Minor Coronary Disease Research Articles

Spontaneous Vanishing of Coronary Collaterals During Cardiac Catheterization for Acute Myocardial Infarction

A patient with acute ST segment elevation inferior myocardial infarction underwent urgent cardiac catheterization. Left coronary arteriography demonstrated minor coronary disease with well-defined collateral filling of the dominant right coronary artery. Shortly thereafter, right coronary arteriography demonstrated entirely normal findings, and a repeat left coronary angiogram no longer demonstrated coronary collaterals. The “vanishing” coronary collaterals are consistent with acute myocardial infarction from transient occlusion of the right coronary artery. These findings are consistent with the phenomenon of myocardial infarction in the presence of angiographically normal coronary arteries. The transient coronary occlusion in this patient is likely secondary to spontaneous lysis of intracoronary thrombus or transient coronary vasospasm. J Med Cases. 2016;7(12):527-530 doi: https://doi.org/10.14740/jmc2667w

Does the Finding of Minor Coronary Disease on CT Coronary Angiography Change Medical Management?

Does the Finding of Minor Coronary Disease on CT Coronary Angiography Change Medical Management?

Normal Electrocardiogram Following Resuscitation for An Out of Hospital Cardiac Arrest is not a Deterrent for Urgent Coronary Angiography

Background: Acute coronary syndrome is the most common cause of an out of hospital cardiac arrest (OOHCA). Currently, controversy surrounds the diagnostic utility of conventional electrophysiological criteria used in the non-arrested population to guide decision making for early coronary intervention. Methods and Results: This was a retrospective, single tertiary centre study observing the initial ECG of all patients resuscitated following an OOHCA. Patients were grouped according to the findings on the post-resusitation ECG: (1) ST elevation (2) ST depression (3) left bundle branch block (LBBB), and (4) no ECG features of ischaemia (normal ECG). 160 patients were included with average age of 62.6 years. A culptrit vessel occlusion or significant stenosis was present in 56%, 52%, 58% and 44% in groups 1-4, respectively. In the selected group with an initial shockable rhythm, a cultprit lesion was present in 19% of patients in group 4. ST-elevation predicted a culptrit lesion in the VF cohort with 61% sensitivity, 75% specificity and positive predictive value of 50%. A normal ECG predicted minor coronary disease or less with 36% sensitivity, 78% specificity and a negative predictive value of 73%. Conclusion: The post resuscitation ECG is not a reliable tool to guide the decision for coronary angiography as an acute culprit lesion was seen in one in five patients with a normal ECG.

132 DOES THE PRYOR RISK SCORE AS RECOMMENDED BY NICE GUIDANCE OVER EGG THE PUDDING IN ASSESSING PATIENTS REFFERRED TO THE CHEST PAIN CLINIC

<h3>Background</h3> NICE guidance recommends risk stratification of patients presenting to chest pain clinics using the Pryor score. The Pryor score calculates a risk for a significant (&gt;50%) coronary stenosis. This score influences which imaging modality to select to confirm or refute the presence of coronary artery disease (CAD) with patients with a risk score of 10–29% undergoing CT calcium scoring ±CT coronary angiography, 30–59% non-invasive functional testing and 60% or more invasive coronary angiography. <h3>Aim</h3> This study evaluates the accuracy of the Pryor risk score in predicting significant coronary artery disease in patients presenting to a rapid access chest pain clinic (RACPC) undergoing either CT evaluation or invasive angiography. <h3>Design</h3> Retrospective analysis of prospectively collected clinical data. <h3>Methods</h3> Data was collected by coronary CT report analysis, and coronary angiogram data base review of patients referred from the RACPC in our Trust from January 2011 to October 2012. Significant coronary disease was confirmed if the reporting consultant recorded a stensosis of 50% or more. Pryor scores were calculated at the time of initial attendance by the nurse specialist using a standardised Pryor risk calculator circulated by the Cardiovascular Network. Statistical analysis was carried out using the χ² test. <h3>Results</h3> In the study period 228 patients underwent CT assessment, one of whom had a non diagnostic study and was excluded. Of the 227, 168 underwent calcium scoring only, and 59 had subsequent CT coronary angiography reflecting the NICE recommendation of undertaking CT angiography in those patients with a calcium score in the range 1–400. Table&nbsp;1 shows the distribution of patients with and without significant diseaase in the NICE recommended calcium scoring categories. The mean Pryor score for this patient group was 21.8% In the whole group, 17/227 (7.4%) had significant CAD compared to 210/227 (92.5%) who had no significant CAD (p&lt;0.0001, see table&nbsp;2). The invasive angiography group was taken from the data base of a single consultant during the same time period. 81 patients were referred from the RACPC for this investigation with a mean Pryor score of 75%. Only 45 of these patients (55.5%) had significant CAD (p&lt;0.0001, see table&nbsp;2). <h3>Discussion</h3> Our study shows that the Pryor risk score significantly overpredicts the prevalence of significant coronary artery disease in our patient population. The number of patients with significant CAD, undergoing calcium scoring and CT angiography was much lower than that expected and the same was also true of the higher risk invasive angiography group. A significant proportion of those referred for calcium scoring were found to have minor coronary disease. However, NICE may need to alter its guidance to improve clinical effectiveness.

Role of Cardiac MRI in Patients Presenting with Acute Coronary Syndromes (ACS) with Normal or Minor Coronary Artery Disease

Background: Increased sensitivity of cardiac biomarkers has increased the number of troponin positive patients with subsequent normal coronary arteries. We evaluated the use of Cardiac MRI (CMR) in this setting from March 2008 to January 2012. Methods: Retrospective and prospective analysis was performed on patients with ACS with normal or minor coronary disease on angiography whom had CMR performed. Results: The total of 36 patients had an average age of 55(SD = 13). Patient demographics revealed that 42% patients were smokers, 40% hypertensive and 36% dyslipidaemic. One patient had a prior stroke whilst another patient had a TIA. One patient was diabetic. Only one patient did not present with chest pain syndrome. Thirty-one patients were troponin positive. Five patients without a troponin rise had an abnormal ECG. Angiography revealed normal coronaries in the majority (75%) and minor coronary artery disease in 19%. One patient did not undergo coronary angiography due to pregnancy. Average ejection fraction (EF) on CMR was 59% (SD 0.09). Eighteen patients normal EF, 16 had mild LV-impairment, two patients had an EF < 45%. CMR was scar positive in 13 patients with a final diagnosis as follows: 7 = myocarditis, 4 = ischaemic infarct, 1 = dilated cardiomyopathy, 1 = sarcoid. The remaining 23 patients who were CMR scar negative; 7 = TakoTsubo, 3 = vasospasm, 10 = myocarditis, 2 = pericarditis, 1 = thrombus Conclusion: CMR is useful to establish a diagnosis in patients presenting with ACS with normal coronary arteries. In this study, findings of an alternative diagnosis was useful in longterm planning and management of these patients.

Effects of Statins on Endothelial Function in Patients with Coronary Artery Disease

Flow-mediated dilatation (FMD) of the brachial artery is a method capable of detecting endothelium dysfunction. Statins are generally consent drugs for reducing cardiovascular morbidity and mortality and are shown to improve the systemic endothelial function. The aim of our study was to assess the endothelial function using FMD of the brachial artery in patients with different degrees of coronary artery stenosis with respect to their treatment with statins. We evaluated the FMD of 221 patients with coronary arteriography performed, of whom 99 (44.8%) were receiving statins and 122 (55.2%) were not receiving statins. We did not find a statistically significant difference in the FMD values between the patients with and without a statin treatment: 5.57 +/- 5.68 and 4.69 +/- 4.48, respectively, P = .581. In the subgroup of patients without angiographically visible coronary artery stenoses or with stenoses <20% (86 patients), patients undergoing statin treatment had a significantly better endothelial function compared to patients without such a treatment: FMD 9.24 +/- 6.87 and 6.50 +/- 4.51, respectively, P = .047. FMD could not distinguish between the patients who were treated with statin and those not treated with statins with the same demographic, clinical, and angiographic characteristics. The only exception was in the group of patients with a minor coronary disease. Statin treatment had a more pronounced effect in the earlier stages of coronary atherosclerosis.

Pneumopericardium masquerading as an acute myocardial infarction

We describe the case of a 92-year-old gentleman who presented with pneumopericardium mimicking an acute anterior myocardial infarction (MI). The patient presented to the emergency rooms with 2 h of retrosternal chest discomfort radiating to the jaw preceded by syncope. Past history was remarkable for large cell lymphoma involving the oesophagus, which had been in remission for at least 10 years. Physical examination revealed: HR 80 bpm, BP 90/60mmHg and JVP elevated to the angle of the jaw. The rest of the examination was normal. An ECG showed 2 mm ST segment elevation in leads V2–V6. He was transferred to the Cath lab for primary percutaneous coronary intervention (PCI) for presumed acute anterior MI. This revealed minor coronary disease and evidence of pneumopericardium (Movie 1). A pericardial drain was inserted in response to hemodynamic instability. A chest X-ray (Fig. 1A) and CT scan (Fig. 1B) confirmed the diagnosis and showed no other abnormalities including lymphadenopathy. Gastrogaffin swallow and endoscopy were normal. Pericardial fluid culture demonstrated Candida albicans, a known element of oro-gastric flora. He was treated with fluconazole and moxifloxacin and made an uneventful recovery. Given the past history of lymphoma affecting the oesophagus and the presence in the pericardial cavity of a micro-organism found in the oro-gastric tract, it was thought that the cause of the pneumopericardium was a microscopic oesophageal perforation leading to a fistulous connection between the gastrointestinal tract and pericardial cavity.

Coronary Artery Spasm*

Variant angina with ST elevation indicates transmural myocardial ischaemia and is due to spasm of a large epicardial coronary artery. Spasm occurs in arteries with varying degrees of fixed obstruction, giving rise to different clinical profiles of variant angina. However, coronary angiography is required to differentiate between those with minor coronary disease, and those with significant (greater than 70%) obstruction. In patients with minor coronary disease or normal arteries, beta-blockers are contraindicated, and treatment with calcium antagonist vasodilators should be commenced after documentation of spontaneous or ergonovine induced spasm. Patients with significant fixed coronary obstructions require bypass grafting if technically feasible. The role of coronary spasm is not confined to variant angina, as it causes angina at rest with ST depression, and may also cause myocardial infarction and sudden death.