Left Anterior Descending Artery Stenosis Research Articles

WELLENS SYNDROME OR PNEUMONIA?

Abstract Background Wellens syndrome, also known as "left anterior descending coronary syndrome," is characterized by the appearance of T–wave changes recorded on the ECG and it is an ECG manifestation of critical proximal left anterior descending artery stenosis. Case Report A 65–year–old man from Bangladesh with a history of chronic ischemic heart disease and trivessel coronary artery disease following surgical revascularization (CABG 2007). Recent admission for NSTEMI (June 2022) with unchanged coronary angiography compared to the previous one. Comorbidities include peripheral arterial disease, type II diabetes with organ damage, and COPD with recent exacerbations. Last myocardial scintigraphy (2021) was positive for inducible myocardial ischemia in the posterolateral region. Admission due to fever, productive cough, and severe chest pain. Initial instrumental assessments revealed ST–segment alterations in inferior leads and V1–V2 with negative/isodiphasic T–waves, not present in previous ECG tracings. A slight troponin elevation with ischemic curve (101 → 303 → 277 → 155 pg/dl, normal range < 50 pg/dl) led to the diagnosis of NSTEMI. Echocardiogram showed concentric remodeling of the left ventricle with normal global systolic function and hypokinesia of the mid–basal inferior wall (noted). Additionally, chest CT revealed pulmonary consolidations in the right middle lobe and upper left lobe, prompting antibiotic therapy and bronchodilator inhalation. Arterial blood gas analysis: pH 7.45, pO2 83, Lactate 0.8, HCO3– 24, P/F 360. Coronary angiography showed an unchanged picture compared to the previous one (patent AMIS and AMID, good run–off in native branches, no distal stenosis at the anastomosis). Clinical symptoms, inflammatory indices, and myocardial damage markers clinically improved during hospitalization. Discharged after optimization of anti–ischemic therapy with DAPT and diagnosis of NSTEMI. However, ECG abnormalities persisted at discharge (negative T–waves in DI–aVL–V1–V2). Post–discharge cardiac MRI was requested. Conclusions Diagnostic hypotheses include, primarily, a possible type II myocardial infarction due to an ongoing pneumonia (although hypoxia/hypovolemia/hypotension sufficient to cause MI was never documented during hospitalization), MINOCA, or microcirculatory disease (functional tests such as iFR/FFR, ACh, IMR were not performed during coronary angiography), or a possible myocarditic outcome (pending MRI).

Factors Associated With Coronary Angiography Performed Within 6 Months of Randomization to the Conservative Strategy in the ISCHEMIA Trial.

ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) did not find an overall reduction in cardiovascular events with an initial invasive versus conservative management strategy in chronic coronary disease; however, there were conservative strategy participants who underwent invasive coronary angiography early postrandomization (within 6 months). Identifying factors associated with angiography in conservative strategy participants will inform clinical decision-making in patients with chronic coronary disease. Factors independently associated with angiography performed within 6 months of randomization were identified using Fine and Gray proportional subdistribution hazard models, including demographics, region of randomization, medical history, risk factor control, symptoms, ischemia severity, coronary anatomy based on protocol-mandated coronary computed tomography angiography, and medication use. Among 2591 conservative strategy participants, angiography within 6 months of randomization occurred in 8.7% (4.7% for a suspected primary end point event, 1.6% for persistent symptoms, and 2.6% due to protocol nonadherence) and was associated with the following baseline characteristics: enrollment in Europe versus Asia (hazard ratio [HR], 1.81 [95% CI, 1.14-2.86]), daily and weekly versus no angina (HR, 5.97 [95% CI, 2.78-12.86] and 2.63 [95% CI, 1.51-4.58], respectively), poor to fair versus good to excellent health status (HR, 2.02 [95% CI, 1.23-3.32]) assessed with Seattle Angina Questionnaire, and new/more frequent angina prerandomization (HR, 1.80 [95% CI, 1.34-2.40]). Baseline low-density lipoprotein cholesterol <70 mg/dL was associated with a lower risk of angiography (HR, 0.65 [95% CI, 0.46-0.91) but not baseline ischemia severity nor the presence of multivessel or proximal left anterior descending artery stenosis >70% on coronary computed tomography angiography. Among ISCHEMIA participants randomized to the conservative strategy, angiography within 6 months of randomization was performed in <10% of patients. It was associated with frequent or increasing baseline angina and poor quality of life but not with objective markers of disease severity. Well-controlled baseline low-density lipoprotein cholesterol was associated with a reduced likelihood of angiography. These findings point to the importance of a comprehensive assessment of symptoms and a review of guideline-directed medical therapy goals when deciding the initial treatment strategy for chronic coronary disease. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Clinical particulars of acute coronary syndrome course in patients with COVID-19

Background: Cardiovascular complications of COVID-19 result in challenges for differential diagnosis, patients referral and treatment, which negatively affect the outcomes.&#x0D; Aim: To identify clinical particulars of various types acute coronary syndrome course in patients with COVID-19.&#x0D; Materials and methods: This retrospective cross-sectional study included 202 patients with COVID-19 and acute coronary syndrome (ACS) admitted to a primary vascular medicine center from September to December 2020. Their medical records were used for the analysis of ACS and COVID-19 clinical course, including physical and history data, laboratory and instrumental work-up. For the analysis, the patient sampling was divided into three study groups: 50 patients with unstable angina (UA), 107 patients with acute myocardial infarction with ST segment elevation (STEMI), and 45 patients with acute myocardial infarction without ST segment elevation (non-STEMI).&#x0D; Results: There were no differences in clinical manifestations of ACS in the study groups. As far as clinical manifestations of coronavirus infections are concerned, the patients differed significantly as per prevalence of fever and dry cough. Fever was present in 22 (44%) UA patients, 18 (17%) of STEMI patients and in 10 (22%) of non-STEMI patients (p 0.001 for comparison of 3 groups, Kruskall-Wallis test), whereas dry cough was present in 18 (36%), 19 (18%), and 14 (31%) patients, respectively (p = 0.029). Paired comparison (Mann-Whitney test with Bonferroni adjustment) showed significant differences between US and STEMI groups for both symptoms. The number of involved vessels (median [25%; 75%]) in UA patients was 0 [0; 2], in STEMI and non-STEMI patients 2 [1; 3] (p 0.001). A left coronary artery stenosis was detected in 2 (6%) of the UA patients, 13 (14%) of the STEMI and 4 (13%) of the non-STEMI patients (p = 0.452); left anterior descending artery stenosis, in 12 (36%), 67 (72%) and 23 (72%) patients, respectively (p 0.001). In the pairwise comparison, there were differences between UA and STEMI groups and between UA and non-STEMI groups. A left circumflex artery stenosis was found in 7 (21%) of the UA patients, 45 (48%) of the STEMI and 18 (56%) of the non-STEMI patients (p = 0.008); the pairwise comparisons showed the difference between UA and non-STEMI study groups. A right coronary artery stenosis was identified in 9 (27%), 64 (69%) and 18 (56%) of the study patients, respectively (p 0.001); in the pairwise comparison the difference was found between the UA and STEMI group. There were significant differences in the percentage of the right descendent and right coronary artery stenosis: the right descending artery stenosis was 70% [45; 80] in the UA patients, 90% [70; 100] in the STEMI and 95% [70; 100] in the non-STEMI patients (p = 0.013), whereas the right coronary artery stenosis was 50% [45; 80], 90% [70; 100], 90% [60; 100], respectively (p = 0.018). In the pairwise comparison, the differences were found between the UA and STEMI patients in both arteries. The STEMI patients had higher TIMI thrombus grade scores than those with non-STEMI: 3 [0; 5] vs 0 [0; 4] (p = 0.023). The rates of successful percutaneous coronary intervention and achievement of TIMI flow grade 3 between them was not significantly different (p = 0.170).&#x0D; Conclusion: The ACS patients with ACS and COVID-19 have high thrombotic load according to coronary angiography and TIMI score in the case of STEMI and more frequent absence of hemodynamically significant stenosis in those with UA and non-STEMI. The absence of any difference in clinical manifestations of ACS and viral infection between the study groups (except fever and dry cough difference between the UA and STEMI patients) indicates that specific characteristics of the ACS course in COVID-19 patients can be identified only by coronaroangiography.

Efficacy of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Treatment for Repeated In-stent Restenosis in a Coronary Artery.

A 57-year-old woman experienced chest pain. A coronary angiogram revealed middle left anterior descending artery stenosis. Despite receiving adequate anti-hyperlipidemia treatment and undergoing percutaneous coronary intervention (PCI), she experienced angina and required PCI six more times for in-stent restenosis. As she had high lipoprotein (a) (LP-[a]) levels at the seventh PCI procedure, proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) was administered, and a reduction in the LP-(a) and low-density lipoprotein cholesterol (LDL-C) values was observed. She experienced no recurrence of angina for five years with PCSK9i treatment. PCSK9i can reduce not only LDL-C but also LP-(a) levels, resulting in cardiac event risk reduction.

Abstract 14961: Revitalizing Graft Patency: Intravascular Lithotripsy in Calcified Saphenous Vein Graft to Left Anterior Descending Artery Stenosis

A 73-year-old man with coronary artery disease (CAD), coronary artery bypass graft, heart failure [EF 25%] &amp; hypertension presented with Non-ST Segment Myocardial Infarction. Angiography revealed multivessel CAD with chronic total occlusion (CTO) of mid-left anterior descending (LAD) after a large first diagonal branch, CTO of mid-left circumflex &amp; distal right coronary artery. Saphenous vein graft (SVG) to obtuse marginal was patent. SVG-diagonal &amp; SVG-ramus intermedius were occluded. Mid SVG-LAD showed severe calcified stenosis (Fig. 1A). Native LAD beyond the SVG provided left to right collaterals to right posterior descending artery. Complex high-risk coronary intervention was performed on the SVG-LAD with mechanical circulatory support (MCS; Impella CP). SVG-LAD had a balloon undilatable lesion despite high pressure inflation with 4.0 mm cutting balloon (Fig. 1B). Intravascular ultrasound (IVUS) revealed severe stenosis with extensive circumferential calcification (Fig. 1C). Subsequently, intravascular lithotripsy (IVL) with 4.0 mm Shockwave balloon followed by high pressure balloon angioplasty with 4.5 mm noncompliant (NC) balloon was performed with significant luminal gain and fractures in calcium (Fig. 1D). The lesion was treated with 5.0 mm drug eluting stents that were post dilated with 5.0 mm NC balloon with excellent angiographic and IVUS result (Figs. 1E &amp; F). MCS was successfully removed at the end of the case.SVG grafts are associated with poor long-term patency compared to arterial grafts. PCI to SVG has a high failure rate and PCI of native vessel is often preferable. High risk SVG interventions with atherectomy have been recently reported, though data is limited. IVL has been safely used in heavily calcified native coronary arteries, however, its use in SVG disease is rare. We report the first off-label use IVL of SVG-LAD with MCS for treatment of a last-remaining conduit. Additional studies to assess IVL efficacy in vein grafts are warranted.

Safety-Net Hospital Status Is Associated With Coronary Artery Bypass Grafting Outcomes at an Urban Academic Medical Center

IntroductionSocioeconomic disparities impact outcomes after cardiac surgery. At our institution, cardiac surgery cases from the safety-net, county funded hospital (CH), which primarily provides care for underserved patients, are performed at the affiliated university hospital. We aimed to investigate the association of socioeconomic factors and CH referral status with outcomes after coronary artery bypass grafting (CABG). MethodsThe institutional Adult Cardiac Surgery database was queried for perioperative and demographic data from patients who underwent isolated CABG between January 2014 and June 2020. The primary outcome was major adverse cardiovascular event (MACE), a composite of postoperative myocardial infarction, stroke, or death. Secondary outcomes included individual complications. Chi-square, Wilcoxon rank-sum, and logistic regression analyses were used to compare differences between CH and non-CH cohorts. ResultsWe included 836 patients with 472 (56.5%) from CH. Compared to the non-CH cohort, CH patients were younger, more likely to be Hispanic, non-English speaking, and be completely uninsured or require state-specific financial assistance. CH patients were more likely to have a history of tobacco and drug use, liver disease, diabetes, prior myocardial infarction, and greater degrees of left main coronary and left anterior descending artery stenosis. CH cases were less likely to be elective. The incidence of MACE was significantly higher in the CH cohort (16.3% versus 8.2%, P = 0.001). There were no significant differences in 30-d mortality, home discharge, prolonged mechanical ventilation, bleeding, sepsis, pneumonia, new dialysis requirement, cardiac arrest, or multiorgan system failure between cohorts. CH patients were more likely to develop renal failure and less likely to develop atrial fibrillation. On multivariable analysis, CH status (odds ratio 2.39, 95% confidence interval 1.25-4.55, P = 0.008) was independently associated with MACE. ConclusionsCH patients undergoing CABG presented with greater comorbidity burden, more frequently required nonelective surgery, and are at significantly higher risk of postoperative MACE.

Interpreting the ECG in patients with chest pain and right bundle branch block: A case report.

A patient with right bundle branch block (RBBB) presented with chest pain. An ECG showed ST-elevation in leads V1, V2, and aVR, with widespread ST-depression in leads II, aVF, I, aVL, and V4-6. The initial ECG interpretation missed ST-elevation myocardial infarction (STEMI), as ST-elevation thresholds were not reached. Non-urgent angiography showed severe left anterior descending artery stenosis requiring percutaneous coronary intervention. The course was complicated by cardiac arrest necessitating resuscitation and dual chamber pacemaker placement with left bundle branch pacing. This case report outlines the deficiencies of the current voltage criteria for identification of anterior STEMI in patients with RBBB.

History of cerebrovascular events is associated with a higher risk of significant left anterior descending artery stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Acute coronary syndrome (ACS) remains a frequent cause of hospital admission, with its prognosis depending on many factors, one being the location of the culprit lesion. It is established that anterior myocardial infarction, caused mostly by left anterior descending artery occlusion is associated with a worse prognosis and higher morbimortality. Therefore, identifying patients at a higher risk of significant LAD lesions could potentially impact outcomes. Purpose We aim to identify if having personal history of cerebrovascular events could be related to more severe LAD stenosis. Methods We retrospectively analysed a population of 988 patients (L) admitted with ACS and divided them into two groups: those who had significant stenosis of the left anterior descending artery (LAD) documented in coronary angiography, defined as a stenosis above 50% (L1), and those who had no significant stenosis of the LAD (L2), which included those with no stenosis or stenosis under 50%. We then compared the prevalence of previous cerebrovascular events, defined as stroke or TIA, between both groups. Age, sex, personal history of smoking, hypertension, dyslipidaemia and diabetes mellitus were also documented. Results L1 was comprised of 553 patients (56,0% of the population). When comparing between groups, results show that L1 had a significantly higher prevalence of previously documented stroke or TIA (1,4% vs 0,2%, p=0,026; odds ratio: 7,628, 95% CI [0,922; 63,120]) than L2. Regarding age, sex and history of hypertension, dyslipidaemia and diabetes, there were no relevant differences and no impact on the severity of the LAD stenosis. Conclusions Patients with ACS and previous history of cerebrovascular events have a sevenfold-increased risk of having significant LAD stenosis on coronary angiography. This could potentially impact pre-procedure risk stratification and timing of percutaneous intervention.

The Comparative Assessment of Wellens' Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review.

Wellens'syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of biphasic or deeply inverted T waves in V2-V6 under specific diagnostic criteria. Although the syndrome is known as a high-grade LAD lesion, its sequence of events can also be seen with the right coronary artery (RCA) and the left circumflex artery (LCX). This systemic review attempts to expand on these findings while analyzing the prevalence of Wellens' syndrome with the RCA and/or the circumflex artery. This study also comparatively indicated that Wellens'syndrome is seen in RCA and circumflex arterystenoses when present; the indication of the same medical management is warranted for effective treatment and survival. We extracted and analyzed 24 case reports each with an atypical presentation of acute coronary syndrome (ACS) and specific Wellens'syndrome pattern of electrocardiogram (ECG) presentation with critical stenosis in the LAD, RCA, and left circumflex artery.The risk of bias assessment was undertaken using internal risk analysis by utilizing medical libraries and certain search phrases to find research articles with the involvement of the LAD as opposed to the RCA and LCX in Wellens' syndrome. Based on the number of respective primary research articles found, a bias calculation was done on the reported respective coronary artery involvement. The finding of our systemic review confirms that Wellens'syndrome is a precordial lead disease with T wave abnormalities that presentwithcritical stenosis of not only the LAD but also the RCA and circumflex artery. The result of our systemic review affirmed that although most Wellens'syndrome cases reported involve the stenosis of the LAD, the critical occlusion of the RCA and/or the circumflex artery was found with Wellens'syndrome pattern of ECG presentation, meaning that the sequence of events is not limited to the proximal LAD.

Minimally Invasive Direct Coronary Artery Bypass Versus Percutaneous Coronary Intervention for Isolated Left Anterior Descending Artery Stenosis: An Updated Meta-Analysis.

The optimal revascularization strategy for isolated left anterior descending (LAD) coronary artery lesion between minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) remains controversial. This updated meta-analysis aims to compare the long- and short-term outcomes of MIDCAB versus PCI for patients with isolated LAD coronary artery lesions. The Pubmed, Web of Science, and Cochrane databases were searched for retrieving potential publications from 2002 to 2022. The primary outcome was long-term survival. Secondary outcomes were long-term target vessel revascularization (TVR), long-term major adverse cardiovascular events (MACEs), and short-term outcomes, including postoperative mortality, myocardial infarction (MI), TVR, and MACEs of any cause in-hospital or 30 days after the revascularization. Six randomized controlled trials (RCTs) and eight observational studies were included in this updated meta-analysis. In total, 1757 patients underwent MIDCAB and 15245 patients underwent PCI. No statistically significant difference was found between the two groups in the rates of long-term survival. MIDCAB had a lower long-term MACE rate compared with PCI. Besides, PCI resulted in an augmented risk of TVR. Postoperative mortality, MI, TVR, and MACEs were similar between the two groups. The updated meta-analysis presents the evidence that MIDCAB has a reduced risk of long-term TVR and MACEs, with no benefit in terms of long-term mortality and short-term results, in comparison with PCI. Large multicenter RCTs, including patients treated with newer techniques, are warranted in the future.

Evaluation of Long-Term Outcomes of Crossover or Focal Ostial Stenting of Left Anterior Descending Artery Ostial Stenosis

Optimal management of patients with ostial left anterior descending artery stenosis remains an unresolved issue. Patients with ostial left anterior descending stenosis who underwent stent implantation were included in this study. Coronary records of all patients were monitored, and long-term clinical outcomes were recorded. The patients were divided into 2 groups according to the stenting method: focal left anterior descending stenting [ostial stenting group] and stenting from the left main coronary artery to the left anterior descending [crossover stenting group]. Of the 97 eligible consecutive patients, 56 were treated with ostial stenting and 41 with crossover stenting. At a mean follow-up of 23.6 ± 12.6 months, non-fatal myocardial infarction (3.9% vs. 12.8%, P=.118), target lesion revascularization (5.9% vs. 12.8%, P=.252), and all-cause death (2.0% vs. 7.7%, P=.191) rates were not statistically significant. However, the rate of major adverse cardiovascular events defined as a composite of non-fatal myocardial infarction, target lesion revascularization, or all-cause death was significantly higher in the crossover stenting group (8.2% vs. 28.2%, P = .013). In the multiple regression analysis, left main coronary artery diameter (odds ratio = 4.506; 95% CI: 1.225-16.582, P = .024) and application of the crossover stenting technique (odds ratio = 5.126; 95% CI: 1.325-19.833, P = .018) were found to be the most effective predictors of major adverse cardiovascular events. In our study, the ostial stenting group was associated with better clinical outcomes in the treatment of ostial left anterior descending stenosis. However, it is notappropriate to apply a single method to all patients with such lesions.

Short and long-term results of endoscopic atraumatic coronary artery off-pump bypass grafting in patients with left anterior descending artery stenosis.

To perform a retrospective analysis of patients who underwent endoscopic atraumatic coronary artery off-pump bypass grafting (EACAB) in a single center over a period of 11 years. Data was acquired from the hospital registry and patient medical records. In order to determine changes in clinical profile, patients were subdivided into three groups regarding year of surgery: 1998-2002 (group 1), 2003-2005 (group 2), 2006-2009 (group 3). In-hospital analysis up to 30 days and long-term observation were conducted. The study cohort consisted of 714 patients (581 male). Procedural success accounted for 99% of all patients. No mortality was observed up to 30 days. Complications in the early period included pleural effusion (7.6%), cardiac arrhythmias (3.6%), bleeding related revision (2.7%) and wound infection (1.6%). Mean follow-up was 6 years (2132 ± 1313 days; median: 1918.5). Nineteen (2.7%) patients died, of which 52.6% (10 patients) were due to heart related conditions. Overall frequency of major adverse cerebral and cardiovascular events (MACCE) was 10.8% (77 patients). The Kaplan-Meyer analysis defined survival rate and event-free survival in long-term observation of 96.1% and 85.3%, respectively. Ejection fraction (EF) < 50% was the only independent factor of mortality (OR: 3.35). Regarding cumulative MACCE, older age (OR: 1.72), lower EF (OR: 3.03), the history of percutaneous coronary intervention (OR: 2.13) and higher New York Heart Association class (OR: 2.63) influenced the incidence rate. The presented short and very long-term results confirm that EACAB is an efficient alternative for patients requiring revascularization of the left anterior descending artery. The elimination of cardiopulmonary bypass significantly reduces the number of complications.

Prognostic Value of Coronary CT Angiography in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

BackgroundSeverity and extent of coronary artery disease (CAD) assessed by invasive coronary angiography (ICA) guide treatment and may predict clinical outcome in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS). ObjectivesThis study tested the hypothesis that coronary computed tomography angiography (CTA) is equivalent to ICA for risk assessment in patients with NSTEACS. MethodsThe VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial evaluated timing of treatment in relation to outcome in patients with NSTEACS and included a clinically blinded coronary CTA conducted prior to ICA. Severity of CAD was defined as obstructive (coronary stenosis ≥50%) or nonobstructive. Extent of CAD was defined as high risk (obstructive left main or proximal left anterior descending artery stenosis and/or multivessel disease) or non–high risk. The primary endpoint was a composite of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or heart failure. ResultsCoronary CTA and ICA were conducted in 978 patients. During a median follow-up time of 4.2 years (interquartile range: 2.7 to 5.5 years), the primary endpoint occurred in 208 patients (21.3%). The rate of the primary endpoint was up to 1.7-fold higher in patients with obstructive CAD compared with in patients with nonobstructive CAD as defined by coronary CTA (hazard ratio [HR]: 1.74; 95% confidence interval [CI]: 1.22 to 2.49; p = 0.002) or ICA (HR: 1.54; 95% CI: 1.13 to 2.11; p = 0.007). In patients with high-risk CAD, the rate of the primary endpoint was 1.5-fold higher compared with the rate in those with non–high-risk CAD as defined by coronary CTA (HR: 1.56; 95% CI: 1.18 to 2.07; p = 0.002). A similar trend was noted for ICA (HR: 1.28; 95% CI: 0.98 to 1.69; p = 0.07). ConclusionsCoronary CTA is equivalent to ICA for the assessment of long-term risk in patients with NSTEACS. (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes [VERDICT]; NCT02061891)

A 75-Year-Old Woman with COVID-19 Pneumonia and Wellens Syndrome Diagnosed by Electrocardiography.

Patient: Female, 75-year-oldFinal Diagnosis: Wellens’ syndromeSymptoms: NoneMedication:—Clinical Procedure: —Specialty: CardiologyObjective:Rare diseaseBackground:There are increasing reports of cardiovascular complications associated with coronavirus disease 2019 (COVID-19) due to infection with severe acute respiratory syndrome coronavirus 2. Wellens syndrome, or left anterior descending T-wave syndrome, is diagnosed by a pattern of electrocardiographic (ECG) changes that include inverted or biphasic T waves in leads V2–V3.Case Report:A 75-year-old woman presented to the emergency department with a 1-week history of fatigue and progressive shortness of breath who acutely decompensated, necessitating mechanical ventilator support. Initial lab workup revealed COVID-19 positivity, which was confirmed by repeat testing. A routine ECG obtained during her hospitalization and compared with her baseline revealed diffuse T-wave inversions of her precordial leads, which was highly suggestive of Wellens syndrome. Cardiac enzymes obtained were slightly elevated and an echocardiogram did not demonstrate wall motion abnormalities. The patient was initiated on non-ST segment elevation myocardial infarction protocol with heparin infusion for 48 hours and dual antiplatelet therapy, in addition to beta blockade. Repeat ECGs showed complete resolution of Wellens syndrome shortly after therapy.Conclusions:Although rare, Wellens syndrome is a significant indicator of left anterior descending artery stenosis and is commonly associated with acute medical illness. COVID-19 pneumonia has been associated with many adverse cardiovascular outcomes, with ischemia and arrhythmia becoming increasingly more common. Diagnosis of Wellens often includes coronary angiography; however, during the current pandemic, many authorities have recommended medical management alone during the acute phase of care, depending on the severity of concomitant illness.

Abstract 14062: Accuracy of Exercise Induced St- Elevation in Lead Avr in the Diagnosis of Significant Left Main or Proximal Left Anterior Descending Artery Stenosis: A Systematic Review

Introduction: ST-segment changes during exercise stress testing are diagnostic of myocardial ischemia in patients with suspected coronary artery disease (CAD). Recent studies have shown that exercise-induced ST-elevation in aVR is associated with significant stenosis of the left main (LM) and proximal left anterior descending (pLAD) arteries Methods: Search of electronic databases (Embase, Medline, and Web of Science) using MeSH terms and keywords for exercise stress test, lead aVR and CAD was performed from inception through December 2019. 2 reviewers independently screened results in 2 stages: title/abstract followed by full text. Included studies had adult patients who underwent exercise stress testing and reported the performance of ST-elevation &gt;1 mm in lead aVR for diagnosing significant LM or pLAD disease. Significant disease was defined as luminal narrowing &gt;50% and &gt;70% for LM and pLAD respectively. Pooled sensitivity, specificity, likelihood ratios (LR) and diagnostic odds ratios were calculated using a bivariate model, and a summary receiver operator curve (SROC) was constructed. Results: We included 6 studies with 1128 patients. The pooled sensitivity was 0.8 (95% CI 0.36-0.97; I 2 =94.7) and pooled specificity was 0.78 (95% CI 0.56-0.90; I 2 =97.8). Overall calculated positive LR was 3.56 (95% CI 2.34-5.4) and negative LR was 0.26 (95% CI 0.07-1.01). The pooled diagnostic odds ratio was 13.5 (95% CI 4.8-38.5). Hierarchical SROC curve showed an area under the curve of 0.84 (95% CI 0.81-0.87) (Figure 1). Conclusions: Our analysis showed moderate sensitivity and specificity of exercise-induced aVR ST-elevation for diagnosing significant LM or pLAD disease. The heterogeneity among studies was high, likely due to differences in patient selection. In conclusion, ST-elevation in aVR during exercise stress test increases the likelihood of having LM or pLAD disease. Large studies are needed to substantiate this finding.

EACVI survey on investigations and imaging modalities in chronic coronary syndromes.

AimsThe European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate current practice for the assessment and management of patients with suspected and confirmed chronic coronary syndromes.Methods and resultsOne-hundred and ten imaging centres from 37 countries across the world responded to the survey. Most non-invasive investigations for coronary artery disease were widely available, except cardiovascular magnetic resonance (available 40% centres). Coronary computed tomography angiography (CCTA) and nuclear scans were reported by a multi-disciplinary team in only a quarter of centres. In the initial assessment of patients presenting with chest pain, only 32% of respondents indicated that they rely on pre-test probability for selecting the optimal imaging test while 31% proceed directly to CCTA. In patients with established coronary artery disease and recurrent chest pain, respondents opted for stress echocardiography (27%) and nuclear stress perfusion scans (26%). In asymptomatic patients with coronary artery disease and an obstructive (>70%) right coronary artery stenosis, 58% of respondents were happy to pursue medical therapy without further testing or intervention. This proportion fell to 29% with left anterior descending artery stenosis and 1% with left main stem obstruction. In asymptomatic patients with evidence of moderate-to-severe myocardial ischaemia (15%), only 18% of respondents would continue medical therapy without further investigation.ConclusionDespite guidelines recommendations pre-test probability is used to assess patients with suspected coronary artery in a minority of centres, one-third of centres moving directly to CCTA. Clinicians remain reticent to pursue a strategy of optimal medical therapy without further investigation or intervention in patients with controlled symptoms but obstructive coronary artery stenoses or myocardial ischaemia.

Prevalence and association of the Wellens' sign with coronary artery disease in an ethnically diverse urban population

BackgroundWellens' sign is considered to be an ominous sign indicative of underlying significant proximal left anterior descending artery stenosis. We sought to identify the prevalence of the Wellens' pattern in a large ethnically diverse urban population and assess its association with the presence and extent of coronary artery disease. MethodsWe utilized the MUSE ECG database of Montefiore Medical Center, an academic tertiary health care system, to identify ECGs from 2012 to 2019 exhibiting a Wellens' pattern. From a dataset of 1.76 million tracings, six screening diagnosis codes were selected to approximate the Wellens' pattern. These codes were used to generate a cohort of ECGs for manual review by a board certified cardiologist to determine if a Wellens' pattern was present. ResultsOf 1,756,742 ECGs performed on 433,218 patients from 2012 to 2019; after initial screening 2186 ECGs were identified for manual review. Of these, 448 (0.1%) patients were confirmed to have a Wellens' pattern. 229 patients underwent cardiac catheterization, while 219 patients were managed medically. No statistical difference was seen in the occurrence of Wellens' Type A and B pattern across the ethnic groups after multivariate analysis. Women were more likely to have Type B Wellens' compared to men (OR 2.40 (1.58, 3.62) P < 0.0001). 80 (35%) patients had single vessel LAD disease of which 22 (10%) had proximal, 40 (17%) had mid, 4 (1%) had distal stenosis, while diffuse LAD disease was seen in 14 (6%) patients. Two vessel disease was seen in 46 (20%) patients with a Wellens' pattern, and triple vessel disease was seen in 23 (10%) patients. Of note, 71 (31%) patients had either normal or nonobstructive coronary disease despite exhibiting a Wellens' pattern ECG. ConclusionWellens' sign is a rare electrocardiographic pattern which when seen in a patient with an appropriate clinical presentation, suggests but is not definitive for the presence of significant coronary disease, often but not exclusively in an LAD distribution. We found no statistical difference in the occurrence of Wellens' sign among different racial/ethnic groups. Patients with a Wellens' pattern may have critical lesions at a variety of LAD sites as well as in multiple vessels. As such, the interventionalist needs to be prepared for these uncertainties at the time of cardiac catheterization.

SUN-LB1 Atypical Presentation Of Myocardial Infarction In A Young Patient With Polycystic Ovarian Syndrome

Background: Polycystic ovarian syndrome (PCOS) is a very common and complex endocrine problem in women of childbearing age, with a prevalence of 4 to 12% globally. Myocardial infarction (MI) is the leading cause of death in women worldwide. PCOS increases the risk of MI because of chronic inflammation, endothelial dysfunction, impaired pulse wave velocity and its association with metabolic syndrome, and hormonal imbalance.Clinical Case: A 36-year-old female with a history of PCOS, hirsutism, severe acne on spironolactone, presented to ER with a chief complaint of lower back pain for 10 days that started after lifting a 60-pounds printer. The pain was attributed to musculoskeletal type, one dose of ketorolac intramuscularly was given and she was discharged on cyclobenzaprine. The next morning, she presented with worsening back pain and new-onset vomiting. Physical exam was normal except for BMI 34.6kg/m2; vitals were stable. Lab work showed elevated troponin of 1.43 which rose to 10.6 ng/ml (normal 0.00-0.034), cholesterol 125 mg/dL (less than 200), HDL 33 mg/dL (normal 40-59), LDL 164 mg/dL (normal 100-129). Electrocardiogram showed sinus tachycardia with Q wave changes in leads III and V1 to V3. Echocardiogram showed hypokinesia of left ventricular wall in the mid to apical anterior septum. Computed tomography (CT) scan of the thoracic spine was negative for abscess or fracture. CT of abdomen and pelvis as well as CT angiography chest were negative. Urine drug screening was also negative.As her presentation was attributed to MI, patient was started on heparin drip, aspirin, atorvastatin, and metoprolol. She underwent cardiac catheterization that showed 99% ostial left anterior descending artery stenosis; a drug-eluting stent was successfully placed. After intervention her back pain resolved. She was discharged on dual antiplatelet therapy (aspirin and Prasugrel) along with atorvastatin, metoprolol and nitroglycerin.Conclusion: This case suggests an association of PCOS with MI. A meta-analysis has shown a two-fold increase in risk of coronary artery disease in patients with PCOS (1). Future studies are need to examine opportunities for cardiovascular disease risk reduction in PCOS patients.Reference:1. de Groot PCM, Dekkers OM, Romijn JA, Dieben SWM, Helmerhorst FM. PCOS, coronary heart disease, stroke and the influence of obesity: a systematic review and meta-analysis. Human Reproduction Update 2011. 17 495-500.

P1404 Additional power of automated longitudinal strain during dobutamine stress echo for detecting inducible ischemia in left anterior descending artery stenosis

Abstract Background Dobutamine stress echo (DSE) is a sensitive but subjective test of inducible ischemia. Speckle tracking allows now a quantitative assessment of regional wall motion, even during DSE. Purpose To investigate the feasibility and accuracy of global and regional longitudinal strain during DSE to detect significant CAD. Methods This is a prospective, observational study, including 88 patients undergoing DSE for suspected CAD. Thirthy-three patients with negative DSE were excluded from analysis. The remaining 50 patients (82% males, mean age 66.3 ± 8.2 years) with positive DSE underwent subsequent invasive coronary angiography (CA). Besides visual regional wall motion score index (WMSI), global longitudinal strain (GLS) and regional longitudinal strain (RLS) were determined at rest, at peak stress and at early recovery by a dedicated software (Automated Function Imaging) incorporated in a quoad-screen of the echo machine and activated by automatic quantification. Obstructive CAD was defined as &amp;gt;70% stenosis or intermediate stenosis combined with fractional flow reserve &amp;lt;0.80. Results The feasibility of DES regional longitudinal strain was 100% (n = 50/50) in the pooled population. Fifteen patients did not show coronary stenosis whereas obstructive CAD was detected in 35 patients (12 with multi-vessel disease). Among these patients, 18 patients had left anterior descending artery (LAD) stenosis, 18 left circumflex coronary artery (LCX) stenosis and 15 right coronary artery (RCA) stenosis. GLS reduction at peak stress (k = 0.253, p = 0.037) and WMSI increase at peak stress (k = 0.217, p = 0.04) showed mild but significant agreement with CA for detecting significant coronary stenosis, whereas the agreement of GLS at recovery (k=-0.087, p = 0.518) was poor. When single lesion territory was considered, GLS at peak stress (17.4 ± 5.5 vs 20.5 ± 4.4%, p = 0.034) and LAD longitudinal strain (= average of 8 myocardial segments: middle and apical posterior septum, basal, middle and apical anterior septum, basal, middle and apical anterior wall) at peak stress showed significantly lower values in the obstructed LAD regions than the territories perfused by non-obstructed coronary arteries (17.1 ± 7.6 vs 21.6 ± 5.5% p = 0.021). Conversely, in presence of significant LCX or RCA stenosis, visual regional wall motion of LCX and RCA territories were higher at peak stress (WMSI LCX = 1.80 ± 0.65 in presence of LCX stenosis vs. 1.38 ± 0.44 in absence of stenosis, p &amp;lt; 0.01; WMSI RCA = 1.89 ± 0.52 in presence of RCA stenosis vs. 1.42 ± 0.42 in absence of stenosis, p = 0.002), but RLS at peak stress showed a trend to increase, without achieving the statistical significance (RLS RCA: p = 0.128, RLS LCX: p = 0.103). Conclusion AFI-based strain quantitative analysis appears to be highly feasible during DSE. It appears also to be more accurate than the visual wall motion for the detection of myocardial ischemia in presence of LAD while the accuracy is suboptimal in patients with LCX and RCA stenosis.

3335First-line coronary computed tomography predicts long-term clinical outcome in patients with Non-ST-segment elevation acute coronary syndrome - The VERDICT trial

Abstract Background In patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) coronary pathology may range from structurally normal vessels to severe coronary artery disease. Current guidelines recommend early invasive coronary angiography (ICA) for risk assessment and choice of treatment strategy. Purpose We tested the hypothesis that 1) a first-line coronary computed tomography angiography (CCTA) predicts long term clinical outcome in patients with NSTE-ACS and 2) adding ICA to CCTA does not improve prediction of cardiovascular events. Methods We included patients with NSTE-ACS confirmed by ischaemic ECG changes and/or elevated biomarkers of myocardial ischaemia, in whom both CCTA and ICA were feasible within 12 hours. According to the VERDICT study protocol (ClinicalTrials.gov number NCT02061891) patients were randomised 1:1 to evaluation within 12 hours (Very Early) or 48–72 hours (Standard). CCTA was conducted prior to ICA and patients with an event between tests were excluded. Based on CCTA and ICA, patients were categorized according to European Society of Cardiology (ESC) guidelines as having prognostic indication for coronary revascularization ESCprog (left main stenosis, proximal left anterior descending artery stenosis or multivessel disease) or no prognostic indication – ESCnon-prog. The primary endpoint was a combined endpoint of all-cause mortality, non-fatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia or hospital admission for left sided heart failure. Discrimination of 1.5-year outcomes was assessed by time-dependent area under the receiver operating characteristic curve (AUC). Results CCTA and ICA was conducted in 979 patients. During a median follow-up time of 4.2 (IQR 2.7–5.5) years the primary endpoint occurred in 209 (21.3%) patients. Patients with ESCprog as defined by CCTA had a hazard ratio of 1.53 (95% CI 1.16–2.03) for occurrence of the primary endpoint. AUC for the prediction of the primary endpoint by CCTA was 68.6 (95% CI: 62.7–74.5) as compared to 68.6 (95% CI: 62.8–74.5), when adding ICA to the model. Similar findings were noted in patients randomized to either Very Early or Standard treatment strategy. Conclusions Long-term risk assessment in patients with NSTE-ACS may be conducted using a first-line CCTA strategy and may thus potentially guide patient management. Adding invasive coronary angiography to CCTA does not improve risk assessment. Acknowledgement/Funding This study was funded by the Danish Agency for Science, Technology, and Innovation and the Danish Council for Strategic Research (grant no. 09–066994)