signs of ongoing ischemia and/or elevated markers of myocardial necrosis. Patients with unstable angina pectoris, especially of the low-risk type, and therefore treated accordingly, are more likely to experience poorer quality of life following an acute hospitalization than patients with other types of acute coronary syndrome. Once myocardial infarction or high-risk unstable angina pectoris has been ruled out, these patients still require a careful and systematic follow-up.

Same-day transfer of patients with unstable angina and non-ST segment elevation myocardial infarction back to their referring hospital after angioplasty

Recent evidence has shown the advantages of an early invasive strategy for patients with high-risk unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). However, the number of beds available for postangioplasty monitoring limits the use of this approach at the Centre hospitalier universitaire de Sherbrooke (Fleurimont, Quebec). To study the safety of a protocol allowing the same-day return of patients with UA or NSTEMI to their referring hospital after angioplasty at the Centre hospitalier universitaire de Sherbrooke. From June 2001 to June 2003, of the 532 patients with UA and NSTEMI who underwent percutaneous coronary intervention with planned same-day transfer back to their referring hospital, 419 consecutive patients who were eligible to return the same day were prospectively followed for 24 h. Stents were used in 94.7% of patients and platelet glycoprotein IIb/IIIa receptor antagonists were used in 34.8% of patients. For 85% of patients, the femoral artery was used as the access route for percutaneous coronary intervention. The mean time that patients stayed in the hospital after angioplasty before returning to their referring centres was 4.4 h. No deaths, life-threatening arrhythmias or urgent revascularizations were reported during the 24 h postangioplasty follow-up period, but one patient had a major bleeding complication. During the study period, the mean angioplasty waiting time decreased from 5.7 days to 2.1 days. The protocol evaluated in the present article is safe. It frees more beds, thus reducing the waiting list and allowing patients with high-risk acute coronary syndromes without ST segment elevation from community hospitals to benefit from the advantages of an early invasive strategy.

Percutaneous Intervention Versus Coronary Bypass Surgery for Patients Older Than 70 Years of Age With High-Risk Unstable Angina

The Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) study was a multicenter Veterans Affairs randomized trial and registry that compared long-term survival of percutaneous coronary intervention with coronary artery bypass graft surgery for the treatment of patients with medically refractory myocardial ischemia and at least one additional risk factor for an adverse outcome with bypass. Both the randomized trial and the registry demonstrated comparable 3-year survival. The purpose of this study was to compare bypass and percutaneous intervention survival of AWESOME patients who were older than 70 years of age. Over a 5-year period (1995 to 2000), 2,431 patients with medically refractory myocardial ischemia and at least one of the following five risk factors (prior heart surgery, myocardial infarction within 7 days, left ventricular ejection fraction less than 35%, age > 70 years, intraaortic balloon pump requirement to stabilize) were identified. Of these patients, 1,278 were older than 70 years of age. Eight hundred, seventy-one patients were turned down by at least one physician, 407 were acceptable to both physician and surgeon for randomization, and 236 (60%) consented to randomization. Of the 1,042 eligible patients who were not randomized, 871 had their revascularization directed by a physician who was not involved in the study. One hundred, seventy-one patients who were acceptable for randomization by both the interventional cardiologist and the cardiac surgeon refused consent. Bypass and percutaneous intervention survival were compared using Kaplan-Meier curves and log rank tests. Bypass and percutaneous intervention 36-month survival rates for patients older than 70 years of age were 76% and 75%, respectively, among the eligible patients. Survival was 71% and 78% among those patients who were randomized and 76% and 67% in the physician-directed subgroup. Of those patients who chose their revascularization techniques, the survivals were 79% and 85%, respectively. The survival differences are not large, and none of the global log rank tests of bypass compared with percutaneous intervention survival showed a statistically significant difference over 5 years. Both the randomized and registry subgroups of patients who were older than 70 years of age support the trial conclusions that either bypass or percutaneous intervention effectively relieves medically refractory ischemia among high-risk unstable angina patients whose age was greater than 70 years.