Normal Angiograms Research Articles

Diagnostic Accuracy of 128-Slice Dual Source CT Coronary Angiography with Invasive Catheter Coronary Angiography in a Tertiary Care Teaching Hospital

Background: Coronary artery disease (CAD) morbidity and mortality increasing day by day in India as well as worldwide. Coronary arteries visualization by using invasive catheterization angiography is still using as a front-line diagnostic tool to evaluate the patients with CAD. 128 slice dual source CT improves the cardiac imaging such as high scanning speed, good temporal resolution and low radiation dose. Objective: To assess the diagnostic accuracy of 128-slice dual source CT cardiac angiography with conventional catheter angiography to find common arteries involved in CAD. Methods: This is a prospective, comparative, cross sectional study conducted at cardiology OPD. Patients with complaint of chest pain and suspected CAD were evaluated by CT and conventional coronary angiography and results were compared. Serum creatinine and ECG status were analyzed before the angiography. SIEMENS 128-slice Dual Source Flash Definition CT Scanner was used as a CT coronary angiography. Severity distribution of coronary artery disease, artery wise distribution of non-significant, significant lesions and coronary artery dominance pattern were analyzed and compared. Results: A total of 70 suspected CAD patients were selected and analyzed. American Heart Association (AHA) model of 17-segment was used to assess the coronary arteries. Normal angiograms reported in 15.71% patients and 58.57% had significant disease. A total of 356 lesions were identified from 690 out of 720 segments. Right coronary artery (RCA) is the most common location of significant lesions which contributes 33.5% (n=55/164). Coronary circulation of right-sided dominance was most commonly reported (70.0%). CT angiography showed 96.13% of an overall sensitivity, 96.28% specificity, 89.72% positive predictive value and 98.49% negative predictive value. Conclusion: 128-slice dual source CT scanner has showed high accuracy and act as non-invasive assessment of coronary arteries in patients with CAD Keywords: Cardiac angiography, Catheter coronary angiography, CT coronary angiography, 128-slice MDCT, Conventional angiography

Repeat Catheter Angiography in Patients with Aneurysmal-Pattern Angiographically Negative Subarachnoid Hemorrhage.

A significant proportion of patients with subarachnoid hemorrhage have a normal cerebral angiogram. Patients with angiographically negative subarachnoid hemorrhage (anSAH) with either perimesencephalic- (panSAH) or aneurysmal-pattern hemorrhage (aanSAH, also known as diffuse anSAH) have an excellent prognosis, but only if underlying vascular abnormalities are completely excluded. The rate of occult aneurysms in patients with aanSAH varies widely across studies. The purpose of this study was to quantify the value of repeat DSA in these patients. We reviewed the records of all patients initially diagnosed with aanSAH after a screening DSA at a single tertiary neurovascular referral center from January 2006-April 2018. Patients with panSAH and traumatic SAH were excluded. We also performed a systematic review and meta-analysis of positive second DSAs in previously published case series of patients with aanSAH who underwent two serial DSAs. For meta-analysis, PubMed Central, MEDLINE and Cochrane Library databases were searched for pertinent studies up to November 2019. The rate of aneurysm detection on repeat angiography was extracted from each study. Pooled rates for positive second angiogram were calculated as untransformed proportions in a binary random-effects model meta-analysis. Inter-study heterogeneity was calculated using an I2 statistic. Three of 27 patients (11.1%) with aanSAH and at least two DSAs were subsequently found to have a cerebral aneurysm in our institutional dataset. Twenty-six studies in our systematic review met inclusion criteria, and the pooled rate of positive second angiogram was 10.4% (95% CI 7.3%-13.5%, P < 0.001). Substantial inter-study heterogeneity was observed in the meta-analysis (I2 = 61.7%, P < 0.001). One in 10 patients with aanSAH has an occult ruptured aneurysm. A second-look DSA should be strongly considered in these cases.

Acute Coronary Syndrome with Normal or Near-Normal Coronary Angiography:Prevalence and Clinical Outcomes among Yemeni Patients

Abstract Background: Nonobstructive acute coronary syndrome or acute coronary syndrome with normal or near-normal coronary angiography (ACSNONCA) occurs in 10% to 25% of patients undergoing coronary angiography and in up to 6% of patients with troponin-positive ACS. Prevalence of ACSN-NOCA and its clinical outcomes were not discussed in previous studies in Yemen. Aim of Study: Our study aimed to compare demographic and clinical findings and prognosis in patients who have ACS with stenosis 50%) with 213 patients (27.6%). During the period January 2010 through September 2015, patients were admitted at Algamhoria Teaching Hospital, Aden and undergone cardiac catheterization in Cardiac Surgery Center at Althawra Hospital, Sana'a. Results: Group I Patients (stenosis <50%) were signifi-cantly younger were more likely to be female, younger, with fewer risk factors, compared to Group I Patients. We isolated and defined two subgroups within Group I: Group IA: Patients with normal angiograms (n=60, 52.6%) and Group IB patients with stenosis of 20-50% (n=54, 47.4%). Patients with stenosis of 20%-50% were relatively older males, with an increasing frequency of nondiabetic, with a history of chronic heavy chewing and with a worse prognosis, during long-term eval-uation. Follow-up data revealed that myocardial infarction was found in 1.8% of Group IA and in 5.2% of Group IB patients. Follow-up revealed no deaths in Group IA patients and two cardiac deaths (3.7%) in Group IB patients. Conclusions: Prognosis of patients with nonobstructive stenosis was significantly better than that of patients with critical obstructive stenosis. However, patients with stenosis of 20-50% had a worse prognosis than did those with normal coronary arteries.

Vermian subtentorial arteriovenous malformation supplied by the artery of Wollschlaeger and Wollschlaeger

BackgroundThe artery of Wollschlaeger and Wollschlaeger is a tentorial branch of the superior cerebellar artery: due to its small diameter, it is not usually seen in normal angiograms except when enlarged in the setting of a dural AVF or tentorial meningioma. Its presence has been rarely described in the Literature. Case reportherein we describe the first ever reported case of a vermian subtentorial arteriovenous malformation supplied by the artery of Wollschlaeger and Wollschlaeger in 70 year old female patient. Conclusionvermian subtentorial AVMs supplied by the artery of Wollschlaeger and Wollschlaeger are extremely rare vascular malformations. The presence of the artery of Wollschlaeger and Wollschlaeger must be carefully evaluated during preoperative surgical planning due to its key role in the supply of vascular malformation and to decrease the risk of intra operative bleeding during surgery.

Comparing Efficacy and Safety of Empirical vs. Guided Therapy for Non-cardiac Chest Pain: A Pragmatic Randomized Trial.

Background: Non-cardiac chest pain is common with two-thirds due to gastroesophageal reflux disease (GERD).Objective: To evaluate the effectiveness and safety of guided vs. empirical therapy in non-cardiac chest pain.Methods: Adults with normal angiogram or stress test were randomized into either a guided or empirical group. In the guided group, after the ambulatory pH-impedance test, if GERD then dexlansoprazole 30 mg/day for 8 weeks, but if functional or hypersensitive chest pain, then theophylline SR 250 mg/day for 4 weeks. In the empirical group, dexlansoprazole 60 mg/day was given for 2 weeks. The primary outcome was global chest pain visual analog score (VAS) and secondary outcomes were Quality of Life in Reflux and Dyspepsia (QOLRAD), GERD questionnaire (GERDQ), and pH parameters, all determined at baseline, 2nd and 8th weeks.Results: Of 200 screened patients, 132 were excluded, and of 68 randomized per-protocol, 33 were in the guided group and 35 in the empirical group. For between-group analysis, mean global pain scores were better with guided vs. empirical group at 8th week (P = 0.005) but not GERDQ or QOLRAD or any of pH measures (all P > 0.05). For within-group analysis, mean QOLRAD improved earliest at 8th week vs. baseline (P = 0.006) in the guided group and 2nd week vs. baseline (P = 0.011) in the empirical group but no differences were seen in other secondary outcomes (P > 0.05). No serious adverse events were reported.Conclusions: Guided approach may be preferred over short-term empirical therapy in symptom response, however QOLRAD, acid-related symptoms, or pH measures are not significantly different (trial registration ID no. NCT03319121).

A novel method of donor‒recipient size matching in pediatric heart transplantation: A total cardiac volume‒predictive model

The pediatric heart transplant community uses weight-based donor-to-recipient size matching almost exclusively, despite no evidence to validate weight as a reliable surrogate of cardiac size. Donor size mismatch is the second most common reason for the refusal of donor hearts in current practice (∼30% of all refusals). Whereas case-by-case segmentation of total cardiac volume (TCV) by computed tomography (CT) for direct virtual transplantation is an attractive option, it remains limited by the unavailability of donor chest CT. We sought to establish a predictive model for donor TCV on the basis of anthropomorphic and chest X-ray (CXR) cardiac measures. Banked imaging studies from 141 subjects with normal CT chest angiograms were obtained and segmented using 3-dimensional modeling to derive TCV. CXR data were available for 62 of those subjects. A total of 3 predictive models of TCV were fit through multiple linear regression using the following variables: Model A (weight only); Model B (weight, height, sex, and age); Model C (weight, height, sex, age, and 1-view anteroposterior CXR maximal horizontal cardiac width). Model C provided the most accurate prediction of TCV (optimism corrected R2 = 0.99, testing set R2 = 0.98, mean absolute percentage error [MAPE] = 8.6%) and outperformed Model A (optimism corrected R2 = 0.94, testing set R2 = 0.94, MAPE = 16.1%) and Model B (optimism corrected R2 = 0.97, testing set R2 = 0.97, MAPE = 11.1%). TCV can be predicted accurately using readily available anthropometrics and a 1-view CXR from donor candidates. This simple and scalable method of TCV estimation may provide a reliable and consistent method to improve donor size matching.

Hyperventilation echocardiography in INOCA: the HEROIC study

Abstract Background Patients with ischemia and no obstructive coronary artery disease (INOCA) are a heterogeneous group and an unmet diagnostic challenge. Noninvasive Doppler is a feasible tool to assess coronary flow velocity (CFV) in left anterior descending coronary artery (LAD) during stress echocardiography (SE). Aim To assess CFV response during coronary vasoconstrictor and vasodilator stimuli in INOCA patients. Methods In a prospective single center study, we enrolled 16 INOCA patients (age 60±12 years, 15 females) with previously normal angiograms. All underwent SE testing with hyperventilation (HYP, respiratory rate of 30 per min for 5') followed by supine bicycle exercise (HYP+EXE); and adenosine CFV evaluation (ADO, 0.84 mg/kg in 1 min) on the other day. The ratio of peak/rest changes of CFV during HYP in LAD was taken as an index of vasoconstriction, and CFV reserve was evaluated after EXE. An abnormal response to HYP was a CFV ratio &amp;lt;1.0 (vasoconstrictor response). An abnormal response to ADO was a CFV reserve &amp;lt;2.0 (blunted vasodilatory response). CFVR at peak HYP+ EXE was an indicator of endothelial dependent vasodilatation. Results The double product increased during HYP, in comparison to rest (13 337 vs 9858, p&amp;lt;0.001), and further increase with EXE (21 118 vs HYP, p&amp;lt;0.001). Chest pain or dyspnea were present in 2/16 pts during HYP, and in 5/16 patients during HYP+EXE (12.5% vs 31.25%, p=0.083). ST segment depression (≥1mm) was present in 1/16 patients during HYP, and 3/16 during HYP+EXE. Two patients showed regional wall motion abnormalities with HYP+EXE. CFVR response was blunted in 9/16 patients during HYP+EXE, and abnormal for vasoconstriction during HYP in 6. Vasodilation during ADO was preserved in all patients. There was significant difference between CFVR response during HYP+EXE and ADO (1.9±0.5 vs 2.4±0.4 respectively, p=0.039), and between CFVR HYP and ADO (1.2±0.3 vs 2.4±0.4, p&amp;lt;0.001). Conclusion In INOCA patients, HYP+EXE is a more powerful ischemic stress than HYP alone and unmasks abnormalities in regional wall motion and/or CFV response in over one- half of patients, likely unmasking the underlying abnormal coronary vasomotor response of large epicardial and/ or small coronary vessels. INOCA patients show profound heterogeneity of coronary vasomotor responses which can be detected with a combined vasodilator - vasoconstrictor SE approach with CFV assessment. The clarification of underlying coronary microcirculatory heterogeneity is the prerequisite for a personalized treatment, and can be easily extracted from CFV-SE. Normal INOCA hearts are all alike, every abnormal heart is abnormal in its own way. Funding Acknowledgement Type of funding source: None

Effects of Statin Treatment on Patients with Angina and Normal or Nearly Normal Angiograms.

This article offers an updated and comprehensive overview of major findings on the effects of statin treatment in patients with chronic angina but without any epicardial coronary artery with obstructive lesion.

Early IVUS-Guided Selection for Non-Invasive Cardiac Allograft Vasculopathy (CAV) Screening in Heart Transplant Recipients

Non-invasive screening for CAV instead of invasive angiography within the first 3-5 years after heart transplantation (HTx) is controversial according to ISHLT guidelines. This study aimed to evaluate a strategy of early IVUS-guided conversion to non-invasive screening for CAV one year after HTx. A single-center study of consecutive HTx recipients with normal angiogram one year after HTx all undergoing IVUS examination for risk stratification between February 2009 and March 2018. Patients with abnormal angiogram at 1 year were excluded and followed invasively. In total 63 patients were included and grouped by maximal intimal thickness (MIT) into: (i) low-risk group (MIT < 0.5 mm) (n=38, 60%) followed with yearly dobutamine stress echocardiography versus (ii) high-risk group (MIT ≥ 0.5 mm) (n=25, 40%) followed with yearly coronary angiography. The primary endpoint was a combined endpoint of angiographically evident CAV (ISHLT criteria) and all-cause mortality at 5-year follow-up post-HTx. Median (IQR) age at HTx was 44 years (33-60), 62% were male and groups did not differ significantly. Median follow-up was 1214 days (717-1455). In total 5 (8%) patients died and angiographic CAV was detected in 12 (19%) patients during follow-up (group differences: p=0.33 and p<.0001, respectively). Survival free from angiographic CAV by Kaplan Meier estimate differed significantly between groups (log-rank test p<.0001) (figure 1). A subgroup of 24 (38%) patients completed coronary angiography at year 5 post-HTx and CAV was detected in 10 patients (42%). Incidence of CAV was 8% in the low-risk group and 82% in the high-risk group (p=0.0005). No CAV above mild grade was found in low-risk patients within follow-up. No re-HTx or revascularization was performed. Early IVUS-guided selection for non-invasive CAV screening in HTx recipients appears to be safe and holds promise as a novel strategy for early risk-stratification and CAV surveillance after HTx.

Clinical Risk Factors and Angiographic Pattern of Coronary Artery Disease in Young Females

Background: Coronary artery disease (CAD) is associated with the highest mortality in women around the world. The objective of this study was to compare the clinical risk factors and angiographic pattern of coronary artery disease in young versus old age females having CAD.Material and Methods: This cross-sectional study was conducted at the Department of Cardiology, Chaudhry Pervaiz Elahi (CPE) Institute of Cardiology Multan, Pakistan from April 2018 to December 2018. All females with diagnosis of angina and consistent ischemic changes on ECG were enrolled in the study. A total of 230 females were included with 123 patients aged &lt;45 years and 107 patients aged &gt;45 years. Comparison of patient characteristics, clinical risk factors and angiographic pattern in young and old age females was done by using SPSS version 21 statistical software.Results: Prevalence of hypertension (P=0.001), dyslipidemia (P=0.06) and diabetes mellitus (P=0.007) was significantly higher in females of older age group (&gt;45 years). Similarly, a larger number of older age females (32; 29.9%) presented with ST-Elevation Myocardial Infarction (STEMI) as compared to young female patients (22; 17.88%) (P=0.03). Regarding angiographic patterns of CAD, there was no difference in the prevalence of single vessel disease (SVD), double vessel disease (DVD) and triple vessel disease (TVD) between the groups. Normal angiogram was found in 13 (12.3%) old age females versus 35 (28.8%) young females, respectively (P=0.002).Conclusions: The risk factors profile and clinical presentation of CAD is different in young female patients with CAD. There is an essential need to determine the coronary atherosclerosis factors in young females and these women should be treated more aggressively to prevent adverse cardio-vascular outcomes.Key words: Angiographic Pattern, Coronary Artery Disease, Clinical Pattern, Young Females

Acute myocardial infarction as the initial presentation of behcet's syndrome

Behcet's disease (BD) is clinically characterized by recurrent oral and genital ulcers and ocular symptoms. However, systemic manifestations involving the lungs, gastrointestinal tract, kidneys, and heart are well known. Acute myocardial infarction (MI) is a rare manifestation of Behcet's syndrome and usually results from coronary arteries vasculitis, leading to aneurysms. More uncommon is the occurrence of acute MI as the initial presenting symptom. Hereby, we report a case of a young male who presented with acute anterior wall MI sans any other conventional risk factors with a normal angiogram. And 3 years later, he was diagnosed with BD.

Serum low density lipoprotein receptor related protein-6 is a discriminator of occluded ‎coronary artery assessed by coronary angiogram

Background: Human lipoprotein receptor-related protein -6 (LRP6) plays a role in the development of coronary artery disease. This study aimed to determine the serum level of the LRP6 in patients referred to the coronary angiogram taking into considerations the findings of ‎coronary angiography, evidence of dyslipidemia, obesity and co-existed diabetes mellitus.&#x0D; Methods: This cross-sectional study included 96 patients who referred to coronary angiogram as an interventional diagnostic test for coronary artery disease. The patients were grouped into Group I (negative angiogram); Group IIA (non-obstructed coronary vessels, positive angiogram) and: Group IIB (obstructed coronary vessels, positive angiogram). The anthropometric measurement, blood pressure, and fasting serum lipid profile and glucose were determined. The serum levels of LRP6 were determined by using the Enzyme-Linked ImmunoSorbent Assay (ELISA). &#x0D; Results: A non-significant higher serum level of LRP6 observed in patients with a positive angiogram ‎0.175 ± 0.074 ng/ml (Group IIA) and ‎0.166 ± ‎‎0.063 ng/ml (Group IIB) ‎compared with the negative angiogram (Group I: 0.160 ± 0.019 ng/ml). The area under the curve of LRP6 in patients with positive angiogram was significantly lower than that with a normal angiogram.&#x0D; Conclusion: We conclude that the serum level of LRP6 is a good discriminator of patients with coronary ‎artery disease as the area under the curve of the serum levels of LRP6 is significantly decreased as the number of occluded coronary vessels increased.‎

Hyperventilation-induced heart rate response as a potential marker for cardiovascular disease

An increase of heart rate to physical or mental stress reflects the ability of the autonomous nervous system and the heart to respond adequately. Hyperventilation is a user-controlled breathing maneuver that has a significant impact on coronary function and hemodynamics. Thus, we aimed to investigate if the heart rate response to hyperventilation (HRRHV) can provide clinically useful information. A pooled analysis of the HRRHV after 60 s of hyperventilation was conducted in 282 participants including healthy controls; patients with heart failure (HF); coronary artery disease (CAD); a combination of both; or patients suspected of CAD but with a normal angiogram. Hyperventilation significantly increased heart rate in all groups, although healthy controls aged 55 years and older (15 ± 9 bpm) had a larger HRRHV than each of the disease groups (HF: 6 ± 6, CAD: 8 ± 8, CAD+/HF+: 6 ± 4, and CAD−/HF−: 8 ± 6 bpm, p < 0.001). No significant differences were found between disease groups. The HRRHV may serve as an easily measurable additional marker of cardiovascular health. Future studies should test its diagnostic potential as a simple, inexpensive pre-screening test to improve patient selection for other diagnostic exams.

78-Year-Old Woman With Intermittent Chest Pain and Palpitations

78-Year-Old Woman With Intermittent Chest Pain and Palpitations

Increased TIMI frame count of coronary arteries in patients with myocardial bridging

Objectives: Myocardial bridging (MB) is associated with recurrent chest pain and cardiovascular events. Recently it has been proposed that MB has the features of vasospastic coronary artery characterized with reduced coronary flow reserve and endothelial dysfunction. In this study, an evaluation was made of the angiographic Thrombolysis in Myocardial Infarction (TIMI) frame counts (TFCs) of patients with normal angiogram and those with MB. Methods: The study was conducted as a retrospective analysis of the demographic, laboratory, and angiographic features of consecutive patients who underwent coronary angiography between January 2014 and December 2017 in Necip Fazıl City Hospital and Sütçü Imam University, Kahramanmaraş, Turkey. Results: The except for age (51.1 ± 11.6 years vs 56.8 ± 11.4 years) (p = 0.011), no difference was determined between the groups in respect of laboratory parameters and demographic features. TFCs of LAD (42.9 ± 6.1 vs 54.5 ± 11.5. p &amp;lt; 0.001), Cx (19.4 ± 4.5 vs 24.4 ± 7.1, p &amp;lt; 0.001), and RCA (26.8 ± 6.2 vs 32.5 ± 8.9, p &amp;lt; 0.001), and corrected TFC of LAD artery (25.2 ± 3.6 vs 32.0 ± 6.8, p &amp;lt; 0.001) were observed to be significantly increased in patients with MB compared to patients with normal coronary flow. Multiple regression analysis revealed that MB was the only determinant of increased corrected TFC of LAD artery (r=0.537, Adjusted r=0.281, p &amp;lt; 0.001). Conclusions: Patients with MB had abnormally slow coronary flow demonstrated by increased TFC. This finding may explain the recurrent angina and cardiovascular events of patients with MB. It may also explain the reversible myocardial perfusion defects which are associated with recurrent cardiovascular events in patients with MB.

Accelerated Cardiac Allograft Vasculopathy: A Clinical and Pathologic Correlation Study

Purpose Cardiac allograft vasculopathy (CAV) is a prevalent cause of graft failure and has remained so despite advances in HLA matching and immunosuppression in recent decades. Several distinct pathologic phenotypes of CAV have been described (Lu et al JHLT 2011 and Huibers et al Atherosclerosis 2014), but the correlation of these phenotypes to clinical features has been limited. Of particular interest in this study are patients who develop accelerated CAV, since this presentation is so clinically devastating but also because it may provide important mechanistic insights into CAV initiation and progression. Methods Patients with accelerated development of CAV were identified from the transplant and pathology databases of the UTAH Cardiac Transplant Program. Dates of transplant, last normal angiogram, and explant or autopsy were collected along with demographic and pertinent clinical information. Histopathologic features of their allograft coronary arteries were systematically collected. The pathologic and clinical features were compared. Results Five patients with accelerated CAV development were identified. Their details are shown in the table below. Four of the patients had a normal angiogram within a mean of one year from graft loss, but all showed diffuse >75% coronary narrowing by pathology (see image below). The CAV phenotypic features observed histologically included prominent active vasculitis (intimal and transmural) and shallow mural thrombus. In 2 cases mural thrombus appeared to be incorporated into the intimal proliferative process (see #3-high). Peri-adventitial inflammation was also a prominent feature in 4 of the patients. Conclusion Accelerated CAV is uncommon, but also unpredictable. From this series of patients, it appears CAV can progress from being undetectable by angiography to critical stenosis and graft failure in as little as 4 months (mean 1 year). Vascular inflammation and shallow mural thrombus play a key role in this rapid progression.

Angiographic findings and predictor analysis for acute coronary ischaemia (ACI) after out-of-hospital cardiac arrest (OHCA)

Coronary artery disease (CAD) is the leading cause of OHCA. However, diagnosis of ACI remains challenging, particularly in patients without ST-segment elevation on the post-resuscitation ECG. In this regard, a consensus statement recommends the implementation of a work-up strategy in the emergency room (ER) to exclude non-coronary causes of collapse within 2 hours. We present data on coronary angiograms for patients who underwent cardiac catheterization after resuscitation. Afterwards, we sought to identify parameters associated with ACI. Retrospective single-centre study performed on 64 consecutive patients with resuscitated OHCA who underwent a diagnostic coronary angiography (CA). Data collection was performed from the patient records at the ER and the catheterization laboratory. ST-segment elevation was noted in 29 patients (45%). ST-segment depression or T-wave abnormalities were noted in 35 patients (55%). Invasive coronary strategy allowed to identify an acute culprit lesion in 46 cases (72%). 29 patients with ST-segment elevation underwent an immediate angioplasty for an acute coronary occlusion. 17 patients without ST-segment elevation underwent an ad hoc percutaneous coronary intervention for a critical lesion. Stable CAD was found in 9 cases (14%) and a normal angiogram was found in only 9 cases (14%) ( Fig. 1 ). The independent predictors of ACI were convertible rhythm (OR 16.02; 95% CI 4.48–57.29), personal history of CAD (OR 15.12; 95% CI 4.19–54.53) and presence of at least 2 cardiovascular risk factors (OR 10.68; 95% CI 2.55–44.74) ( Table 1 ). ACI was the leading precipitant of collapse. ST-segment elevation was highly predictive of coronary occlusion. A culprit coronary lesion was identified in nearly 50% of patients undergoing CA despite the lack of ST-segment elevation. Our findings also suggest that the identification of risk criteria may help to improve the recognition of ACI after OHCA.

Evaluation of SERENE-CAG score for assessing suitability for coronary angiography preoperatively in patients undergoing valve replacement surgery

AimsThe aim of this study was to identify better selection criteria for subjecting patients of rheumatic heart disease (RHD) to preoperative coronary angiography (CAG) based on indigenous scoring system (SERENE-CAG [Selecting Patients Of Rheumatic Heart Disease Undergoing Valve Surgery For Presurgical Coronary Angiography]). MethodsThis prospective study included all consecutive 798 patients of RHD patients undergoing preoperative CAG from January 2016 to December 2017 over a duration of 2 years. Multivariate logistic regression analysis was performed with the presence of significant CAD [coronary artery disease] as the dependent variable with traditional risk factors of CAD. An additive score was developed using coefficient derived logistic regression for those variables that were significant. Receiver-operator curve analysis was performed to assess the ability of this score to predict diseased vs normal CAG. ResultsA total of 798 patients had a mean age of 51.7 ± 12.5 years. Significant CAD requiring revascularization along with valve surgery was identified in 50 (6.26%) patients. Male gender was found as significant predictors of CAD with odds ratio 2.6. A SERENE CAG SCORE of >2.8 resulted in sensitivity of 80% and specificity of 36.9% of predicting CAD in RHD patients with positive and negative predictive value of 7.8% and 96.5%, respectively. ConclusionThe prevalence of CAD in RHD patients is low. Patient risk can be minimized by exploring noninvasive modalities for screening of CAD and by more appropriate selection of patients for invasive coronary angiogram. Using threshold SERENE-CAG score of >2.8 would result in deferring 34.6% of normal angiograms.

Mechanisms of Myocardial Infarction in Patients With Nonobstructive Coronary Artery Disease: Results From the Optical Coherence Tomography Study

ObjectivesThis study sought to assess the presence and morphological features of coronary plaques on optical coherence tomography (OCT) as the causes of myocardial infarction with nonobstructive coronary arteries (MINOCA). BackgroundAlthough coronary atherosclerosis has been postulated as a potential mechanism of MINOCA, the interaction between disrupted coronary plaques and myocardial injury remains unknown. MethodsIn a prospective study, consecutive patients with MI but without significant coronary stenosis (≥50%) at angiography underwent OCT and cardiac magnetic resonance (CMR) with late gadolinium-enhancement (LGE). The infarct-related artery (IRA) was identified by localization of ischemic-type LGE. ResultsThirty-eight MINOCA patients (mean age 62 ± 13 years, 55% female, 39% with ST-segment elevation) were enrolled. Maximal diameter stenosis was 35% by angiography, and 5 patients (13%) had normal angiogram results. Plaque disruption and coronary thrombus were observed in 9 patients (24%) and 7 patients (18%), respectively. Sixteen of 31 patients (52%) undergoing CMR showed LGE. Ischemic-type LGE was present in 7 patients (23%) and was more common in patients with than without plaque disruption (50% vs. 13%, respectively; p = 0.053) and coronary thrombus (67% vs. 12%, respectively; p = 0.014). In the per-lesion analysis, the IRA showed significantly more plaque disruption (40% vs. 6%; p = 0.02), thrombus (50% vs. 4%; p = 0.014), and thin-cap fibroatheroma (70% vs. 30%; p = 0.03) than the non-IRA. ConclusionsPlaque disruption and thrombus are not uncommon in MI without obstructive coronary stenoses at angiography and may be associated with the presence and location of ischemic-type myocardial injury on CMR. OCT may be valuable in identifying atherosclerotic etiology in individuals with MINOCA. (Optical Coherence Tomography in Patients With Acute Myocardial Infarction and Nonobstructive Coronary Artery Disease [SOFT-MI]; NCT02783963)

Epicardial and microvascular coronary vasomotor dysfunction and its relation to myocardial ischemic burden in patients with non-obstructive coronary artery disease

AimTo assess the relative contribution of epicardial endothelium-dependent (EDD) and microvascular endothelium-independent (EIMVD) coronary vasomotor dysfunction to the extent of myocardial ischemia in patients with normal angiograms or non-obstructive coronary artery disease (NOCAD). MethodsCoronary vasomotion was evaluated by quantitative angiography and blood flow (CBF) measurements during intracoronary acetylcholine, nitroglycerine, and adenosine in 101 patients. Myocardial SPECT ischemic burden was evaluated by semi-quantitative scoring of summed stress (SSS) and summed ischemic (SDS) perfusion defect size. ResultsCoronary vasomotor dysfunction was found in most patients (83; 77%) with a divergent behavior of EDD and EIMVD in one half of them (52.4%). There was no significant difference in SDS between patients with and without EIMVD, whereas SDS was significantly greater in subjects with EDD as compared to patients with normal response to acetylcholine (4.31 ± 2.44 vs 1.35 ± 1.45; P < .0001). Patients with EDD, either alone or in combination with EIMVD, had significantly higher SSS as compared to patients with lone EIMVD or normal vasomotor function (8.50 ± 5.32; 5.55 ± 3.21; 2.60 ± 2.14; and 1.74 ± 1.66, respectively; P < .0001). Acetylcholine CBF correlated inversely with both SDS (r = −0.545; P < .001) and SSS (r = 0.538; P < .001). ConclusionsIn NOCAD patients with symptoms and signs of myocardial ischemia, vasomotor dysfunction is common. EDD is associated with greater extent of ischemia as compared to isolated EIMVD. Thus, assessment of both EIMVD and EDD is needed to recognize mechanisms of ischemia and identify patients with greater ischemic burden.