Normal Angiograms Research Articles

Diagnosis of Crohnʼs Disease in a Patient with Pulmonary Embolism: A ‘Clotʼ to Think About

Background: The risk of venous thromboembolism (VTE) amongst patients with inflammatory bowel disease (IBD) is increased by a 2-4 time fold compared to non-IBD patients. This case describes a patient who incidentally was diagnosed with Crohn's disease while investigated for a pulmonary embolism. History: A 66-year old woman was admitted to our hospital after a witnessed episode of loss of consciousness. She had recently been on a 2-hour aeroplane flight. She had lost weight recently but her medical history was otherwise non-contributory and was not on any regular medications. She was an ex-smoker. On physical examination a systolic heart murmur was diagnosed. She was pyrexial. The rest of the examination was unremarkable. Laboratory assessment revealed elevated inflammatory markers and a raised d-dimer. Her head CT was normal and echocardiogram showed severe aortic stenosis. A chest radiograph was normal but CT pulmonary angiogram confirmed a pulmonary embolism (PE). Gastroscopy was normal and cross sectional imaging of the thorax, abdomen and pelvis were showed terminal ileal thickening consistent with Crohn's disease. Ileo-colonoscopy with biopsies confirmed mild to moderately active ileitis but no colonic disease. With the possible exception of weight loss she had no other symptoms attributable to IBD. Her son was diagnosed some years ago with ulcerative colitis from which he as asymptomatic after investigations for pulmonary embolism. Management: She has been anticoagulated with warfarin and awaits surgery for aortic valve replacement. She is currently being managed with aminosalicylates despite limited evidence for 5-ASA's in Crohn's disease given the relatively short segment of otherwise asymptomatic disease with a plan to reassess disease after aortic valve replacement. Discussion: Venous thromboembolism (VTE) is a well-recognised complication of IBD with an overall mortality as high as 25% per episode. Despite emerging evidence that Inflammation and coagulation are interdependent processes that perpetuate and intensify each other, this important complication may not be appreciated as well as it should and a high index of suspicion and prompt treatment are necessary for optimal outcomes. Up to 75% of IBD patients may have no identifiable provoking factors but as many as a third of these will have recurrent VTE within 5 years. Between 55-80% have active IBD at diagnosis of VTE. There remains paucity of clinical data driving evidence- based decisions and although anticoagulation is the cornerstone of therapy, randomised trials testing catheter directed thrombolysis or anticoagulation are much needed.

Predictors of normal coronary arteries at coronary angiography

Coronary angiograms are important in the diagnostic workup of patients with suspected coronary artery disease. However, little is known about the clinical predictors of normal angiograms and whether this rate varies across different cardiac centers in Ontario. We conducted a study using the Cardiac Care Network Variations in Revascularization Practice in Ontario database of 2,718 patients undergoing an index cardiac catheterization for an indication of stable angina between April 2006 and March 2007 at one of 17 cardiac hospitals in Ontario. We determined predictors of normal coronary angiograms (0% coronary stenosis) and compared rates of patients with normal catheterizations across centers. Overall, 41.9% of patients with stable angina had a normal catheterization. A multivariate model demonstrated female gender to be the strongest predictor of a normal angiogram (odds ratio 3.55, 95% CI 2.93-4.28). In addition, atypical ischemic symptoms or no symptoms, the absence of diabetes, hyperlipidemia, smoking history, peripheral vascular disease, and angiography performed at a nonteaching site were associated with higher rates of normal catheterization. The rate of normal angiograms studied varied from 18.4% to 76.9% across hospitals and was more common in community compared with academic settings (47.1% vs 35.4%, P < .001). The absence of traditional cardiac risk factors, female gender, and lack of typical angina symptoms are all associated with a higher frequency of normal cardiac catheterizations. The wide variation in Ontario in the frequency of normal angiograms in patients with stable angina suggests that there are opportunities to improve patient case selection.

Impact of Expeditious Management of Perioperative Myocardial Ischemia in Patients Undergoing Isolated Coronary Artery Bypass Surgery

To analyze the effect of immediate treatment of perioperative myocardial ischemia (PMI) because of early graft failure or incomplete revascularization in patients undergoing coronary artery bypass grafting (CABG) surgery. Between January 2004 and December 2010, 7461 patients underwent isolated CABG at our institution. All patients showing evidence of PMI (n=399; 5.3% of total) underwent emergent coronary angiography. A total of 900 grafts and 1061 distal anastomoses were examined. Two hundred fifty-five patients had 360 distal anastomoses compromised because of early graft failure or incomplete revascularization (ie, abnormal postoperative coronary angiogram). Revision CABG or percutaneous coronary intervention was performed in 130 (51.0%) and 34 (13.3%) patients with abnormal angiograms, respectively. Nonsurgical therapy was implemented in the remaining 91 patients (35.7%) with abnormal angiograms. One hundred forty-four patients had normal postoperative graft-related angiograms. In-hospital mortality was 7.3% and 2.9% in patients with and without PMI (P<0.001). In patients with PMI, in-hospital mortality was 9.4% and 3.5% in patients with abnormal and normal postoperative angiograms, respectively (P=0.03). Significant multivariable predictors of in-hospital mortality were hemodynamic deterioration, preangiography creatine kinase-MB isoenzyme rise >2 × normal, and time interval between primary CABG and coronary angiography >30 hours. Five-year survival in patients without PMI (85.7 ± 0.5%) was significantly better than those with PMI and abnormal angiograms (74.9 ± 2.9%; P<0.001 log-rank). When in-hospital mortality was excluded, however, this difference in midterm survival disappeared (P=0.9). PMI is associated with increased in-hospital mortality in patients undergoing isolated CABG. Expeditious management of bypass graft failure results in similar midterm survival to nonischemic patients in hospital survivors.

Endothelial dysfunction versus early atherosclerosis: a study with high resolution imaging

Purpose: Endothelial dysfunction has been shown to be of prognostic significance in predicting major coronary events. Characterization of microstructural changes of the vessel wall in coronary segment with endothelial dysfunction may have potential prognostic importance for detection of ischemic heart disease (IHD). Methods: We studied 5 patients with IHD, found to have normal or near normal angiograms. These patients received graded doses of intracoronary acetylcholine (10-6, 10-5 and 10-4 mol/L over 3 minutes at 10 minutes intervals) to assess endothelial dysfunction. Epicardial endothelial dysfunction was defined as >30% epicardial vessel diameter reduction during testing. An intracoronary bolus dose of 1000 μg of nitroglycerin was administered to relieve vasoconstriction; IVUS was performed 10 minutes after relief of vasoconstriction and OCT 20 minutes later. The OCT imaging wire was positioned at the site, and 1 cm proximal and distal to of the observed coronary vasomotor abnormality. Each OCT image was analyzed by two independent observers who were blinded to the results. Using OCT imaging, the intima is identified by a signal-rich layer near to the lumen, the media by a signal-poor middle layer, and the adventitia by a signal-rich outer layer. Loss of layered architecture reflects early sign of atherosclerosis. Results: A total of 7 coronary segments showed vasoconstriction. Wall morphology was evaluated by IVUS. Subjects with normal smooth coronaries exhibited a thickness of the coronary wall<1mm. We obtained a total of 83 OCT images. There were 49 images of dysfunctional sites and 34 of the control segments. Of the 49 images of dysfunctional sites, 9 (19.4%) showed the usual layer structure of a normal artery (three-layer structure: intima, media and adventitia), and the remaining 40 (81.6%) showed early structural changes (single intimal thickened layer up to 380 micron). 16 of these 40 images revealed small signal-poor regions compatible with lipid deposits. Imaging of the control segments showed the usual three-layer structure in 5 (14.7%) images, small signal-poor regions in 14 (41.2%) images, and early structural changes in the remaining 15 (44.1%) images. Conclusions: Our findings indicate that endothelial dysfunction and early atherosclerosis, although related in many coronary segments, may exist separately. Functional alterations can be identified safely at a stage when atherosclerotic lesions are not detectable by any imaging technique. Acetylcholine testing may be useful in designing early effective interventions that restore endothelial function.

Zinc status in Cardiovascular patients in the north of Islamic Republic of Iran

Studies have demonstrated that zinc plays an important role in development of cardiovascular diseases in Western populations. But there is little data for other racial groups. This study was aimed to investigate the association between serum zinc and coronary artery disease (CAD) in Iranian subjects.This study was conducted on 81 subjects,which referred to Heshmat Hospital of Guilan province , Iran, for routine coronary angiography from June to August 2011. Subjects were assigned into 2 groups; 41 CAD patients.case and 40 healthy subjects in control group. Data about smoking habit,physical activity, dietary intake and anthropometric indices were collected by questionnaire. Serum zinc was measured by atomic spectroscopy.The serum zinc concentrations were significantly lower in case group than control ( p <0.05). The mean serum zinc concentration in the case and control group was 73.50±1.61μg/dl and 78.47±1.66μg/dl, respectively. subjects that lives in rural area had 7.11-fold higher CAD risk in compare to subjects lives in urban after adjustment for confounder factors,they also had lower zinc concentration than urban ( p <0.05). in our study With increasing in serum zinc concentration CAD risk decrease 0.94-fold.Zinc concentration had significant correlation with age (r= -0.23 p <0.05), weight (r=0.26 p <0.05) and Place for living (r= - 0.22 p = 0.04).There were no significant correlation between the dietary intake , Waist circumference ,smoking and serum zinc concentration in our study.Serum zinc concentration was significantly lower in the north of Islamic Republic of Iran patients with abnormal versus those with a normal angiogram. It seems Serum zinc concentration correlate with some risk factors for coronary artery disease

PWE-198 Outcomes for Patients undergoing Mesenteric Angiography for Acute Severe Gastrointestinal Bleeds in an Intensive Care unit of a Tertiary Hospital

IntroductionIn acute severe gastrointestinal bleeding, endoscopy has a failure rate of 10–30% in detecting active bleeders and achieving haemostasis. Further aggressive treatment may be necessary and mesenteric angiography has the...

Suspected coronary artery disease and myocardial infarction with normal coronary angiography: A heterogeneous but benign condition?

IntroductionPrevious follow-up studies of patients with symptoms and/or non-invasive tests suggestive of ischemia or an acute coronary syndrome and a normal coronary angiogram have reported a good prognosis. ObjectivesThe aim of this study was to evaluate the clinical characteristics and outcome of a cohort of patients with suspected ischemic heart disease and normal coronary arteries. MethodsA clinical follow-up was performed of 607 patients (mean age 62±11 years) with symptoms or non-invasive tests suggestive of ischemia (544) or myocardial infarction (63) and normal coronary angiography. The occurrence of major cardiac events or of readmission due to chest pain was recorded during a mean follow-up of 33.6±9.5 months after angiography. ResultsPatients with myocardial infarction were older (65.4±11.1 vs. 61.9±10.7, p=0.05), and the majority were women (68.3%). Hypertension was reported by 65.5% of patients, diabetes by 17.9%, dyslipidemia by 58.6%, smoking by 14% and family history of coronary artery disease in 11%. During follow-up no patient died from cardiovascular causes; three patients (0.5%) suffered myocardial infarction and 50 (8.3%) had recurrent chest pain leading to emergency admission. Patients with myocardial infarction had more events (20.6%) than those referred for angiography due to symptoms and/or positive non-invasive tests for ischemia (7.4%) (log-rank chi-square test: 13.6, p<0.0005). ConclusionThe incidence of risk factors was high. Our data suggest that patients with a normal angiogram had a good prognosis in spite of their baseline clinical presentation. A significant number of patients showed persistence of symptoms.

Suspected coronary artery disease and myocardial infarction with normal coronary angiography: A heterogeneous but benign condition?

IntroductionPrevious follow-up studies of patients with symptoms and/or non-invasive tests suggestive of ischemia or an acute coronary syndrome and a normal coronary angiogram have reported a good prognosis. ObjectivesThe aim of this study was to evaluate the clinical characteristics and outcome of a cohort of patients with suspected ischemic heart disease and normal coronary arteries. MethodsA clinical follow-up was performed of 607 patients (mean age 62±11 years) with symptoms or non-invasive tests suggestive of ischemia (544) or myocardial infarction (63) and normal coronary angiography. The occurrence of major cardiac events or of readmission due to chest pain was recorded during a mean follow-up of 33.6±9.5 months after angiography. ResultsPatients with myocardial infarction were older (65.4±11.1 vs. 61.9±10.7, p=0.05), and the majority were women (68.3%). Hypertension was reported by 65.5% of patients, diabetes by 17.9%, dyslipidemia by 58.6%, smoking by 14% and family history of coronary artery disease in 11%. During follow-up no patient died from cardiovascular causes; three patients (0.5%) suffered myocardial infarction and 50 (8.3%) had recurrent chest pain leading to emergency admission. Patients with myocardial infarction had more events (20.6%) than those referred for angiography due to symptoms and/or positive non-invasive tests for ischemia (7.4%) (log-rank chi-square test: 13.6, p<0.0005). ConclusionThe incidence of risk factors was high. Our data suggest that patients with a normal angiogram had a good prognosis in spite of their baseline clinical presentation. A significant number of patients showed persistence of symptoms.

The Human Myocardial Stain as Mitigated by Coronary Collaterals

If the human coronary artery tree were an end-arterial system, ie, one without interarterial anastomoses, as stated in 1881 by Cohnheim et al on the basis of canine studies,1 permanent total upstream occlusion of an epicardial branch would invariably result in the necrosis of the downstream myocardium. So far, data from less historical works have, however, indicated an absence of myocardial infarction in 50% of patients with chronic coronary artery occlusion.2 One of the concluding remarks of the study by Choi and coworkers3 published in the present issue of Circulation is that “most patients with chronic coronary artery occlusions show evidence of prior myocardial infarction.” Are we on the way back to Cohnheim’s paradigm? Maybe not, because Choi et al3 reassure the reader that it is the presence of coronary collaterals that mitigates the transmural extent of myocardial scar and regional wall-motion abnormalities (Figure 1). Figure 1. Chronic total occlusion of the proximal left anterior descending coronary artery (LAD; arrow ) with a normal left ventricular angiogram ( upper panels ). Contrast injection into the right coronary artery (RCA) of the same patient shows complete retrograde filling of the LAD via a branch collateral artery ( white arrow ) up to the proximal occlusion site ( lower panel ). Article see p 703 Moliere’s “imaginary invalid” ( Le Malade Imaginaire , 1673, a 3-act comedie-ballet) may challenge psychiatrists, but the gradual extinction of the “imaginary sane” by new “evidence,” that is, increasingly sensitive diagnostic tools, could pose similar problems. “Most” in the above-quoted sentence is equal to not quite the 100% as ordered by Cohnheim but rather to 86%, which could be reasonably translated to “most” only if the study accounted for all patients with chronic coronary artery occlusion. However, the “imaginary sane” with stained myocardium not admitted to a hospital because of well-being …

Rapid, sequential bilateral acute carotid blowout syndrome

This study aims to report the treatment and outcome of sequential bilateral acute carotid artery blowout syndrome. From 2004 to 2010, we treated seven male patients with sequential bilateral blowout syndrome long after irradiation treatment for head and neck cancer. After first common carotid artery (CCA)-internal carotid artery (ICA) rupture, six were treated with CCA-ICA occlusion and one with graft stenting. The contralateral ICAs were normal or stenotic on angiography in all patients. After the contralateral CCA-ICA rupture, five patients received CCA-ICA occlusion, one received graft stent treatment, and one received no treatment. Five of the seven patients died soon after the final treatment. Two patients developed cerebral infarctions (one treated with bilateral stenting, one treated with occlusion), one died from extensive local infection, one died soon after a third treatment, one died of progression of the disease, and one refused a second treatment and died soon after the diagnostic angiography. Two patients survived with follow-up periods of 1 and 5 years. In all seven patients, the contralateral CCA-ICA blowout occurred within 3 months after the first ICA occlusion. Bilateral ICA occlusion is an alternative management for sequential carotid artery blowout, but the mortality is high and outcome is poor. A normal angiogram cannot exclude the possibility of rapid development of a contralateral carotid artery blowout shortly after a first episode in patients who have received radiotherapy for head and neck cancer.

Does Vascular Injury Affect the Outcome of Open Tibial Fractures?

Consensus on the definition of a Gustilo grade IIIC injury was sought, and the influence of vascular injuries on outcome of severe open tibial fractures was investigated. Three thousand three hundred fifty-one plastic and orthopedic surgeons were sent questionnaires to determine their interpretation of Gustilo grade IIIC injuries. Notes of patients with severe open tibial injuries reconstructed at Frenchay orthoplastic center with free tissue transfer between 2006 and 2010 were reviewed. Data were collected on patient demographics and vascular integrity. Outcome was measured using the Enneking score. Four hundred seventy-six plastic surgeons and 2875 orthopedic surgeons were contacted. Seven hundred fifty-three responses (22.5 percent) were received; 46.2 percent thought a grade IIIC injury was a devascularized limb, 24.2 percent felt it was a one- or two-vessel injury, 6.9 percent thought it represented any vascular injury, and 22.7 percent had no definite answer. Sixty-eight patients (50 men and 18 women; mean age, 42.7 years) were identified. Fifty had normal angiograms and 18 sustained vascular injuries. Forty-two percent of vascular injuries were to the anterior tibial artery, 37 percent were to the posterior tibial, and 27 percent were to the peroneal. Mean follow-up was 11.2 months. Mean Enneking score for patients without and with vascular injury was 29.8 and 24.4, respectively (p = 0.004). Vascular injury independently influences long-term limb function. The authors suggest a modification to the current classification to improve communication among surgeons, and advocate the use of preoperative angiography before free soft-tissue reconstruction of severe open tibial fractures.

The serum pentraxin-3 is elevated in patients with cardiac syndrome X

Cardiac syndrome X (CSX) is a clinical entity that is defined as normal coronary arteries with angina pectoris and objective sins of ischemia. The correlation between CSX and inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) is well established, however an association with pentraxin-3 (PTX-3) has not been examined. The aim of this study was to investigate the association between PTX-3 and CSX. A total of 122 patients (58 female, 64 male, mean age 49.6±5.8 years) with suspected of coronary artery disease (CAD) were included in the study. Those with evidence of ischemia (50 patients with positive treadmill tests, 32 patients with positive myocardial perfusion scintography) underwent coronary angiography (82 patients). Patients with a normal angiogram were considered the CSX group (n=41) and patients with coronary lesions were referred to as the CAD group (n=41). Patients without signs of ischemia served as the control group. Serum PTX-3 and hs-CRP levels were measured in all patients. The CSX group had significantly increased PTX-3 levels relative to the control group (0.46±0.16 vs. 0.23±0.09 ng/ml, p<0.001). However there were no differences in levels of PTX-3 and hs-CRP between the CSX and the CAD groups (PTX-3: 0.46±0.16 vs. 0.51±0.13 ng/ml, p=0.21; hs-CRP: 1.04±0.45 vs. 1.16±0.64 mg/dl, p=0.62). The control group had significantly lower hs-CRP levels (0.73±0.51 mg/dl) when compared to the both CSX and CAD groups (p=0.03 and p=0.002, respectively). Serum PTX-3 levels were weakly correlated with hs-CRP levels (r=0.30, p=0.001). PTX-3, a novel inflammatory marker, is elevated in patients with CSX, similar to the well known inflammatory marker hs-CRP, and may be a promising biomarker reflecting inflammatory status in these patients.

Role of delayed contrast enhancement cardiovascular magnetic resonance at 3.0 Tesla in patients with chronic heart failure

Cardiovascular magnetic resonance (CMR) with delayed contrast enhancement (DCE) has been recently emerged as an easy-to-perform method for differentiation between normal and diseased myocardium. The aim of this study was to delineate the etiology of chronic heart failure (CHF) non-invasively using DCE-CMR at 3.0 Tesla. Thirty-four patients with CHF, left ventricular ejection fraction (LVEF) <40%, and no clear history or objective evidence of coronary artery disease (CAD) were evaluated by contrast-enhanced CMR (Philips Achiva 3.0 T) and conventional coronary angiography. Significant CAD was defined as >50% diameter stenosis of major epicardial coronary vessel. Fifteen patients showed subendocardial and/or transmural pattern of DCE (group A). Nineteen patients showed pattern of mid wall and/or subepicardial or no DCE (group B). Group A patients were older (52 ± 9 vs. 45 ± 10 years, p = 0.042), had higher prevalence of diabetes mellitus, hypertension and dyslipidemia, p = 0.001. LVEF was comparable in both groups. Coronary angiography showed significant CAD in 14/15 patients in group A. The other patient had coronary artery ectasia of the left anterior descending coronary artery. Normal angiogram was seen in 18/19 patients in group B. The other patient had 60% diameter stenosis of mid dominant right coronary artery. The sensitivity and specificity of DCE-CMR for detection of CAD were 93.3% and 94.7% respectively. The positive likelihood ratio was 17.74. Pattern of DCE-CMR at 3.0 Tesla may help delineation of etiology of CHF and makes clear distinction between ischemic and non-ischemic pathomorphology.

The Y factor in the cardiac syndrome X

What is interesting in a patient with chest pain and normal coronary arteries on the angiogram? Not much for the Y factor, especially as there is not much we can see, investigate, measure or treat. The publication by Vermeltfoort et al. in this issue is very reassuring [1]. The group in Tilburg in collaboration with the VU University Medical Center in Amsterdam did an excellent job in highlighting the recent data on the prognosis of patients with cardiac syndrome X. The term cardiac syndrome X was first used in 1973 to describe a condition that to this day still remains a bit of a mystery [2]. Defining cardiac syndrome X is difficult as there is still no real agreement on a definition. The diagnosis is generally made when angina-like chest pain, a positive response to stress testing and angiographically normal coronary arteries are present. Over the years, many theories have been discussed [3]. Syndrome X is currently accepted to be a heterogeneous clinical diagnosis which includes genetic, coronary microvascular, metabolic, hormonal and cardiovascular risk factors. Vermeltfoort et al. observed and reported in this Journal that there is no markedly increased mortality within 5 years after making the diagnosis, only 1.5 % [1]. Yet the average age of the population is around 55 years and in the largest study included in the analysis (Women’s Ischemia Syndrome Evaluation: WISE study, n = 318)) there was a 2.5 fold increase in mortality in cardiac syndrome X patients, compared with a control population [4]. Also the number of cardiovascular events reported is considered to be small in the meta analysis, but that is partly related to disregarding left ventricular dysfunction as a relevant endpoint. In the WISE cohort there was a tenfold increase in women admitted for cardiac failure compared with controls in 5 years. A significant increase in events has also been found in other studies, as reflected by the 5 % cardiovascular event rate reported in the meta analysis. What is very striking is the high rate of ongoing and recurrent symptoms in syndrome X patients. Apparently they are hard or impossible to treat and it seems difficult to make them symptom free. There is always room for improvement. It is crucial to know in how many patients ischaemia has been really proven prior to the coronary angiogram procedure. Was ischaemia detection only based on ECG changes, complaints or METS score during the stress test? This is even more relevant if the data from the WISE study are again used. Patients with cardiac syndrome X and exercise-induced, MRI-detected ischaemia had an event rate of 43 % within 3 years. Such a high event rate in a subgroup of patients would suggest that it should be feasible to identify a specific high-risk group. In this high-risk group, short-term pharmacological studies would be feasible to demonstrate efficacy. Another piece of information the authors could look into is the X-Y story. The variation in male and female patients goes from 0 % in some studies to 100 % in others. It is essential to also perform the analysis based on gender, as conflicting data exist with respect to cardiovascular outcome. There could be fundamental differences in diagnosis, treatment, prognosis and underlying mechanisms, especially in the light of the interesting paradox in female patients who have a higher frequency of normal angiogram, less extensive coronary artery disease, higher prevalence of angina and worse clinical outcome [5]. Should we redefine the cardiac syndrome X? There are two options on how to proceed in this patient group. If the coronary angiogram is normal, without any sign of coronary disease and in absence of calcifications, it would be of interest to perform an invasive coronary flow reserve (CFR) measurement to rule out microvascular disease. An alternative strategy could be to perform more profound ischaemia detection through magnetic resonance imaging perfusion or positron emission tomography perfusion with CFR added following the coronary angiogram to show subendocardial hypoperfusion. The distinction between microvascular disease and lack of disease can be assessed with these diagnostic modalities. Subsequently, the concrete diagnosis should be translated into adequate treatment where several drugs can be considered that improve endothelial function [6]. The extra step in the diagnostic approach is mandatory to reduce symptoms and improve prognosis to match the prognosis of the ‘healthy’ population, as was measured in the WISE study where only female patients were included. Therefore, the proposed larger prospective study by Vermeltfoort seems a logical step in unravelling the Y of the syndrome X mystery.

Insulin resistance predicts progression of de novo atherosclerotic plaques in patients with coronary heart disease: a one-year follow-up study

BackgroundThe aim of our study was to explore and evaluate the relationship between insulin resistance and progression of coronary atherosclerotic plaques. With the great burden coronary heart disease is imposing on individuals, healthcare professionals have already embarked on determining its potential modifiable risk factors in the light of preventive medicine. Insulin resistance has been generally recognized as a novel risk factor based on epidemiological studies; however, few researches have focused on its effect on coronary atherosclerotic plaque progression.MethodsFrom June 7, 2007 to December 30, 2011, 366 patients received their index coronary angiogram and were subsequently found to have coronary atherosclerotic plaques or normal angiograms were consecutively enrolled in the study by the department of cardiology at the Ruijin Hospital, which is affiliated to the Shanghai Jiaotong University School of Medicine. All patients had follow-up angiograms after the 1-year period for evaluating the progression of the coronary lesions. The modified Gensini score was adopted for assessing coronary lesions while the HOMA-IR method was utilized for determining the state of their insulin resistance. Baseline characteristics and laboratory test results were described and the binomial regression analysis was conducted to investigate the relationship between insulin resistance and coronary atherosclerotic plaque progression.ResultsIndex and follow-up Gensini scores were similar between the higher insulin lower insulin resistant groups (9.09 ± 14.33 vs 9.44 ± 12.88, p = 0.813 and 17.21 ± 18.46 vs 14.09 ± 14.18, p =0.358). However the Gensini score assessing coronary lesion progression between both visits was significantly elevated in the higher insulin resistant group (8.13 ± 11.83 versus 4.65 ± 7.58, p = 0.019). Multivariate logistic binomial regression analysis revealed that insulin resistance (HOMA-IR > 3.4583) was an independent predictor for coronary arterial plaque progression (OR = 4.969, p = 0.011). We also divided all the participants into a diabetic (n = 136) and a non-diabetic group (n = 230), and HOMA-IR remained an independent predictor for atherosclerosis plaque progression.ConclusionsInsulin resistance is an independent predictor of atherosclerosis plaque progression in patients with coronary heart disease in both the diabetic and non-diabetic population.

Elevated HDL is the main negative risk factor for coronary artery disease in the elderly patient with calcific aortic valve disease

In spite of high prevalences of hypertension and hypercholesterolemia, the majority of elderly patients admitted for aortic valve surgery due to calcific aortic valve disease (CAVD) do not have significant coronary artery disease (CAD). ObjectiveTo evaluate the lipid profile (LP) of patients undergoing surgery for CAVD and to correlate this with coronary angiographic data and prior cardiovascular risk factor profile. MethodsThis was a prospective observational cohort study of 264 consecutive patients aged >59 years (mean 72), 126 men (48%) and 138 women (52%). According to the angiographic presence (irregularities, moderate or significant lesions) or absence (normal angiogram) of significant CAD respectively, patients were divided into two groups: A (n=127, 48%) and B (n=137, 52%). A mean of 3.5 classical risk factors were identified in men and 2.6 in women. LP (obtained on admission, in the fasting state) included total cholesterol (TC), HDL, triglycerides (TG), LDL, and lipoprotein(a). ResultsWith the exception of male gender, diabetes and HDL, the other factors studied – smoking, hypertension, TC, TG, LDL (in both statin-treated and non-statin-treated patients) and lipoprotein(a) – did not show significant differences between groups A and B; LDL was 116±40mg/dl in group A vs. 123±38mg/dl in group B, in non-statin-treated patients; significant CAD was identified in 64% of men vs. 26% of women (p<0.001); 43% of group A had diabetes vs. 27% of group B (p<0.01); HDL was 49±14mg/dl in group A vs. 59±16mg/dl in group B (p<0.001); HDL in group A was 49±14mg/dl in men vs. 49±13mg/dl in women (NS) and 45±13mg/dl in diabetic patients vs. 52±14mg/dl in non-diabetics (p<0.02); HDL in group B diabetic patients was 54±17mg/dl in men vs. 56±18mg/dl in women (NS), and HDL in group B non-diabetic patients was 55±13mg/dl in men vs. 63±17mg/dl in women (p<0.02). Multivariate analysis showed that only low HDL and diabetes (in women) were independent risk factors for significant CAD. The effect of male gender as a risk factor appears to be exerted mainly through lower HDL levels. ConclusionsElevated HDL is the main negative risk factor for significant CAD in elderly high-risk but mildly dyslipidemic CAVD patients. HDL does not appear to have any protective effect in the pathophysiology of CAVD. In terms of long-term intervention, primary prevention of significant CAD should in the future be hybrid, focusing mainly on improving HDL function, but also on lowering LDL.

Um valor elevado de HDL é o principal fator protetor contra a doença coronária no idoso com doença fibrocalcificante valvular aórtica

In spite of high prevalences of hypertension and hypercholesterolemia, the majority of elderly patients admitted for aortic valve surgery due to calcific aortic valve disease (CAVD) do not have significant coronary artery disease (CAD). ObjectiveTo evaluate the lipid profile (LP) of patients undergoing surgery for CAVD and to correlate this with coronary angiographic data and prior cardiovascular risk factor profile. MethodsThis was a prospective observational cohort study of 264 consecutive patients aged >59 years (mean 72), 126 men (48%) and 138 women (52%). According to the angiographic presence (irregularities, moderate or significant lesions) or absence (normal angiogram) of significant CAD respectively, patients were divided into two groups: A (n=127, 48%) and B (n=137, 52%). A mean of 3.5 classical risk factors were identified in men and 2.6 in women. LP (obtained on admission, in the fasting state) included total cholesterol (TC), HDL, triglycerides (TG), LDL, and lipoprotein(a). ResultsWith the exception of male gender, diabetes and HDL, the other factors studied – smoking, hypertension, TC, TG, LDL (in both statin-treated and non-statin-treated patients) and lipoprotein(a) – did not show significant differences between groups A and B; LDL was 116±40mg/dl in group A vs. 123±38mg/dl in group B, in non-statin-treated patients; significant CAD was identified in 64% of men vs. 26% of women (p<0.001); 43% of group A had diabetes vs. 27% of group B (p<0.01); HDL was 49±14mg/dl in group A vs. 59±16mg/dl in group B (p<0.001); HDL in group A was 49±14mg/dl in men vs. 49±13mg/dl in women (NS) and 45±13mg/dl in diabetic patients vs. 52±14mg/dl in non-diabetics (p<0.02); HDL in group B diabetic patients was 54±17mg/dl in men vs. 56±18mg/dl in women (NS), and HDL in group B non-diabetic patients was 55±13mg/dl in men vs. 63±17mg/dl in women (p<0.02). Multivariate analysis showed that only low HDL and diabetes (in women) were independent risk factors for significant CAD. The effect of male gender as a risk factor appears to be exerted mainly through lower HDL levels. ConclusionsElevated HDL is the main negative risk factor for significant CAD in elderly high-risk but mildly dyslipidemic CAVD patients. HDL does not appear to have any protective effect in the pathophysiology of CAVD. In terms of long-term intervention, primary prevention of significant CAD should in the future be hybrid, focusing mainly on improving HDL function, but also on lowering LDL.

Nonoperative Management of Penetrating Kidney Injuries: A Prospective Audit

The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we review the management and outcome of penetrating kidney injuries at a center with a high incidence of penetrating trauma. Data from all patients presenting with hematuria and/or kidney injury discovered on imaging or at surgery admitted to the trauma center at Groote Schuur Hospital in Cape Town, South Africa during a 19-month period (January 2007 to July 2008) were prospectively collected and reviewed. These data were analyzed for demographics, injury mechanism, perioperative management, nephrectomy rate and nonoperative success. Patients presenting with hematuria and with an acute abdomen underwent a single shot excretory urogram. Those presenting with hematuria without an indication for laparotomy underwent computerized tomography with contrast material. A total of 92 patients presented with hematuria following penetrating abdominal trauma. There were 75 (80.4%) proven renal injuries. Of the patients 84 were men and the median age was 26 years (range 14 to 51). There were 50 stab wounds and 42 gunshot renal injuries. Imaging modalities included computerized tomography in 60 cases and single shot excretory urography in 18. There were 9 patients brought directly to the operating room without further imaging. A total of 47 patients with 49 proven renal injuries were treated nonoperatively. In this group 4 patients presented with delayed hematuria, of whom 1 had a normal angiogram and 3 underwent successful angioembolization of arteriovenous fistula (2) and false aneurysm (1). All nonoperatively managed renal injuries were successfully treated without surgery. There were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2) and shattered kidney (3). Post-nephrectomy complications included 1 infected renal bed hematoma requiring percutaneous drainage. Of the injuries found at laparotomy 12 were not explored, 2 were drained and 5 were treated with renorrhaphy. Penetrating trauma is associated with a high nephrectomy rate (24.3%). However, a high nonoperative success rate (100%) is achievable with minimal morbidity (9%).

The effects of significant coronary stenosis and percutaneous coronary intervention on aortic stiffness

Although aortic stiffness (AS) is a strong predictor of cardiovascular events, its value is unknown in patients who have coronary stenosis and undergo percutaneous coronary intervention (PCI). Our hypothesis was that AS might provide additional information about coronary hemodynamic status. In this context, we investigated the effects of coronary stenosis and PCI on AS. The study included 107 patients undergoing coronary angiography. The patients were divided into three groups based on the angiographic results: 39 patients with significant lesions (≥50%) formed the 'critical group' and 38 patients with nonsignificant lesions (<50%) formed the 'noncritical group'. The control group (30 patients) had normal angiograms. Aortic stiffness was determined using the carotid-femoral aortic pulse wave velocity (PWV) method. All patients in the critical group underwent successful PCI and repeat PWV measurements. All baseline characteristics were similar in the three groups except for the mean PWV, which was significantly higher (9.4±2.2 m/sec) in the critical group compared to the control group (5.7±1.1 m/sec) and the noncritical group (5.8±1.1 m/sec) (p<0.0001). The latter two groups had similar PWV values (p=0.6). After PCI, the mean PWV decreased significantly by 24.4% to 7.1±2.0 m/sec (p=0.002); however, it was still significantly higher than that of the control group (p<0.0001). In correlation analysis, PWV showed significant correlations with age (r=0.412, p=0.01), systolic blood pressure (r=0.342, p<0.01), and hemoglobin (r=-0.370, p=0.02). Multiple logistic regression analysis showed that PWV was a predictor for significant stenosis [Exp(B) 3.960, 95% CI 2.014-7.786]. Our findings suggest that significant coronary stenosis is associated with significantly increased AS and successful PCI improves AS to some extent.

Pure coronary ectasia differs from atherosclerosis: Morphological and risk factors analysis

Coronary artery ectasia (CAE) is defined as localized coronary dilatation that exceeds the diameter of the normal adjacent segments or the diameter of the patients' largest coronary artery by 1.5 times [ [1] Syed M. Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis. 1997; 40: 77-84 Google Scholar ]. The prevalence of the disease varies between 1.5 and 5% with an occurrence rate of 10% among Indians, and with male predominance [ 2 Giannoglou G.D. Antoniadis A.P. Chatzizisis Y.S. Damvopoulou E. Parcharidis G.E. Louridas G.E. Prevalence of ectasia in human coronary arteries in patients in northern Greece referred for coronary angiography. Am J Cardiol. 2006; 98: 314-318 Google Scholar , 3 Sharma S.N. Kaul U. Sharma S. et al. Coronary arteriographic profile in young and old Indian patients with ischaemic heart disease: a comparative study. Indian Heart J. 1990; 42: 365-369 Google Scholar ]. Such variation in disease prevalence is related to other associated conditions e.g. Kawasaki disease [ [4] Newburger J.W. Burns J.C. Kawasaki disease. Vasc Med. 1999; 4: 187-202 Google Scholar ] and connective tissue disorders, e.g. particularly polyarteritis nodosa [ [5] Pick R.A. Glover M.U. Vieweg W.V. Myocardial infarction in a young woman with isolated coronary arteritis. Chest. 1982; 82: 378-380 Google Scholar ] and Takayasu arteritis [ [6] Suzuki H. Daida H. Tanaka M. et al. Giant aneurysm of the left main coronary artery in Takayasu aortitis. Heart. 1999; 81: 214-217 Google Scholar ]. Despite the documented etiological role of atherosclerois [ [7] Antoniadis A.P. Chatzizisis Y.S. Giannoglou G.D. Pathogenetic mechanisms of coronary ectasia. Int J Cardiol. 2008; 130: 335-343 Google Scholar ], it fails to explain the paradoxically low prevalence of CAE among diabetics [ [8] Androulakis A.E. Andrikopoulos G.K. Kartalis A.N. et al. Relation of coronary artery ectasia to diabetes mellitus. Am J Cardiol. 2004; 93: 1165-1167 Google Scholar ], the anatomical predominance of the right coronary artery (RCA) [ [9] Farto e Abreu P. Mesquita A. Silva J.A. Seabra-Gomes R. Coronary artery ectasia: clinical and angiographic characteristics and prognosis. Rev Port Cardiol. 1993; 12: 305-310 Google Scholar ], the histological loss of the musculo-elastic component of the arterial wall [ [10] Markis J.E. Joffe C.D. Cohn P.F. Feen D.J. Herman M.V. Gorlin R. Clinical significance of coronary arterial ectasia. Am J Cardiol. 1976; 37: 217-222 Google Scholar ] and the potential genetic polymorphisms found in the promoter regions of MMP-2, MMP-3, MMP-9 and MMP-12 [ [11] Lamblin N. Bauters C. Hermant X. Lablanche J.M. Helbecque N. Amouyel P. Polymorphisms in the promoter regions of MMP-2, MMP-3, MMP-9 and MMP-12 genes as determinants of aneurysmal coronary artery disease. J Am Coll Cardiol. 2002; 40: 43-48 Google Scholar ]. We hypothesized that CAE has different nature from that of atherosclerotic coronary artery disease (CAD). We therefore examined consecutive coronary angiograms performed at the Umeå Heart Centre, Sweden and Letterkenny General Hospital, Ireland, between 2003 and 2009, with the objective of identifying all patients diagnosed as having CAE (Fig. 1), described the exact angiographic findings and analyzed the cardiovascular risk factors. Patients were classified as having pure or mixed lesions according to the following criteria. Pure CAE (Fig. 2A and C) when there was no evidence for atherosclerosis and mixed CAE (Fig. 2B and D) when, in addition to the dilated segments, there was classical evidence for atherosclerotic changes (plaque formation or minor atheromata ≤10% of lumen narrowing). We also recorded the anatomical sites of ectatic arteries and any ectatic lesion exceeding 20 mm in length. Patients with evidence for prior coronary intervention or other cardiac conditions were excluded. Clinical and angiographic variables of patients with CAE were later compared with 37 age-matched controls (65±8 years, 13 male) who were found to have normal angiograms. Conventional statistics including unpaired Student t test, chi-square test, univariate and multiple logistic regression analyses were used with p<0.05 as significance. Fig. 2Image showing the quantitative angiographic diferences between Pure (A, C) and mixed CAE (B, D). View Large Image Figure Viewer Download Hi-res image