Inferior ST Elevation Research Articles

Acute Aortic Dissection Complicating Emergency Coronary Intervention for Hyperacute Stent Thrombosis

Introduction: Iatrogenic acute aortic dissection resulting from coronary interventions can have fatal consequences. Although it is an uncommon complication during percutaneous coronary interventions (PCI), it can arise from various factors. Our case report aims to address this rare presentation further, seeking to enhance preprocedural planning which can result in better outcomes. Case Report: We describe an intriguing case of an elderly female patient with multiple cardiovascular risk factors who came to our emergency department presenting with chest pain. Her Electrocardiogram revealed an inferior ST-elevation myocardial infarction (STEMI) for which she underwent successful primary PCI of the right coronary artery (RCA). Four days later, she had an infero-posterior STEMI, which necessitated immediate coronary angiography. Angiography revealed thrombosis of the stent placed earlier in the RCA. On attempting recanalization of the vessel, an acute aortic dissection was identified and was successfully managed by ostial stenting. Follow-up imaging showed no residual dissection, and the patient was found to be comfortable and stable post-procedure. Conclusion: We recommend optimizing blood pressure and performing rapid ostial stenting in these cases, irrespective of the dissection’s origin. This will facilitate effective sealing of the entry site and prevent further progression of the dissection. Our report highlights the favorable results achieved with immediate ostial stenting while discussing the conservative approach to managing such cases.

Abstract 4119470: ST-Elevation Myocardial Infarction as a Complication of Granulomatosis with Polyangiitis

Description of Case: A 19-year-old female with history of granulomatosis with polyangiitis (GPA) presented to the emergency department after a syncopal episode at a concert. She reported a prodrome of feeling hot and dizzy prior to the event, followed by epigastric discomfort, nausea, and vomiting after regaining consciousness. She had been diagnosed with GPA one year prior to presentation based on serology and biopsy results. Because her disease was felt to be well-controlled on azathioprine, she had been tapered off of prednisone one month prior to presentation. Initial vitals included blood pressure of 90/60 mmHg, and heart rate of 94 bpm. A 12-lead EKG revealed ST segment elevation in leads I, II and aVF with T wave inversions in the lateral leads ( Figure 1 ). Initial bloodwork was notable for troponin I of 0.11ng/mL (upper limit of normal 0.034 ng/mL). A diagnosis of inferior ST-elevation myocardial infarction was made. She was treated with oral aspirin and prasugrel load as well as intravenous heparin and taken urgently to the catheterization laboratory. Diagnostic coronary angiography was significant for single vessel coronary artery disease (CAD) of the right coronary artery (RCA), with acute complete occlusion of the mid-RCA ( Figure 2A-B ). She was treated successfully with primary percutaneous coronary intervention and implant of two overlapping drug eluting stents in the mid-RCA ( Figure 2C ). Discussion: GPA is a systemic necrotizing vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA) that predominantly affects small to medium sized vessels in the respiratory tract and kidneys. Cardiovascular manifestations in GPA are uncommon, but include pericarditis, myocarditis, and coronary arteritis. GPA can affect the coronary arteries either primarily through inflammatory changes in the arterial wall or via systemic inflammation leading to accelerated atherosclerosis. No standardized criteria exist to establish the diagnosis of coronary arteritis and to differentiate it from accelerated atherosclerosis. Long-term treatment of vasculitis patients with coronary involvement is also poorly supported by evidence. Optimization of cardiovascular risk factors is advocated as per standard of care, and vasculitis control may slow disease progression. This case not only raises awareness of cardiac complications in GPA, but highlights the current lack of evidence surrounding secondary prevention in young patients with vasculitis and cardiac complications.

Impella 5.5 as a bridge-to-surgery in acute ischemic mitral regurgitation post-percutaneous coronary intervention: a case report

BackgroundAcute ischemic mitral regurgitation (AIMR) is a significant complication of acute coronary syndrome that leads to severe and immediate hemodynamic deterioration and cardiogenic shock. Intra-aortic balloon pumps (IABP) are commonly used to support patients with AIMR as a bridge to surgery, though they may be insufficient in some cases.Case PresentationA 74-year-old male presented with two days of indigestion and evident hypoxia, and an electrocardiogram revealed inferior and lateral ST-elevation myocardial infarction. Angiography demonstrated severe two-vessel coronary disease with a 100% thrombotic occlusion of the second obtuse marginal artery (OM2, culprit lesion) and an 80% stenosis of the proximal left anterior descending artery (LAD). Despite stenting of OM2, the patient remained hypoxic and hypotensive, necessitating escalated support via an IABP. A follow-up echocardiogram revealed severe mitral regurgitation presumed to be AIMR secondary to a ruptured posteromedial papillary muscle with a flail anterior leaflet (A2). Despite aggressive supportive measures with the IABP, the patient’s hemodynamics continued to show cardiogenic shock and clinical status did not improve. However, the patient was required to abstain from surgery for a P2Y12 inhibitor therapy wash out period. Consequently, the IABP was upgraded to Impella 5.5 as bridge-to-surgery support on day 1 post-admission. Subsequently, the patient’s hemodynamics improved, and he underwent a combined mitral valve replacement and coronary artery bypass grafting surgery on day 7 post-admission without incident. The Impella was successfully explanted on day 25 post-admission. Delay in explant was due to hypotension and respiratory status despite normalizing hemodynamics and echocardiogram revealing recovered left ventricular ejection fraction. The patient developed bacterial pneumonia and acute respiratory distress syndrome and expired on day 27 post-admission.ConclusionAlthough IABP is standard for supporting AIMR patients as a bridge to surgery, it may not provide sufficient hemodynamic support. This case supports a growing body of evidence that alternative forms of hemodynamic support should be considered if the traditional therapeutic modalities for AIMR do not adequately support patients. Clinicians may consider upgrading IABP to Impella to provide increased hemodynamic support and maintain AIMR patient stability while awaiting cardiac surgery.

Evaluation of Right Atrial Function by 2D Speckle Tracking Echocardiography in Patients Undergoing Primary Percutaneous Coronary Intervention after Inferior ST Segment Elevation Myocardial Infarction

Abstract Aim and Objectives The aim of the study is to evaluate right atrial function by 2D speckle tracking echocardiography in patients undergoing primary percutaneous coronary intervention after inferior ST segment elevation myocardial infarction. Patients and Methods This study included 100 patients diagnosed with Inferior STEMI subdivided into patients with RV infarction (26 patients) and those without RV Infarction (74 patients) in the ER fulfilling the inclusion criteria compared to the Control Group (50 patients) of healthy individuals matched in the same age group with no history of acute coronary syndrome and no cardiovascular risk factors, these patients were assessed demographic data, risk factors, general examination, local examination, laboratory measure, ECG and full echocardiographic assessment including 2DSTE evaluation of the RA. Results In our study the results showed that RA strain during reservoir phase (RASr) and RA strain during conduit phase (RAScd) were reduced among the patients with inferior wall MI compared to the control group (P-value: <0.001), While RA strain during contractile phase (RASct) was preserved among the patients group (P-value: <0.001), Also RA total emptying fraction (RA EF) and RA total emptying volume (RA EV) were preserved among the patients group compared to the control group (P-value: 0.095, 0.062 respectively). Then we compared the patients with inferior wall myocardial infarction with RV infarction to the patients with no RV infarction, The results showed that RA strain during reservoir, conduit and contractile phases were preserved among the patients with RV infarction compared to those without RV infarction (P-value: 0.196, 0.118, 0.266 respectively), While RA EF and RA EV were significantly reduced among the patients with RV infarction compared to those without RV infarction (P-value: 0.029, 0.038 respectively), There was a positive correlation between RA EF with RV functions parameters as TAPSE (r: 0.377, P-value: <0.001), FAC (r: 0.425, P-value: <0.001), Also There was a positive correlation between RA EV with RV functions parameters as TAPSE (r: 0.239, P-value: 0.017), FAC (r: 0.378 P-value: <0.001) Conclusion RA strain during reservoir phase (RASr) and RA strain during conduit phase (RAScd) were significantly lower in patients with inferior wall myocardial infarction compared to the control group, while RA strain during contractile phase (RASct),RA Emptying Fraction (RA EF) and RA Emptying Volume were preserved among the patients with inferior wall myorcardial infarction compared to control group. Patients with inferior wall myocardial infarction with RV infarction have lower RA emptying fraction (RA EF) and RA emptying volume than those without RV infarction.

Assessment of Right Ventricular Function before and after Primary Percutaneous Coronary Intervention in Patients with Acute Inferior Wall ST-elevation Myocardial Infarction by Tissue Doppler Imaging

Abstract Background: Assessing right ventricular performance using two-dimensional (2D) echocardiography has been difficult due to its complex shape. Tissue Doppler imaging was used as a noninvasive method in this study to evaluate right ventricular function in patients with acute inferior wall ST-elevation myocardial infarction (IWMI) treated with primary percutaneous coronary intervention (PCI). Materials and Methods: Forty patients with IWMI admitted to a tertiary care hospital in India were included in this prospective, observational study. The patient’s detailed history, physical examination along with laboratory parameters, electrocardiogram, echocardiogram, and coronary angiogram profile were recorded from which the decision for PCI was made. The follow-up period for each patient was 6 weeks, during which 2D color Doppler and pulse-wave echocardiographic parameters were assessed. Results: This study comprised 40 patients, among which 16 patients had right ventricular myocardial infarction (RVMI), and the mean age of RVMI patients was 56.65 ± 12.03 years. In RVMI patients, tricuspid annular plane systolic excursion (mm) and RV FAC (%) values were lower than in IWMI patients, and a surge in its respective value to 15.66 ± 1.20 and 32.64 ± 3.17 (P = 0.03) was observed post-PCIs. Furthermore, an inclination in tissue annular systolic velocity (Sm; cm/s) to 11.24 ± 1.55, P = 0.02, and early diastolic tissue annular velocity (Em; cm/s) to 10.98 ± 1.27, P = 0.003, from the baseline was observed after revascularization. The myocardial performance index value accounted to be higher in RVMI patients; however, after PCI, a change from 0.73 ± 0.06 to 0.61 ± 0.12 was noted (P = 0.002). Conclusion: In this study, a significant difference in the echocardiographic parameters assessing RV function in RVMI and IWMI patients was noted, and hence, it can be considered a reliable diagnostic tool to predict the RV performance.

TCT-280 Patterns of Disease Progression and Outcomes of Inferior ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Insights From the INSTINCT Registry

TCT-280 Patterns of Disease Progression and Outcomes of Inferior ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Insights From the INSTINCT Registry

Comparing One-Year Survival in Anterior Versus Inferior ST-Elevation Myocardial Infarction Patients: Results of a Cohort Study in Western Iran

Background: The site of acute myocardial infarction (MI) plays a pivotal role in determining the prognosis and risk assessment for patients experiencing their first ST-segment elevation MI (STEMI). Objectives: This study aims to compare one-year survival rates in patients with anterior versus inferior ST-elevation myocardial infarction. Methods: This registry-based cohort study was conducted from July 2018 to December 2019, examining data from STEMI patients. A total of 643 patients diagnosed with STEMI who met the inclusion criteria were enrolled. Patients were categorized based on the location of their myocardial infarction (MI) into two groups: Those with anterior MI and those with inferior MI. Their progress was meticulously followed over the course of one year. For data analysis, Cox proportional hazards models were used to calculate two sets of hazard ratio estimates: The initial unadjusted (crude) hazard ratios and the fully adjusted hazard ratios, which accounted for potential confounding factors. Along with these hazard ratio estimates, their corresponding 95% confidence intervals (HR, 95% CI) were obtained. All statistical analyses were performed using R software version 4.2.1. Results: Throughout the follow-up period, totaling 598 patients and 4,109 person-days, only 7 patients (1.09%) were lost to follow-up. The analysis revealed no significant difference in one-year mortality rates between the inferior and anterior STEMI groups, with rates of 37 (8.39%) versus 15 (7.69%), respectively, yielding a P-value of 0.767. However, it is noteworthy that the mortality risk trended higher in the inferior MI group, with a hazard ratio of 1.093 (95% CI: 0.60 - 1.99). Conclusions: In conclusion, our study highlights the heightened mortality risk associated with inferior wall MI. These results underscore the prognostic value of MI location, shedding light on its potential role in predicting the severity and extent of infarction, thereby guiding clinical decision-making and risk management strategies in STEMI patients.

Inferior ST elevation myocardial infarction in a patient with anomalous origin of the left coronary artery from the right coronary cusp.

Inferior ST elevation myocardial infarction in a patient with anomalous origin of the left coronary artery from the right coronary cusp.

Comparison of Heart Rates in Patients Initiated on Ticagrelor Versus Other P2Y12 Inhibitors After an Inferior ST Elevation Myocardial Infarction (STEMI).

P2Y12 inhibitors have differing associations of bradyarrhythmias. Ticagrelor has been shown to increase adenosine plasma concentrations leading to increases in bradyarrhythmias. While clopidogrel and prasugrel have not been shown to have any association with bradyarrhythmias. The objective of this study was to determine heart rates after ticagrelor initiation compared to clopidogrel/prasugrel in inferior ST Elevation Myocardial Infarction (STEMI) patients. This was a retrospective, multicenter study conducted at 3 primary percutaneous coronary intervention (PCI) centers between January 1, 2017 and September 30, 2022. Adult patients were included if they were diagnosed with an inferior STEMI to the right coronary artery (RCA) and treated with PCI followed by an oral P2Y12 inhibitor. The primary outcome was heart rate at 48 hours or discharge, whichever first, after administration of ticagrelor compared to clopidogrel/prasugrel. This study reviewed 331 patients, 172 in the ticagrelor group and 159 in the clopidogrel/prasugrel group. There were no statistical differences between groups regarding the primary outcome, with a median heart rate of 76 beats per minute (bpm) [67-85] in the ticagrelor group versus 73 bpm [66-84] in the clopidogrel/prasugrel group (P = 0.238). No differences were observed between groups regarding any secondary outcomes. There were similar heart rates between ticagrelor and clopidogrel/prasugrel. There were also similarities in the ability to tolerate beta-blocker therapy after initiation of a P2Y12 inhibitor. The results of this study suggest that in inferior STEMIs when using ticagrelor as the P2Y12 inhibitor, there are not increased clinical manifestations of bradycardia.

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

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

THE INTELLIGENT USE OF ADRENALINE

Abstract Case Report A 52–year–old patient experienced anterior and inferior ST–elevation myocardial infarction, leading to cardiogenic shock necessitating invasive hemodynamic and pharmacological support. During angiography, an intra–aortic balloon pump (IABP) was inserted, and a norepinephrine infusion along with dobutamine was initiated, showing partial clinical and laboratory improvement. Critical disease in all three vessels was detected, prompting angioplasty with stenting of the right coronary artery and left anterior descending artery. Echocardiography revealed severe reduction in left ventricular systolic function (ejection fraction 10%). Despite revascularization and intensive support, the patient‘s hemodynamic status deteriorated (SCAI D), necessitating the addition of adrenaline (0.03 μg/kg/min) to the ongoing dobutamine infusion, suspending noradrenaline. Subsequent days showed gradual improvement, allowing for withdrawal from amine support and discontinuation of the IABP. Follow–up included a cardiac MRI displaying severe systolic dysfunction (EF 21%), extensive ischemic–pattern delayed enhancement across three–vessel distribution. Given the persistent severe left ventricular dysfunction, the patient underwent subcutaneous defibrillator implantation for primary prevention after optimizing anti–remodeling therapy. Despite optimized medical therapy and cycles of levosimendan, the patient experienced heart failure exacerbation, requiring hospitalization (INTERMACS 3). Considering the clinical condition and absence of contraindications, the patient was listed for heart transplantation. Due to refractory hemodynamic instability despite inotropic agents, a left ventricular assist device was implanted as a bridge to transplantation. Roughly 6 months later, the patient successfully underwent heart transplantation without acute complications. Conclusions Very low doses of adrenaline demonstrate increased sensitivity to β2 receptors over α receptors, thereby enhancing mean arterial pressure and peripheral perfusion. At the cardiac level, it induces an increase in both heart rate and coronary blood flow, while peripherally reducing resistances, predominantly due to the prevalence of β2 receptors in skeletal muscle. This improvement contributes to the enhancement of ventricular–arterial coupling. In conditions characterized by a primary pump deficit, such as cardiogenic shock, the use of low–dose adrenaline emerges as a valid therapeutic option.

Effect of reperfusion time on right ventricular remodeling in inferior ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background: Right ventricle (RV) remodeling and dysfunction are frequent in inferior ST-elevation myocardial infarction (STEMI) patients and possibly implicated to poor outcomes. Objective: The purpose of this study is to investigate the influence of reperfusion time on RV remodeling in patients with inferior STEMI who had primary percutaneous coronary intervention (PPCI).Methods: The subjects were patients with inferior STEMI who had undergone PPCI and met the inclusion and exclusion criteria. From September 2021 to April 2022, samples were taken in the order in which they arrived at the Dr. Sardjito Hospital in Yogyakarta, Indonesia. To investigate the occurrence of RV remodeling, 2D-transthoracic echocardiography was performed before PPCI as baseline and 3-months after PPCI. Confounding factors were investigated using bivariate and multivariate analysis.Results: The RV remodeling was observed in 12 (28.6%) of 42 inferior STEMI patients undergoing PPCI. The RV remodeling group had a longer median reperfusion time (798.5 vs 710 minutes, p=0.568). The baseline RV end-systolic area (RVESA) and RV end-diastolic area (RVEDA) had significant correlations with the occurrence of RV remodeling (p=0.046; p=0.008, respectively). The tricuspid annular plane systolic excursion (TAPSE) rose considerably in both groups during the 3-month follow up. There were significant variations in RVEDA and RV basal diameter in the RV remodeling group, but there was a substantial rise in fractional area change (FAC) and RVESA in the non-RV remodeling group.Conclusion: In patients with inferior STEMI undergoing PPCI, reperfusion time showed no significant effect on RV remodeling.

Clinical significance of R-wave amplitude in lead V1 and inferobasal myocardial infarction in patients with inferior wall myocardial infarction.

To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h. Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V1 <0.3 mV with ST-segment elevation (ST↑) V7-V9, Group B: R V1 <0.3 mV without ST↑ V7-V9, Group C: R V1 ≥0.3 mV with ST↑ V7-V9, and Group D: R V1 ≥0.3 mV without ST↑ V7-V9. Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V6, indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V3R + V4R + V5R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset. For inferior STEMI patients, concurrent R V1 <0.3 mV with ST↑ V7-V9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations.

Limitation of Marginal Arteries Flow and Its Impact on Clinical Prognosis In Patients with Acute Inferior ST-Elevation Myocardial Infarction treated with primary Percutaneous Coronary Intervention

Limitation of Marginal Arteries Flow and Its Impact on Clinical Prognosis In Patients with Acute Inferior ST-Elevation Myocardial Infarction treated with primary Percutaneous Coronary Intervention

Severe COVID-19 post pregnancy complicated by acute thromboemboli resulting in ST-elevation myocardial infarction - A case report.

Introduction: It has been shown that pregnancy can cause alterations in the severity of COVID-19 infection. We demonstrate an immediate post-partum patient diagnosed with severe COVID-19 and subsequently developed acute thrombosis of coronary artery.Case Summary: 35-year-old female unvaccinated for COVID-19 presented in labor and delivered on the same day. Several hours later, she was found to be in respiratory distress and tested positive for COVID-19. On day 7, computerized tomography (CT) of chest revealed bilateral pneumonia and pneumomediastinum. On day 8, she developed chest pain with electrocardiogram (EKG) showing inferior STelevations with troponin I of 0.6 ng/mL. She was intubated for airway protection and emergent diagnostic angiogram revealed thrombus occlusion of the third right posterolateral segment that resulted in thrombolysis in myocardial infarction (TIMI) 0 flow without evidence of underlying atherosclerotic disease in the remaining vessels. Intracoronary IIb/IIIa inhibitor was administered. Arterial blood gas in the lab revealed profound hypoxia despite being on 100% inspired oxygen. Multidisciplinary decision was made to cannulate patient for venovenous extracorporeal membrane oxygenation (ECMO) to treat severe COVID-19 pneumonia. She was finally decannulated from ECMO on day 65. After prolonged hospital stay, she eventually recovered and was discharged to rehabilitation.Conclusions: The center for disease control (CDC) surveillance has reported that pregnant patients with COVID-19 are more likely to require invasive ventilation and ECMO, and die given the immunological changes during pregnancy. Hypercoagulable state caused by combination of pregnancy and COVID-19 resulting in coronary thrombosis is rarely described in literature, our case demonstrated the paucity of this phenomenon.

Unravelling a Case of Coronary Vasculitis

Background Coronary vasculitis is a rare cause of myocardial infarction through varied mechanisms. We report the case of a 32-year-old female found to have diffuse coronary microaneurysms during treatment for an Inferior ST Elevation Myocardial Infarction (STEMI), with challenges in pinpointing the underlying aetiology. Results Our patient has been diagnosed with a seronegative arthritis and had been initiated on regular Golimumab 4 months prior. She presented with prolonged fever for 4 weeks and inflammatory oligoarthritis with left sacroiliac joint pain. During this admission, Antinuclear antibody was 1:2560 and anti ds DNA was 1:80. She had highly positive Rickettsia conorii IgG titres of 1:128, suggestive of acute infection with Orientia tsustsugamushi. Meropenem and doxycyclin for presumed typhus had no impact on her fever spikes. In the 10th week of the illness, she developed ischaemic chest pain with electrocardiographic changes of inferior STEMI and was thrombolysed. Invasive coronary angiography revealed numerous coronary microaneurysms affecting all major myocardial vessels, with minimal coronary artery disease. Following multidisciplinary discussion, she was treated with intravenous methylprednisolone, antiplatelets, a statin and warfarin for a diagnosis of coronary vasculitis. Repeat angiography showed complete resolution of the microaneurysms. She continues on anticoagulation and has since had no coronary events. Conclusion Typhus and medium vessel vasculitis such as Kawasaki and Polyarteritis Nodosa were potential diagnoses for this presentation. A diagnosis of SLE was established due to the highly specific immunological profile. As there are reports of high Rickettsial titres in autoimmune disease, which alongside the lack of response to doxycyclin makes Typhus unlikely. The possibility of golimumab induced SLE was briefly entertained due to similar reports, but the positivity of ds DNA and major organ involvement made this possibility unlikely. We highlight the cardiac involvement in this case due to its high morbidity on young patients, and the current paucity of knowledge on SLE-related endothelial dysfunction and immune-mediated vascular damage. The role of anticoagulation in this inflammatory milieu too, is controversial. This case highlights a rare presentation of SLE, with an emphasis on coronary vasculitis. It adds to the current knowledge on the complex cardiovascular risk in SLE and highlights ambiguous areas in current management strategies to prompt further research.

Rare Presentation of Myocardial Ischemia in a Patient with an Anomalous Right Coronary Artery

BACKGROUND: Coronary anomalies are coronary patterns that occur rarely in the general population. The most common type of these anomalies is the emergence of the right coronary artery (RCA) from the left coronary sinus, which in most patients is either asymptomatic or leads to sudden cardiac death (SCD). THE CASE: This case report presents the case of a 35-year-old male patient who had an inferior ST elevation myocardial infarction (STEMI) for which percutaneous coronary intervention was attempted and failed due to the patient going into cardiac arrest. The patient was subsequently managed medically in the cardiac intensive care unit and followed up outpatient with a cardiologist. The patient experienced symptoms of exertional angina and had a CT angiography of the heart and coronary vessels that identified an anomalous RCA emerging from the left coronary sinus. He was diagnosed with an anomalous RCA with malignant take-off from the left coronary sinus, and subsequent management was surgical with a coronary artery bypass graft (CABG) x1 using the right internal mammary artery (RIMA to RCA). Intraoperatively, the patient was found to have sclerosis of the RCA proximally for about 5cm. The patient did well post-operatively and had no symptoms of exertional angina upon outpatient follow up with both his cardiologist and cardiothoracic surgeon. CONCLUSION: Most cases of coronary anomalies have been found to be either completely asymptomatic or lead to SCD, especially in young patients, however very few cases in literature identified patients with this anomaly presenting with STEMI such as in this case. Another significant finding in this patient is sclerosis of the RCA, where although some articles propose that anomalous coronary arteries may be more susceptible to atherosclerosis, others conclude that there may be no association; concluding that factors such as intramural course, slit-like origin, and acute angle take-off might be more significantly associated. Moreover, patients with coronary anomalies rarely experience cardiac events solely due to their anomaly, such as with this patient. Finally, this patient’s significantly young age at 35 years old is significant given the mean age of patients undergoing CABG being 60.8 years in one cross-sectional study. Current management of symptomatic patients with these anomalies is under debate, with many patients undergoing CABG such as in this case, although one study shows no significant difference in mortality or 10-year survival with surgical intervention despite having higher surgical intervention rates. Percutaneous coronary intervention (PCI) of patients with coronary anomalies has been shown to be difficult or unsuccessful in most studies, although a few cases in literature were successful with tools such as multidetector CT (MDCT). Awareness of these anomalies and their possible presentation, risk factors, and radiologic findings is important especially given their potential for SCD. More research is needed to further elucidate the best treatment options and perhaps even improve the potential for non-invasive interventional techniques such as PCI.

TAPSE, Tissue Doppler Systolic annular velocity(S’) and myocardial performance Index (MPI) as a predictor of proximal RCA occlusion in acute inferior wall myocardial ST elevation infarction

TAPSE, Tissue Doppler Systolic annular velocity(S’) and myocardial performance Index (MPI) as a predictor of proximal RCA occlusion in acute inferior wall myocardial ST elevation infarction

Heart rhythm complexity analysis in patients with inferior ST-elevation myocardial infarction

Heart rhythm complexity (HRC), a subtype of heart rate variability (HRV), is an important tool to investigate cardiovascular disease. In this study, we aimed to analyze serial changes in HRV and HRC metrics in patients with inferior ST-elevation myocardial infarction (STEMI) within 1 year postinfarct and explore the association between HRC and postinfarct left ventricular (LV) systolic impairment. We prospectively enrolled 33 inferior STEMI patients and 74 control subjects and analyzed traditional linear HRV and HRC metrics in both groups, including detrended fluctuation analysis (DFA) and multiscale entropy (MSE). We also analyzed follow-up postinfarct echocardiography for 1 year. The STEMI group had significantly lower standard deviation of RR interval (SDNN), and DFAα2 within 7 days postinfarct (acute stage) comparing to control subjects. LF power was consistently higher in STEMI group during follow up. The MSE scale 5 was higher at acute stage comparing to control subjects and had a trend of decrease during 1-year postinfarct. The MSE area under scale 1–5 showed persistently lower than control subjects and progressively decreased during 1-year postinfarct. To predict long-term postinfarct LV systolic impairment, the slope between MSE scale 1 to 5 (slope 1–5) had the best predictive value. MSE slope 1–5 also increased the predictive ability of the linear HRV metrics in both the net reclassification index and integrated discrimination index models. In conclusion, HRC and LV contractility decreased 1 year postinfarct in inferior STEMI patients, and MSE slope 1–5 was a good predictor of postinfarct LV systolic impairment.

Differentiation of acute inferior wall myocardial infarction caused by acute type A aortic dissection from atherosclerotic inferior myocardial infarction

Abstract Background Myocardial infarction (MI) caused by acute type A aortic dissection (AAD) is a rare but serious complication. To avoid unnecessary and possibly harmful treatment, differentiation of AAD-MI from atherosclerotic MI (AMI) is very important. However, there is a paucity of data regarding differentiation between AAD-MI and AMI. Purpose To compare the differences of clinical features between AAD-MI and AMI, and develop an effective way of differentiation. Methods Among 318 cases with AAD between 1982 and 2020, 18 cases (5.7%) had AAD-MI, of which 13 had inferior wall AAD-MI. Clinical features were compared with 25 consecutive inferior ST elevation AMI cases between 2017-2019. Categorial data and numerical data were compared using Fisher’s exact test and Student T test, respectively. Results Mean age and male/female ratio in AAD-MI and AMI were similar at 67.5 vs 66.3 years and 7/6 vs 13/12, respectively. The distribution of coronary risks factors and pain as presenting symptoms were similar in both groups. Initial systolic blood pressure (SBP) was significantly lower, and the incidence of shock was significantly higher in AAD-MI group compared to AMI group (SBP: 97.5 ± 26.4 vs 124.6 ± 32.7 mmHg, P = 0.014. shock: 9/13, 69.2% vs 5/25 20.0%, P = 0.0048). Although the heart rate was similar in both groups, AAD-MI group was more tachypnoeic than AMI group (27.8 ± 7.4 vs 22.7 ± 5.9/min, P = 0.046). All cases in both groups had ST elevation &amp;gt;1mm in inferior leads (by definition). There were no differences of the degree of ST elevation (2.46 ± 1.19 vs 2.54 ± 1.50 mm. P = 0.87), and the incidence of arrhythmias such as AV block. Chest X-ray showed higher incidence of mediastinal widening (MW) in AAD-MI group compared to AMI group (11/13, 84.6% vs 5/25, 20.0%. P =0.0003), whereas the incidence rates of cardiomegaly and congestive heart failure were not different. Pulse deficit (PD) and hemiplegia were seen in AAD-MI group only (pulse deficit: 5/13, 38.5% vs 0/25, 0%. P = 0.0026. hemiplegia: 2/13, 15.4% vs 0/25, 0% P = 0.11). The incidence of tamponade (T) and aortic regurgitation (AR) were higher in AAD-MI group than in the AMI group (T: 7/13, 53.8% vs 0/25, 0%. p=0.00014. AR: 8/13, 61.5% vs 4/25 16.0% P = 0.009). The combination of either PD, AR, or T increased the sensitivity up to 84.6% while the specificity was 84.0%. Intimal flap was successfully identified by bedside echocardiography in 7 out of 9 cases (77.8%) in AAD-MI group. Conclusion ADD-MI and AMI present with similar risk factors, clinical symptoms, and electrocardiographic findings. However, ADD-MI cases were associated with worse findings, such as, lower initial SBP, tachypnoea and had higher incidences of shock, PD, MW, T, and AR compared to AMI cases. Echo is of critical importance as it can identify abnormalities more specific for AAD (AR, T) and can make final diagnosis of AAD through visualizing the intimal flap.Summary tableA representative case