Ischemic ECG Changes Research Articles

Electrocardiography changes in acute aortic dissection—association with troponin leak, coronary anatomy, and prognosis

BackgroundElectrocardiography (ECG) offers some information that may be used to prognosticate acute type A aortic dissection (AAOD) for short- and long-term mortality. MethodsWe retrospectively analyzed the electrocardiograms of patients with AAOD admitted from March 2004 to March 2015. The frequency of ECG findings and their prognostic value on hospital and follow-up mortality were investigated. Findings pertaining to coronary involvement and troponin level were also examined. ResultsA total of 120 men and 64 women were admitted. Acute ischemic changes were reported in 38.0%, whereas T inversion was the most common recorded abnormality, which occurred in 38.6%. Acute ST-elevation myocardial infarction was detected in 16.3%. Troponin increased in 36.6%; 21.9% of the patients underwent coronary angiography among which 70% were normal. Coronary involvement or troponin increase was not different in patients with acute ECG changes. During hospitalization, 45.7% of the patients died. In multivariate analyses, ST elevation in lead aVR was associated with higher hospital death (odds ratio, 5.30; 95% confidence interval, 1.09-25.73; P = .038), whereas QRS greater than 120 milliseconds was associated with long-term mortality (hazard ratio, 2.45; 95% confidence interval, 1.25-3.76; P = .006). ConclusionAcute ischemic ECG changes are common in AAOD, and a completely normal ECG is infrequently encountered. Acute ECG changes were not associated with the increased troponin or the presence of coronary lesions in angiography.

A systematic review of the risks factors associated with the onset and natural progression of hydrocephalus

The purpose of this study was to systematically assess and synthesize the world literature on risk factors for the onset and natural progression of hydrocephalus, thereby providing a basis for policy makers to identify appropriate risk management measures to mitigate the burden of disease in Canada. Evidence for risk factors was limited for both onset and progression. Two meta-analyses that examined a risk factor for onset met the inclusion criteria. One found a significant protective effect of prenatal vitamins among case control studies, but not cohort/randomized controlled trials (RCTs). The second found maternal obesity to be a significant risk factor for congenital hydrocephalus. Significant risk factors among 25 observational studies included: biological (multiple births, maternal parity, common cold with fever, maternal thyroid disease, family history, preterm birth, hypertension, ischemic heart disease, ischemic ECG changes, higher cerebrospinal fluid protein concentration following vestibular schwannoma); lifestyle (maternal obesity, high-density lipoprotein (HDL) cholesterol, maternal diabetes, maternal age), healthcare-related (caesarean section, interhospital transfer, drainage duration following subarachnoid hemorrhage, proximity to midline for craniectomy following traumatic brain injury); pharmaceutical (prenatal exposure to: tribenoside, metronidazole, anesthesia, opioids); and environmental (altitude, paternal occupation). Three studies reported on genetic risk factors: no significant associations were found. There are major gaps in the literature with respect to risk factors for the natural progression of hydrocephalus. Only two observational studies were included and three factors reported. Many risk factors for the onset of hydrocephalus have been studied; for most, evidence remains limited or inconclusive. More work is needed to confirm any causal associations and better inform policy.

The Who, What, Why, When, How and Where of Vasospastic Angina.

Ischemic heart disease involves both "structural" and/or "functional" disorders of the coronary circulation. Structural atherosclerotic coronary artery disease (CAD) is well recognized, with established diagnostic and treatment strategies. In contrast, "functional CAD" has received limited attention and is seldom actively pursued in the investigation of ischemic heart disease. Vasospastic angina encompasses "functional CAD" attributable to coronary artery spasm and this "state of the art" consensus statement reviews contemporary aspects of this disorder. Patients with vasospastic angina typically present with angina at rest that promptly responds to short-acting nitrates and is associated with transient ischemic ECG changes. Although spontaneous episodes may be documented, provocative spasm testing may be required to confirm the diagnosis. It is important to diagnose vasospastic angina because it may be associated with major adverse events that can be prevented with the use of appropriate vasodilator therapy (eg, calcium-channel blockers) and the avoidance of aggravating stimuli (eg, smoking). Future studies are required to clarify the underlying pathophysiology, natural history and effective treatments for patients refractory to conventional therapy.

Ischemic heart disease among subjects with and without chronic obstructive pulmonary disease--ECG-findings in a population-based cohort study.

BackgroundCardiovascular comorbidity in COPD is common and contributes to increased mortality. A few population-based studies indicate that ischemic electrocardiogram (ECG)-changes are more prevalent in COPD, while others do not. The aim of the present study was to estimate the presence of ischemic heart disease (IHD) in a population-based COPD-cohort in comparison with subjects without COPD.MethodsAll subjects with obstructive lung function (COPD, n = 993) were identified together with age- and sex-matched controls (non-COPD, n = 993) from population-based cohorts examined in 2002–04. In 2005, data from structured interview, spirometry and ECG were collected from 1625 subjects. COPD was classified into GOLD 1–4 after post-bronchodilator spirometry. Ischemic ECG-changes, based on Minnesota-coding, were classified according to the Whitehall criteria into probable and possible IHD.ResultsSelf-reported IHD was equally common in COPD and non-COPD, and so were probable and possible ischemic ECG-changes according to Whitehall. After excluding subjects with restrictive spirometric pattern from the non-COPD-group, similar comparison with regard to presence of IHD performed between those with COPD and those with normal lung-function did neither show any differences. There was a significant association between self-reported IHD (p = 0.007) as well as probable ischemic ECG-changes (p = 0.042), and increasing GOLD stage. In COPD there was a significant association between level of FEV1 percent of predicted and self-reported as well as probable ischemic ECG-changes, and this association persisted for self-reported IHD also after adjustment for sex and age.ConclusionIn this population-based study, self-reported IHD and probable ischemic ECG-changes were associated with COPD disease severity assessed by spirometry.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-015-0149-1) contains supplementary material, which is available to authorized users.

Abstract 18729: Prosthetic Valve Positioning - Not a Static Question

A 65-year-old female with a history of bicuspid aortic valve s/p AVR with a Medtronic Hall mechanical valve presented with chest pain. Her recent history was notable for one week of intermittent substernal chest pain present when lying in the left lateral position. Initial ECG, obtained during an episode of chest pain, revealed 2 mm ST segment depression in the anterolateral leads and ST segment elevation in lead aVR. The ECG changes normalized with cessation of her chest pain. Laboratory evaluation showed an INR of 3.5 (on warfarin), and normal cardiac biomarkers. Chest imaging, including CT angiography, was unremarkable. Physical examination demonstrated a normal jugular venous pressure, a mechanical second heart sound, and a II/VI crescendo-decrescendo systolic murmur at the right upper sternal border. Transthoracic echocardiography (TTE) revealed normal biventricular systolic function and a mechanical valve in the aortic position, associated with mild aortic regurgitation. Valve fluoroscopy revealed an aortic monoleaflet mechanical prosthesis with normal opening and closing angles in the supine position, but with closing restriction when in the left lateral decubitus position (closing angle 46 degrees, associated with recurrent chest pain and ischemic ECG changes). Transesophageal echocardiography (TEE) showed moderate aortic stenosis, mild aortic regurgitation, and multiple linear echodensities on the aortic prosthesis. These echogenicities were felt to represent thrombi, and the patient was treated with 5 doses of tPA and intravenous heparin. Subsequent TEE and valve fluoroscopy revealed improved prosthetic leaflet motion in supine and lateral decubitus positions. This case describes an unusual presentation of mechanical aortic valve thrombosis. The contiguous association of the mechanical valve with the coronary ostia can contribute to ischemic complications, in this case positionally induced. It also highlights the value of timely valve fluoroscopy and the consideration of patient maneuvers to delineate valve function. Current guidelines support the use of thrombolytic therapy for small, left-sided thrombi, with recent literature suggesting that slowly infused low-dose tPA provides the optimal risk-benefit profile.

Microalbuminuria in non-diabetic patients with unstable angina/non ST-segment elevation myocardial infarction.

BackgroundMicroalbuminuria (MAU) is defined as an urinary albumin excretion rate between 20–200 mg/l or 30–300 mg/day. It is a surrogate marker for endothelial dysfunction and is independently associated with atherosclerotis in diabetic and in non-diabetic patients. We assessed the prevalence of MAU in non-diabetic patients who presented with UA/NSTEMI and the relation of MAU to the severity of coronary artery disease in patients at a cardiac care center in Iraq.MethodsSeventy non-diabetic patients referred to the Iraqi Center for Heart Disease, Baghdad, between November 1st 2010 and June 1st 2011 with the diagnosis of UA/NSTEMI were included in this study. Physical examination, ECG and echocardiography were performed on all patients. TIMI (“Thrombolysis in Myocardial Infarction”) risk score was obtained. Urine samples were collected and sent for quantitative determination of MAU. All patients underwent diagnostic coronary angiography. Data are give as mean (quantitative and percent) ± SD.ResultsFifty-three men (76 %) and 17 (24 %) women (mean age 56 ± 12 years) were investigated. Overall 37 (53 %) individuals presented with arterial hypertension and 41 (59 %) with a history of smoking. 58 patients (83 %) had ischemic ECG changes (defined as ST segment depression more than 1 mm from baseline, and/or T wave inversion), 52 (74 %) had echocardiographic findings indicative of ischemia (defined as segmental wall motion abnormalities). Twenty-one (30 %) patients tested positive for MAU. There was a significant correlation of echocardiographic signs of ischemia and MAU, (n = 20 (38 %), p < 0.01). There was a clear relationship between MAU and TIMI risk score. Additionally, MAU was more common in patients with multivessel coronary artery disease (CAD) (p < 0.001). There was no statistically significant correlation between MAU and mean age, sex, smoking, and blood pressure.ConclusionIn this analysis of patients with UA/NSTEMI we found a strong correlation of microalbuminuria with echocardiographic changes and findings in coronary angiography.

The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

ObjectivesInternational guidance recommends that early serial sampling of high sensitivity troponin be used to accurately identify acute myocardial infarction (AMI) in chest pain patients. The background evidence for this approach is limited. We evaluated whether on presentation and 4-hour high-sensitivity troponin I (hs-cTnI) could be used to accurately rule-out AMI. Design and methodshs-cTnI was measured on presentation and at 4-hours in adult patients attending an emergency department with possible acute coronary syndrome. We determined the sensitivity for AMI for at least one hs-cTnI above the 99th percentile for a healthy population or alone or in combination with new ischemic ECG changes. Both overall and sex-specific 99th percentiles were assessed. Patients with negative tests were designated low-risk. Results63 (17.1%) of 368 patients had AMI. The median (interquartile range) time from symptom onset to first blood sampling was 4.8h (2.8–8.6). The sensitivity of the presentation and 4h hs-cTnI using the overall 99th percentile was 92.1% (95% CI 82.4% to 97.4%) and negative predictive value 95.4% (92.3% to 97.4%) with 78.3% low-risk. Applying the sex-specific 99th percentile did not change the sensitivity. The addition of ECG did not change the sensitivity. ConclusionHs-cTnI >99th percentile thresholds measured on presentation and at 4-hours was not a safe strategy to rule-out AMI in this clinical setting irrespective of whether sex-specific 99th percentiles were used, or whether hs-cTnI was combined with ECG results.

Very high coronary artery calcium score with normal myocardial perfusion SPECT imaging is associated with a moderate incidence of severe coronary artery disease.

PurposeMyocardial perfusion imaging (MPI) has limitations in the presence of balanced multivessel disease (MVD) and left main (LM) coronary artery disease, occasionally resulting in false-normal results despite the high cardiovascular risk associated with this condition. The purpose of this study was to assess the incidence of severe coronary artery disease (CAD) in the presence of a very high Agatston coronary artery calcium (CAC) score (>1,000) in stable symptomatic patients without known CAD but with normal MPI results.MethodsA total of 2,659 prospectively acquired consecutive patients were referred for MPI and evaluation of CAC score by CT. Of this patient population, 8 % (222/2,659) had ischemia without myocardial infarction (MI) on MPIand 11 % (298/2,659) had abnormal MPI (MI and/or ischemia). On presentation 1 % of the patients (26/2,659) were symptomatic, had a CAC score >1,000 and normal MPI results. The definition of normal MPI was strict and included a normal hemodynamic response without ischemic ECG changes and normal imaging, particularly absence of transient ischemic dilation. All of these 26 patients with a CAC score >1,000 and normal MPI findings underwent cardiac catheterization.ResultsOf these 26 patients, 58 % (15/26) had severe disease (≥70 % stenosis) leading to revascularization. Of this group, 47 % (7/15) underwent percutaneous intervention, and 53 % (8/15) underwent coronary artery bypass grafting. All of these 15 patients had either MVD (14/15) or LM coronary artery disease (1/15), and represented 0.6 % (15/2,659) of all referred patients (95 % CI 0.3 – 0.9 %). The majority, 90 % (8/9), had severe CAD with typical chest pain.ConclusionA very high CAC score (>1,000) with normal MPI in a small subset of symptomatically stable patients was associated with a moderate incidence of severe CAD (95 % CI 37 – 77 %). Larger studies and/or a meta-analysis of small studies are needed to more precisely estimate the incidence of CAD in this population. This study also supports the concept that a normal MPI result in patients with severe CAD may be due to balanced MVD.Electronic supplementary materialThe online version of this article (doi:10.1007/s00259-015-3072-z) contains supplementary material, which is available to authorized users.

Evaluation of the Relative Efficacy and Safety of Prasugrel and Clopidogrel in Medically Managed High Risk UA/NSTEMI ACS Population

Background: The term acute coronary syndrome encompasses unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI) and ST-segment elevation myocardial infarction (STEMI). Antiplatelet therapy is one of the cornerstones of therapy in UA/NSTEMI. Objective: To compare efficacy and safety of Prasugrel and clopidogrel both theinopyridines antiplatelet drugs in high risk (TIMI Score 3 or more) medically managed UA/NSTEMI. Materials and Methods: A prospective, randomized study was conducted in GNDH, Amritsar. 100 patients were included, 50 patients received Prasugrel and 50 received clopidogrel. Outcomes like angina episodes, bleeding, stroke, ischemic ECG changes, and arrhythmia were compared during hospital stay and follow-up for 3 months. Results: Prasugrel was associated with significant lower incidence of major adverse cardiac event (MACE) 9 compared to 19 with clopidogrel during hospital stay. During follow up for 3 months 2 events occurred with Prasugrel and 3 with clopidogrel which were non-significant. Conclusion: Use of Prasugrel was associated with less number of MACE than the patients who were on clopidogrel. Although for the individual adverse coronary events, except for angina there was no statically significant difference, but when the total MACE observed during the study was compared, it was significantly less in the patient on Prasugrel therapy. Safety of the Prasugrel in present study was identical to clopidogrel.

An Increase of Cardio-Ankle Vascular Index/Year Was the Risk of the Onset of Ischemic Changes in ECG in the Urban Japanese Residents

An Increase of Cardio-Ankle Vascular Index/Year Was the Risk of the Onset of Ischemic Changes in ECG in the Urban Japanese Residents

Cardiac troponin I levels in an elderly population from the community — The implications of sex

ObjectivesThe importance of sex on cardiac troponin levels is increasingly recognized. We investigated whether the entities associated with troponin leakage and the prognostic consequences thereof would differ between elderly men and women from the community. Design and methodsCardiac troponin I (cTnI) levels were measured using a high-sensitivity assay (Abbott Laboratories) in 70-year old men (n=502) and women (n=502) from the PIVUS study. All study participants were followed up for 10years regarding all-cause mortality and incident cardiovascular (CV) disease. ResultsMedian cTnI levels were 4.1 and 3.0ng/L in men and women, respectively (p<0.001). By multiple linear regression, the relative contribution of lower left-ventricular ejection fraction and ischemic ECG changes to cTnI levels was greater in men compared to women. For other clinical and echocardiographic variables, similar associations were found. cTnI independently predicted all-cause mortality in men (n=93 [18.5%]; hazard ratio [HR] 1.38 [1.12–1.70]) and women (n=62 [12.4%]; HR 1.59 [1.11–2.28]) but not incident CV disease in subjects being CV healthy at baseline (n=163/857). The interaction terms of sex on the associations of cTnI with both outcomes were non-significant. Sex-specific cut-offs did not improve prognostication. Variations in the pattern of entities associated with cTnI leakage had no impact on event rates. ConclusionsWe found some differences in the entities associated with higher cTnI levels in elderly community-dwelling men and women. However, this did not translate into differences in the associations of cTnI with adverse outcome.

Abstract P224: The Haptoglobin (Hp) Genotype Predicts Coronary Artery Disease (CAD) During 25 Years of Follow-up in Type 1 Diabetes: Potential Pole of Impaired HDL Cholesterol Efflux Capacity

Background: The Hp 2-2 genotype has been associated with increased cardiovascular risk in type 2 diabetes, potentially relating to dysfunctional HDL mediated cholesterol efflux. We have shown that the Hp 2 allele predicts the development of both coronary artery disease (CAD) and kidney dysfunction also in childhood onset type 1 diabetes over 18 years of follow-up in the Epidemiology of Diabetes Complications (EDC) study. We now present results on the Hp-CAD association after an additional 7 year follow-up and Hp’s relation to impaired sterol efflux capacity, a proposed cardioprotective effect of HDL. Methods: Participants free of CAD at baseline and with Hp determined were studied (n=565; mean age, 27 and duration, 19 years; 11.5% Hp 1-1, 42.5% Hp 2-2). CAD was defined as EDC physician diagnosed angina, ischemic ECG changes (MC 1.3, 4.1-4.3, 5.1-5.3, 7.1), confirmed MI (MC 1.1, 1.2 or validated medical records), stenosis &gt;50%, revascularization or CAD death. In a pilot study, serum HDL sterol efflux was assessed in Mifepristone stimulated ABCA1-BHK cells among 20 individuals (6 Hp 1-1; 7 Hp 2-1; 7 Hp 2-2) attending the 25 year exam. Results: During follow-up, 186 (32.9%) developed CAD. Incidence increased with the number of Hp 2 alleles (24.6% in Hp 1-1, 31.1% in Hp 2-1 and 37.1% in Hp 2-2, p-trend=0.04; Fig. 1). Multivariably, Hp 2-2 significantly increased risk by almost 80% (HR=1.79, 1.03-3.09). The risk associated with Hp 2-1 did not reach significance (HR=1.46, 0.85-2.53). In the pilot study, serum HDL sterol efflux was lower in Hp 2 allele carriers: 14.0% in Hp 1-1, 12.5% in Hp 2-1, 12.4% in Hp 2-2, p-trend=0.06, p-value Hp 1-1 vs Hp 2-1/2-2 =0.04. Conclusion: These results extend our previous findings of increased CAD risk associated with the Hp 2 allele in type 1 diabetes and further suggest that this allele associates with impaired sterol efflux capacity. These results support the hypothesis that sterol efflux explains the increased Hp 2 risk for CAD and should be confirmed prospectively. Figure 1. CAD-free survival curves by Hp genotype

Increased circulating malondialdehyde-modified low-density lipoprotein levels in patients with ergonovine-induced coronary artery spasm

ObjectiveCoronary endothelial dysfunction is thought to underlie the development of coronary artery spasms. Malondialdehyde-modified low-density lipoprotein (MDA-LDL) was suggested as a marker of endothelial damage. This study investigated the diagnostic impact of MDA-LDL on ergonovine-induced coronary spasms. MethodsWe included 152 patients with suspected coronary spastic angina. MDA-LDL levels were measured before an ergonovine provocation test. Coronary spasm was defined as total or subtotal occlusion, compared to the relaxed state after nitroglycerin, associated with ischemic ECG changes and concurrent chest pain. Changes in vessel diameter in response to ergonovine were evaluated with quantitative coronary angiography. ResultsCoronary spasms were observed in 41 patients (27%). MDA-LDL levels were significantly higher in patients with spasms compared to those without spasms (139.9±45.9U/L vs. 109.6±36.6U/L, p<0.01). Univariate logistic regression analyses indicated significant relationships between coronary spasms and MDA-LDL (per 10U/L, odds ratio (OR): 1.20; p<0.01), high-density lipoprotein (per 10mg/dL, OR: 0.76; p=0.03), smoking (OR: 3.04; p<0.01), and male gender (OR: 3.51; p<0.01). In the multivariate model, MDA-LDL (per 10U/L, OR: 1.17; p<0.01) remained a significant predictor of coronary spasm. Regression analysis showed a positive correlation between MDA-LDL levels and coronary luminal diameter changes induced by ergonovine (r=0.57, p<0.01). The optimal MDA-LDL threshold for predicting coronary spasm was 121.3U/L, identified with a receiver operating characteristic curve. ConclusionsIncreased circulating MDA-LDL levels were associated with ergonovine-induced coronary artery spasm.

Giant saphenous vein graft aneurysm: A complex multi-disciplinary percutaneous approach

A 75-year old hypertensive, type II diabetic gentleman presented with an episode of cardiac sounding chest pain, without ischemic ECG changes or troponin rise. His previous cardiac history included coronary artery bypass grafting (CABG) in 1991 for stable angina, with a left internal mammary artery to left anterior descending artery and saphenous vein grafts (SVGs) to right coronary artery (RCA) and first diagonal branch. He was under regular cardiac review following treatment of an aneurysmal segment of his SVG to the RCA in 2008 with two Graftmaster® covered stents (Abbott Vascular Inc., Illinois, USA).

Prolonged P wave duration predicts stroke mortality among type 2 diabetic patients with prevalent non-major macrovascular disease.

BackgroundProlonged P wave duration is a marker of delayed inter-atrial conduction which may predict cardiovascular disease (CVD). Type 2 diabetes is a risk factor for all atherosclerotic manifestations including stroke. We evaluated the prognostic significance of prolonged P wave duration among middle-aged Finnish type 2 diabetes patients with and without prevalent non-major macrovascular disease (PNMMVD) with respect to total and stroke mortality.MethodsWe followed up for 18 years 739 type 2 diabetic patients without previous major CVD event at baseline. Participants were stratified according to P wave duration (<114 or ≥114 ms) and PNMMVD (i.e. coronary heart disease defined as ischaemic ECG changes and typical symptoms of angina pectoris, or claudication; yes or no). The Cox proportional hazards model was used to estimate the joint association between P wave duration, PNMMVD and the mortality risk.ResultsDuring the follow-up, 509 patients died, and 59 of them died from stroke. Those who had prolonged P wave duration had 2.45 (95% confidence interval: 1.11-5.37) increased stroke mortality among PNMMVD patients. In patients without PNMMVD, there was no relationship between P wave duration and stroke mortality.ConclusionsAs an easily measurable factor P wave duration merits further studies with higher number of patients to evaluate its importance in the estimation of stroke risk in type 2 diabetic patients with PNMMVD.

Abstract 14862: Gender Differences in Impact of CYP2C19 Polymorphism and Low Grade Inflammation on Coronary Microvascular Disease

Background: Specific CYPs localized in vascular smooth muscle and endothelium contribute to the regulation of vascular tone and homeostasis. CYP2C19 two loss-of-function alleles (PM) were found to be an independent risk factor for diabetic retinopathy, and PM is associated with the coronary spasm especially in female. However, it is unknown whether CYP2C19 genotype is associated with the coronary microvascular disease. The aim was to evaluate the impact of CYP2C19 genotype on coronary microvascular disease. Methods: We examined CYP2C19 genotype in patients with microvascular disease (n=40) who were diagnosed by intra-coronary acetylcholine infusion test and healthy subjects (n=455) as control group. We defined the coronary microvascular disease that have no epicardial spasm and have angina, ischemic ECG changes, reduced coronary blood flow, or inversion of lactic acid level between intra-coronary and coronary sinus. CYP2C19 genotypes were divided into 3 groups; (1) CYP2C19*1/*1: EM, (2) one loss-of-function allele (*1/*2, *1/*3: IM), and (3) two loss-of-function alleles (*2/*2, *2/*3, *3/*3: PM). Results: The ratios of CYP2C19 genotype (EM, IM, and PM) were 33, 35, and 32% in microvascular disease group, and 32, 49, and 19% in control group. In short, PM frequency was significantly higher in microvascular disease group (32%vs19%,P=0.039). In microvascular disease group, the ratios of CYP2C19 genotype (EM, IM, and PM) were 44, 38, and 19% in male, and 25, 33, and 42% in female, respectively. Briefly, the PM frequency was significantly higher in female than in male (42%vs19%,P=0.011). Moreover, the level of hs-CRP was significantly higher in microvascular disease group (0.37±0.908 vs 0.10±0.240, P&lt;0.001). Multivariate analysis for microvascular disease indicated that gender, high age, smoking, hypertension, and the high level of hs-CRP are predictive factors among all subjects. PM is a predictive factor for microvascular disease in female group only (OR3.214, 95%RI 1.286-8.034, P=0.012), but not in male (OR0.909, 95%RI 0.251-3.285, P=0.884). Conclusion: The CYP2C19 two loss-of-function alleles (PM) and low grade inflammation may be associated with pathophysiology of coronary microvascular disease, especially in female.

Abstract 16182: Diabetics With Acute Chest Pain Have Similar Length of ED Stay From Early CCTA Compared to Standard Evaluation but More Downstream Testing and Radiation Exposure: The ROMICAT II Trial

Objective: In the evaluation of acute chest pain (ACP), early cardiac computed tomographic angiography reduces emergency department (ED) length of stay (LOS) compared with standard evaluation. It is unknown whether patients with diabetes mellitus (DM) have similar benefits. Methods: In the ROMICAT II multicenter trial, we randomized 1000 patients (17.3% DM) 40-74 years old with symptoms suggestive of acute coronary syndrome (ACS) but without ischemic ECG changes or initial positive troponin to early CCTA or standard ED evaluation. In this pre-specified analysis, we compared differences between the two strategies for the primary endpoint of LOS in DM and non-DM patients. Secondary endpoints were examined in Table 1. Results: ACS rate was similar between DM and non-DM (both 7.5%, p=1.0). DM (70% on oral hypoglycemics, 25% insulin) were older (57 vs 54 years) with more cardiac risk factors, though more frequently female (56%) and on cardiac medications than non-DM (all p&lt;0.001). Table 1 shows the effects of early CCTA versus standard evaluation in DM and non-DM groups. LOS was unaffected by CCTA strategy in DM, whereas LOS was significantly reduced in non-DM. Early CCTA was associated with higher rates of direct ED discharge in both groups, but hospital admissions were significantly reduced with CCTA only in non-DM. Although both groups had more downstream testing and higher radiation dose with CCTA, these differences were accentuated in DM (all p-interaction≤0.04). There was no missed ACS. More DM had abnormal CCTA than non-DM (68% vs 50%, p=0.003), but among DM with no CAD or non-obstructive CAD (69%) by CCTA, LOS was similar compared to non-DM patients (p=NS). Conclusions: An early CCTA strategy in the ED was associated with shorter LOS in non-DM but not in the DM group. The higher prevalence of CAD in DM and direct visualization of atherosclerosis by CCTA may explain the increased testing and radiation exposure with CCTA that were accentuated in DM.

Coronary microvascular spasm triggers transient ischemic left ventricular diastolic abnormalities in patients with chest pain and angiographically normal coronary arteries

AimsImpaired coronary microvascular dilatory function can lead to exercise induced myocardial ischemia and angina pectoris even in patients without significant (>50%) obstructive coronary atherosclerosis (APWOCA). Diffuse distal vessel epicardial spasm and microvascular spasm have been also proposed as a plausible explanation for angina at rest in these patients. However, objective systematic evidence for the latter i.e. echocardiographic wall motion abnormalities during angina, is lacking at present. Coronary epicardial and microvascular spasm can be triggered in susceptible patients by the administration of intracoronary acetylcholine (Ach). We sought to assess whether Ach induced diffuse distal epicardial coronary artery spasm (≥75% diameter reduction) and coronary microvascular spasm can cause transient ischemic left ventricular dysfunction, as assessed by echocardiography. Methods50 patients (19 men aged 60.5 ± 8.9 years) with stable APWOCA were assessed for coronary spasm and myocardial ischemia with intracoronary Ach infusion, 2D transthoracic echocardiography (before and during Ach testing), continuous 12-lead ECG monitoring, and ultrasensitive cardiac troponin (US-cTn) measurement before and within 4 h after Ach testing. Results14 patients (28%) had a “negative” Ach test, 14 (28%) developed coronary microvascular spasm and 17 (34%) had diffuse distal epicardial spasm. In 5 patients (10%) the test was inconclusive. Echocardiographic variables including deceleration time, EF slope and E/A, as well as ultrasensitive-cTn concentrations were abnormal during Ach induced ischemic ECG changes. Conclusions: We have, for the first time, demonstrated that Ach induced coronary microvascular spasm is associated with echocardiographic changes and ultrasensitive-cTn elevations, indicative of myocardial ischemia.

Universal MI definition update for cardiovascular disease.

The new third universal definition of myocardial infarction (MI) is based on troponin elevation together with ischemic symptoms, ischemic ECG changes, and imaging evidence. MIs are classified into five types as to whether they are spontaneous, secondary to imbalance between coronary artery blood supply and demand, related to sudden death, or related to revascularization procedures. The definition is based on a rise and/or fall in troponin levels occurring in a clinical setting. There have been modifications over previous definitions with adding intracoronary thrombus as a criterion, adding a new type of MI type 4c, and raising the cutpoint for the diagnosis of MI related to percutaneous coronary intervention to five times the 99(th) percentile upper reference limit and requiring evidence of ischemia or angiographic complications. In clinical practice, trials, and registries, different definitions are used. There is a need for consistency with regard to the definition of MI and the universal definition should be implemented.

Novel insights into the pathophysiology of different forms of stress testing

BackgroundThe impact of different forms of cardiac stress testing (exercise versus pharmacological stress testing) on cardiac wall stress and myocardial ischemia is incompletely understood. MethodsIn a prospective study, 331 consecutive patients with suspected myocardial ischemia referred for nuclear perfusion imaging were enrolled: 266 underwent exercise (bicycle) stress testing and 65 adenosine stress testing. Levels of B-type natriuretic peptide (BNP) measured before and 1min after stress testing, ischemic ECG changes, and typical angina symptoms were used to compare the 2 testing modalities. ResultsCardiac wall stress as quantified by changes in BNP levels significantly increased in the exercise stress group, but not in the adenosine group (increase in BNP levels 22pg/ml (IQR 6–46) versus −3pg/ml (IQR −3 to 28); p<0.001). In the bicycle exercise stress group, patients with reversible defects on nuclear perfusion imaging more often had angina symptoms (25% vs. 9%, p=0.0001) and ischemic ECG changes (33% vs. 12%, p=0.0001) during the stress test, and a greater increase in BNP levels (28 (IQR 11–58) versus 16 (IQR 3–34) pg/ml, p=0.001) compared to those without reversible defects. Those differences between patients with and without reversible defects were not observed with the adenosine protocol (p-values all >0.05). ConclusionExercise stress testing but not adenosine stress results in an increase of cardiac wall stress, angina symptoms and ECG changes. The absence of these surrogates of myocardial ischemia suggests that adenosine stress does not induce acute myocardial ischemia, but rather displays relative perfusion differences.