Normal Coronaries Research Articles

Epicardial Fat Volume Assessed by Multi-Detector Computed Tomography and it’s Relation with the Severity of Coronary Artery Disease

Abstract Background Recent studies have suggested that fat disposition in epicardial tissue may be a predictor of the severity of coronary artery disease (CAD). Epicardial adipose tissue (EAT) is defined as the adipose tissue located between the outer wall of the myocardium and the visceral layer of pericardium, surrounding the heart and the coronary vessels. EAT is closely related to the adventitia of the coronary arteries without a barrier that may directly influence the development and progression of atherosclerosis and CAD through pro-inflammatory mediators. Objective The aim of the work is to investigate the relation between epicardial fat volume (EFV) [assessed by multidetector computed tomography (MDCT)] and severity of CAD. Methods This cross sectional study was conducted on 40 patients referred for MDCT coronary angiography to assess their complaint. EFV was quantified during non-contrast phase and severity of CAD was assessed by segment involvement score (SIS) and segment stenosis score (SSS) during contrast phase at Nasr City Police Hospital in the period between August 2018 and April 2019. Results The 40 consecutive subjects consisted of 30 males (75%) and 10 females (25%) with mean age 56 ±10.27 years. Risk factors of atherosclerosis were analyzed among the studied population as followed; the BMI ranged between 24 and 30.9 kg/m2, hypertensive patients were 77.5%, diabetic patients were 55% and smokers were 67.5%. The laboratory finding of the studied group revealed that the serum LDL.C ranged between 70 and 218 mg/dl (Mean±SD =163.88±43.37, Median= 183.5). The serum HDL.C ranged between 30 and 62 mg/dl (Mean±SD = 41.45±9.87, Median= 37). The serum total cholesterol ranged between 136 and 280 mg/dl (Mean±SD = 214.35± 35.51, Median= 224). The serum triglycerides ranged between 110 and 215 mg/dl (Mean±SD = 164.13±27.38, Median= 173).The serum creatinine ranged between 0.8 and 1.8 mg/dl (Mean±SD = 1.12±0.19, Median= 1.1). 17.5% of the studied patients had normal coronaries while 37.5% had single vessel disease and 45% had multi-vessel disease. There was a significant relationship between EFV and CAC score (p = 0.011, r = 0.397), a highly significant relationship between EFV and SSS score (p = 0.001, r = 0.518) and significant relationship between EFV & SIS score (P = 0.003, r = 0.459). Patients with normal coronary arteries were noted to have a lower EFV value than those with coronary lesions (highly significant relationship, p = 0.004) either single vessel disease or multi-vessel disease. There is no significant difference between the effects of EFV on number of diseased coronaries either single vessel disease or multi-vessel disease. Conclusion EFV increased in patients with both significant coronary artery stenosis or coronary calcification. EFV is considered an independent risk factor for CAD.

COMPARISON OF R WAVE AMPLITUDE CHANGES VERSUS ST-SEGMENT DEPRESSION IN STRESS TESTING ELECTROCARDIOGRAM AMONG ISCHEMIC HEART DISEASE PATIENTS

Background: R-wave changes might be helpful in accurate diagnosis of coronary artery disease with exercise testing in combination with ST segment changes as ∆RST index and might be superior to the traditional ST segment depression only. Objective: To further clarify R-wave amplitude (RWA) changes during exercise stress test (EST) among established IHD patients. Patients and methods: The study enrolled 50 subjects - aged from above 35 to below 65 years old of both sexes, known to be ischemic by a previous angiography, divided into two main groups: Group I (control group): 15 subjects with normal coronaries (lesion 70 % stenosis).The study was conducted at the Department of Cardiovascular Medicine and its Out-patient Clinic, Al-Hussein University Hospital during the period from September 2019 to March 2021. ∆RST index was formed from algebraic summation of RWA difference between (rest and immediate recovery) plus ST segment depression in mile meters. Results: ∆RST index was more useful in detection of coronary artery disease with higher sensitivity and specify among chronic ischemic patients than RWA difference or ST segment depression alone. When cutoff ≥ -1.65 cardiac ischemia could be predicted with a sensitivity rate of 98.93%, a specificity rate of 96.00%, a positive predictive value of 96.3 %, and a negative predictive value of 98%. RWA at a cut-off point of -1.2 was sensitive 95.02% and specific 94.0 % , a positive predictive value of 95.7%, and a negative predictive value of 96.6%. ST segment depression at a cut-off point of ≥ 0.45 was sensitive 77.1% and specific 80%, a positive predictive value of 78.4%, and a negative predictive value of 60.3%. Conclusion: ∆RST index was more useful in detection of coronary artery disease with higher sensitivity and specify among chronic ischemic patients than RWA difference or ST segment depression alone.

Prospective analysis of risk factors and angiographic profile in women with coronary artery disease –A hospital based study

Background: In order to facilitate diagnosis and timely intervention, it is essential to understand the presentation pattern of cardiac symptoms, and distribution of risk factors in women with Coronary Artery Disease (CAD). However, limited data is available regarding the salient features of CAD in women like distribution of risk factors and anatomical extent. Aims and Objective: The purpose of the present study was to determine the clinical and risk factor profile of women admitted with CAD and to analyze their angiographic findings in relation to the clinical presentation and risk factors in a tertiary care referral center of eastern India. Materials and Methods: In this study we prospectively analysed risk factors and angiographic patterns of 140 consecutive female patients who underwent coronary angiography for suspected CAD over a period of 2 years. Results: CAD most commonly affected females of age group >60yrs with higher incidence among postmenopausal as compared to premenopausal women. Unstable angina was the commonest presentation among patients with normal coronaries as well as obstructive CAD.A substantial percentage of women presenting with anginal pain were angiographically normal. Hypertension was the most common associated risk factor followed by diabetes, elevated total cholesterol, high LDL & low HDL. Most common coronary angiography finding was single vessel disease. On analysis, diabetes mellitus, elevated cholesterol, elevated LDL & triglycerides were most commonly associated with triple vessel disease. Conclusion: The incidence of CAD in females increased with age. Single vessel disease was the commonest presentation with Left Anterior Descending Artery, the most frequently involved vessel.

Clinical profile of Kawasaki disease in children admitted at a tertiary care hospital of North India and their short-term follow-up.

Aim:The aim of this study was to evaluate presenting symptoms, clinical features, and laboratory tests for the diagnosis of Kawasaki disease (KD) in children and their short-term follow-up at a tertiary care hospital of North India from April 2017 to March 2020.Materials and Methods:A total of 31 children (23 boys and 8 girls) up to 10 years of age were included in this study. The diagnosis of KD was made as per the American Heart Association 2017 guidelines. Clinical features, laboratory parameters, and coronary involvement were compared between the complete and incomplete KD groups.Results:The incidence of complete versus incomplete KD was 19 (61.2%) versus 12 (38.7%) children, respectively. Change in extremities and oral mucosal changes were more encountered in the complete KD group as compared to the incomplete KD group (100% vs. 58.3%, P = 0.004, and 78.9% vs. 33.3%, P = 0.002, respectively). Coronary artery aneurysm was seen in 54% of the patients on echocardiography which was greater in the incomplete KD group (83.3%) as compared to the complete KD group (36.8%). The median time from the onset of symptoms to intravenous immunoglobulin infusion was <10 days in 84.2% of the patients with complete KD versus 41.7% with incomplete KD which was statistically significant. Fifty percent of the children with coronary ectasia and small aneurysm had normal coronaries at follow-up of 6 months.Conclusion:KD is probably underdiagnosed in most developing countries, like that of ours, and requires a high index of suspicion.

UNVEILING THE VILLAIN: AN INTRIGUING CASE OF DIAGNOSING BRUGADA SYNDROME

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Brugada syndrome is a rare condition that is associated with an increased risk of ventricular tachyarrhythmias and sudden cardiac death. The typical electrocardiographic features of Brugada syndrome are variable and are known to be revealed by several precipitants such as drugs, and febrile illnesses. The following case describes the incidental ECG findings of Brugada pattern in a patient who presented with dizziness, shortness of breath and recently diagnosed deep vein thrombosis in her left leg. CASE PRESENTATION: A 63-year-old female with a history of breast cancer on tamoxifen, and recently diagnosed deep vein thrombosis on rivaroxaban presented to the emergency department with shortness of breath. Chest x-ray revealed no radiographic abnormality. EKG was significant for coving ST segment elevations on V1 and V2 consistent with Brugada type 1. She underwent emergent left heart catheterization which revealed normal coronaries. CT chest with contrast demonstrated the presence of a right subsegmental pulmonary embolism. Echocardiography revealed a left ventricular EF of 70% and no valvular pathology. Her shortness of breath improved. She was counselled on risks, given a list of medications to avoid and advised to treat fevers. She declined to have genetic testing. DISCUSSION: The typical EKG features of Brugada syndrome are variable and are known to be revealed by several precipitants. The patient was not aware of any family history of Brugada syndrome. She stated that during her knee replacement surgeries, she had a witnessed vasovagal syncopal episode with no VF or VT reported on telemetry. CONCLUSIONS: This case highlights the presentation of Brugada syndrome in a patient precipitated by pulmonary embolism. It is recommended that such patients undergo genetic testing. Current recommendations are to place an ICD in those who survived cardiac arrest. Pharmacological treatment with quinidine is also an option. Treatment of asymptomatic patients is more complicated, and personalized risk-stratification is essential to providing the right management for these patients. REFERENCE #1: Antzelevitch C, Brugada P, Borggrefe M, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111:659–70 REFERENCE #2: Veltmann C, Schimpf R, Echternach C, et al. A prospective study on spontaneous fluctuations between diagnostic and non-diagnostic ECGs in Brugada syndrome: implications for correct phenotyping and risk stratification. Eur Heart J 2006;272544–52 REFERENCE #3: Lamelas P, Labadet C, Spernanzoni F, et al. Brugada electrocardiographic pattern induced by fever. World J Cardiol 2012;4:84–6 DISCLOSURES: No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by Jeff Courson, source=Web Response No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response

Association of Obesity and C-Reactive Protein with Coronary Artery Disease

Background: Obesity is now becoming a global epidemic. It is most of the times associated with hypertension, diabetes mellitus (DM), metabolic syndrome and dyslipidemia which are known risk factors for coronary artery disease (CAD). Coronary arteriosclerosis comprises a series of inflammatory responses at cellular and molecular level, whose reactions are stronger in obese patients. The objective of this study was to observe the association of obesity and raised inflammatory markers with CAD. Method: This cross-sectional study was carried out in the Department of Cardiology, Dhaka Medical College Hospital, Dhaka, Bangladesh, involving 668 patients of ischemic heart disease who underwent coronary angiography (CAG) from January 2017 to December 2017. Obesity was defined as body-mass index (BMI) ≥30.0 kg/m2. C-reactive protein (CRP) was measured as the inflammatory marker, and was considered as high if &gt;10 mg/L. CAD was classified on the basis of CAG findings: insignificant if stenosis is &lt;50% and significant if stenosis is ≥50%; and single-vessel, double-vessel, triple-vessel disease and normal coronaries according to number of vessels involved. Chi square test was used to analyze the categorical variables, and Pearson’s correlation coefficient was used to test the relationship between CRP and BMI in CAD patients. p values of &lt;0.05 were considered as statistically significant. Results: Demographic characteristics like age, sex and educational status did not differ significantly between obese and non-obese patients. Risk factors for CAD were similar between obese and non-obese, as well as, between high-CRP (&gt;10 mg/L) and non-high CRP (≤10 mg/L) groups, however, DM, hypertension and dyslipidaemia were significantly more common in obese and high-CRP groups than in non-obese and non-high CRP groups. Raised CRP was significantly more common in obese than in non-obese patients (56.9% vs. 47.9%, p=0.04). Significant positive correlation was found between CRP and BMI (r=0.228; p=0.001). Triple-vessel CAD was found significantly more commonly in obese group than in non-obese group (29.3% vs 24.4%, p=0.04), whereas normal coronaries were more common in nonobese than in obese counterpart. Obesity, high CRP (&gt;10 mg/L), DM, and high HbA1c (≥6.5%) were found significant predictors of severe CAD (p &lt;0.5) in multivariate logistic regression analysis. Conclusion: Obesity is associated with raised inflammatory marker in patients with CAD, and a significant positive association exists between obesity and inflammation and CAD. Future studies are needed to explore the impact of type of obesity and inflammation on CAD. Bangladesh Heart Journal 2021; 36(1): 9-16

STUDY OF RISK FACTORS,CLINICAL PROFILES AND ANGIOGRAPHIC PATTERNS IN PATIENTS OF CORONARY ARTERY DISEASE IN A TERTIARY CARE CENTRE IN KOLKATA

BACKGROUND:Coronary artery disease (CAD) is one of the most common causes of mortality and morbidity in both developed and developing countries. It is a leading cause of death in India, and its contribution to mortality is rising. Considering the increasing burden of coronary artery disease and its mortality and the usefulness of identifying risk factors, studying the clinical profile and angiographic pattern will help us intervene the disease at various levels which can help control the morbidity and mortality of coronary artery diease. MATERIALS AND METHOD: The present study was conducted in the Department of Cardiology,IPGMER &amp; SSKM Hospital,Kolkata during the period of January 2019 to December 2019.This is a hospital based observational prospective study with prospective data collection,where all patients of coronary artery disease who had undergone coronary angiography has been taken into consideration to find out the risk factors,clinical profiles and angiographic patterns in coronary artery disease patients in Kolkata. RESULTS: Maximum patients were present in the age group 51-60 years of age.Mean age is 56.7+11.6sd.Male patients were 70% and female patients were 30%.Most common symptom was chest pain,90% of patients had it during the time of presentation.The next frequent symptom was shortness of breath which was seen in 52% of patients. Most common risk factor was smoking which was seen in 58% of patients.Next frequent risk factor being hypertension seen in 43.5% of patients.Obesity was seen in 59.2% of patients.On coronary angiography,40% of patients had Single vessel CAD,27.3% had double vessel CAD,23.5% had Double vessel CAD,6.5% had Non-Significant CAD and 2.7% had Normal coronaries(recanalized epicardial coronaries).LAD was involved in 73.5% of patients,51.7 % had RCA involved,43.5 % had LCX involved and LMCA was involved in 1.7% of patients. CONCLUSION:Smoking and hypertension are the most common risk factors.Single vessel disease is the most common angiographic pattern.Risk factors should be addressed properly to decrease the morbidity and mortality of coronary artery disease

Correlation between Free Testosterone and Severity of Coronary Artery Disease in Young Adult Male Patients

Historically, High level of serum testosterone was thought to have deleterious effect on cardiovascular system. In the last few years, studies have suggested that low testosterone levels are associated with increase prevalence of risk factors for cardiovascular diseases. This study aimed to determine the relationship between free testosterone level and the angiographic severity of coronary artery disease in young adult male patients. This cross-sectional study was conducted at Department of Laboratory Medicine in collaboration with Department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU) and National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh from March, 2020 to February, 2021. Total 110 subjects from inpatient Department of Cardiology were enrolled, 60 were CAD patients and 50 were Normal Coronaries according to coronary angiography report. Serum level of free testosterone was significantly lower in CAD group than Normal coronaries (4.74±2.10 vs 9.36±3.69 pg/ml, p=0.001). There were significant negative correlation between free testosterone with Gensini score (r= -0.739, p=0.001). Low level of free testosterone was negatively correlated with CAD and its severity in young adult male.

Plasma catecholamine levels in the acute and subacute stages of takotsubo syndrome: Results from the Stockholm myocardial infarction with normal coronaries 2 study.

AimsIt is well‐accepted that takotsubo syndrome (TS) is characterized by a massive surge of plasma catecholamines despite lack of solid evidence. The objective of this study was to examine the hypothesis of a massive catecholamine elevation in TS by studying plasma‐free catecholamine metabolites in patients participating in the Stockholm myocardial infarction (MI) with normal coronaries 2 (SMINC‐2) study where TS constituted more than one third of the patients.Methods and resultsThe patients included in the SMINC‐2 study were classified, according to cardiac magnetic resonance (CMR) imaging findings (148 patients), which was performed at a median of 3 days after hospital admission. Plasma‐free catecholamine metabolites; metanephrine, normetanephrine, and methoxy‐tyramine were measured on day 2–4 after admission. Catecholamine metabolite levels were available in 125 patients. One hundred and ten (88%) of the 125 patients included in SMINC‐2 study, and 38 (86.4%) of the 44 patients with TS had completely normal plasma metanephrine and normetanephrine levels. All patients had normal plasma methoxy‐tyramine levels. Fourteen (11.2%) of the 125 patients included in SMINC‐2 study, and 5 (11.6%) of the 43 patients with TS had mild elevations (approximately 1.2 times the upper normal limits) of either plasma metanephrine or normetanephrine. One patient with pheochromocytoma‐triggered TS had marked elevation of plasma metanephrine and mild elevation of plasma normetanephrine. There were no significant differences between the number or degree of catecholamine metabolite elevations between the different groups of patients with CMR imaging diagnosis included in SMINC‐2 study.ConclusionThere was no evidence of massive catecholamine elevations in the acute and subacute stages of TS apart from one patient with pheochromocytoma‐induced TS. Most of the TS patients had normal catecholamine metabolites indicating that blood‐borne catecholamines do not play a direct role in the pathogenesis of TS.

Longitudinal Outcomes for Multisystem Inflammatory Syndrome in Children.

In spring 2020, a novel hyperinflammatory process associated with severe acute respiratory syndrome coronavirus 2 multisystem inflammatory syndrome in children (MIS-C) was described. The long-term impact remains unknown. We report longitudinal outcomes from a New York interdisciplinary follow-up program. All children <21 years of age, admitted to NewYork-Presbyterian with MIS-C in 2020, were included. Children were followed at 1 to 4 weeks, 1 to 4 months, and 4 to 9 months postdischarge. In total, 45 children were admitted with MIS-C. The median time to last follow-up was 5.8 months (interquartile range 1.3-6.7). Of those admitted, 76% required intensive care and 64% required vasopressors and/or inotropes. On admission, patients exhibited significant nonspecific inflammation, generalized lymphopenia, and thrombocytopenia. Soluble interleukin (IL) IL-2R, IL-6, IL-10, IL-17, IL-18, and C-X-C Motif Chemokine Ligand 9 were elevated. A total of 80% (n = 36) had at least mild and 44% (n = 20) had moderate-severe echocardiographic abnormalities including coronary abnormalities (9% had a z score of 2-2.5; 7% had a z score > 2.5). Whereas most inflammatory markers normalized by 1 to 4 weeks, 32% (n = 11 of 34) exhibited persistent lymphocytosis, with increased double-negative T cells in 96% of assessed patients (n = 23 of 24). By 1 to 4 weeks, only 18% (n = 7 of 39) had mild echocardiographic findings; all had normal coronaries. At 1 to 4 months, the proportion of double-negative T cells remained elevated in 92% (median 9%). At 4 to 9 months, only 1 child had persistent mild dysfunction. One had mild mitral and/or tricuspid regurgitation. Although the majority of children with MIS-C present critically ill, most inflammatory and cardiac manifestations in our cohort resolved rapidly.

Coronary Angiographic Characteristics of Type 2 DM Compared with Nondiabetic Patients in Benghazi-Libya. A Cross-Sectional Study

Background/Aim: The absolute risk of death due to coronary artery disease (CAD) is two to five times higher in patients with diabetes than in those without diabetes regardless of the cholesterol concentration, and females with diabetes have the worst prognosis. The aim of the current study was to investigate the angiographic severity and extent of CAD in patients with Type 2 diabetes mellitus, compared with nondiabetic patients. Patients and Methods: A hospital-based retrospective cross-sectional study was performed on 340 patients who were diagnosed with CAD. The two groups were matched for age, gender, and other major risk factors. Data collected include demographic data, distribution, and extent of coronary artery involvement. Results: Three hundred and forty patients were included in the study, 175 of them (51.4%) were diabetics, and 165 (48.5%) were nondiabetics, comparing coronary angiographic results of both groups: One hundred and twenty-six patients (73%) of the diabetic patients have multivessel diseased (P = 0.003), 49 patients (27%) have a single-vessel diseased and none of them have a normal coronaries (0%). While for the nondiabetic patients 82 (50%) of them have a multivessel diseased, 63 patients (38%) have a single-vessel diseased, and 20 patients (12%) have normal coronaries. Conclusion: Multivessel disease with diffuse lesion is more prevalent among diabetic Libyan patients compared with nondiabetics. The affected vessels in diabetic patients are diffusely diseased more than nondiabetic.

ASSOCIATION OF HYPERURICEMIA WITH THE PRESENCE AND SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS UNDERGOING CORONARY ANGIOGRAPHY

Objectives: To determine the association of hyperuricemia with the presence and severity of coronary artery disease in patients undergoing coronary angiography.&#x0D; Methodology: This case control study was carried out in the Department of Cardiology, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan for six months. Total number of 292 patients (146 cases with coronary artery disease and 146 controls with normal coronary arteries) having age 40-60 years of both genders were included in this study. Coronary angiography was performed using standard angiographic techniques. After undergoing coronary angiography, patients with 50% luminal stenosis or more in any one of the coronary arteries were labeled case group. Patients with normal coronaries or less than 50% luminal stenosis in any one of the coronary vessels were taken as control group. Serum uric acid was advised and value was noted along with the basic demographic data and established risk factors of coronary artery disease.&#x0D; Results: Mean age was 50.79±6.08 years. Mean serum uric acid was 7.54±3.60 mg/dl. Hyperuricemia was diagnosed in 94 (64.40%) patients with significant CAD (case group) and in only 59 (40.40%) in control group. The odds ratio was 2.66 (95% CI 1.66 to 7.28) with p-value of &lt;0.001. Triple vessel disease was diagnosed in 66.7% patients with hyperuricemia and in only 33.3% patients without hyperuricemia [OR 4.0 (2.09-7.64), p-value &lt;0.001].&#x0D; Conclusion: There is a significant association between the presence and severity of coronary artery disease with hyperuricemia.

Microvascular Angina : A Diagnosis Hidden in Plain Sight

Background: Patients who are initially suspected of having ischemic heart disease, but in whom normal coronaries are discovered at angiography, are frequently believed to have pain of a non-cardiac aetiology. Micro vascular angina is hardly ever diagnosed save in peri-menopausal women. Physicians traditionally tend to view coronary microvascular disease and obstructive coronary artery disease as two separate entities. Notwithstanding, recent studies have begun to focus on endothelial dysfunction as being a key component in all cardiovascular diseases, with or without obstructive coronary lesions. Hypothesis: Patients suspected of having obstructive coronary disease associated with a significant risk factor burden, but in whom normal coronaries are found at angiography, in reality possess microvascular dysfunction. Objectives: • To determine the prevalence of normal coronaries at elective angiography compared to subjects with significant obstructive lesions. • To examine the influence of risk factor burden in patients who present normal coronaries in comparison with those who demonstrate obstructive lesions at angiography. • To suggest endothelial dysfunction as the common nexus underlying the disparities in cardiovascular morbidity observed among population samples. Methods: A group of 90 patients were randomly selected from clinical files of those who underwent elective coronary angiography between January, 2013 and May, 2017. The study cohort was comprised of 55 males and 35 females between the ages of 43 to 84 years. All subjects presented chest pain suspected of being coronary in origin. Coronary risk factors were recorded for each patient and the results were compared with findings at coronary angiography and then correlated with those encountered in medical literature. Results: Normal coronary angiograms were more prevalent in the African-Caribbean population (54.16%), than within the Mestizo-Mayan population (37.5%) Conversely, the finding of an obstructive lesion was more common in the Mestizo-Mayan population (56.25%), than within the African-Caribbean group (31.25%). The African-Caribbean group generally possessed a greater risk factor burden than their Mestizo-Mayan counterparts. Mayan counterparts. The percentage of women with normal coronaries (52.94%) showed a slight increase over that of men (47.05%). Males possessed a prevalence for obstructive disease of almost 4 times greater (79.48% vs. 20.5%) than females, yet females demonstrated a greater risk factor burden than males in most risk parameters. Hypertension was the most prevalent risk factor followed by dyslipidaemia and diabetes mellitus but these factors were more commonly encountered in patients with “normal” coronaries, than in those with obstructive lesions. Conclusion: Our study reported a significant number (56.66%) of “normal” coronaries at angiography. The majority (54.16%) of this figure pertained to the African-Caribbean sub-group, which in other studies also appeared to have a lesser coronary disease morbidity and mortality than their white counterparts despite having a greater risk factor burden. This is particularly true in the female African-Caribbean population. Several research papers have made reference to racial, ethnic and gender disparities in the manifestation of cardiovascular diseases. Paradoxically in some cases risk factor burden may be higher in the non-obstructive group rather than in the obstructive population. Convincing research has led us to believe that the vascular endothelium in its state of dysfunction plays a key role in explaining these disparities. Wherever cardiovascular risk factors exert their damage, endothelial injury and dysfunction ensues. Therefore, having an established risk factor burden portends microvascular dysfunction independently of any angiographic result.

Assessment of the relationship among breast milk intake, birth pattern, antibiotic use in infancy, and premature atherosclerosis.

Previous studies have shown cesarean section (C-section) and antibiotic use in the infantile period lead to chronic diseases in later life. It is also known that breastfeeding, which forms the basal system of immunity, is a protector in neonates. In this study, we aimed to investigate the association between breastfeeding, antibiotic use, C-section, and premature atherosclerosis. A total of 100 patients who underwent coronary angiography and had stenosis in at least 1 epicardial vessel and 100 controls with normal coronaries were included in the study. In addition to traditional risk factors, type of delivery, breast milk intake and duration, and antibiotic use and frequency were evaluated for each participant. Lipid profile was added to the study procedure. Angiographic images of the study groups were examined to calculate the Gensini score. Smoking, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and family history were different between the groups. In the control group, 3 were born via C-section, whereas 26 were born via C-section in the atherosclerosis group (p<0.001). Breast milk intake and duration was also significantly higher in the control group (p=0.018). Antibiotic use was less in the control group, but there was no statistically significant difference (p=0.099). In multivariate logistic regression analysis, diabetes mellitus, smoking, and C-section were predictors of atherosclerosis (p=0.036, p=0.001, and p=0.003, respectively). In receiver operating characteristics curve analysis, the ability of C-section to predict premature atherosclerosis was superior to diabetes but not to smoking (area under curve, 0.607; p=0.023). Mode of delivery and breast milk intake should be evaluated and considered among the risk factors of premature atherosclerosis.

Left ventricular mechanical dyssynchrony in patients with chest pain and normal epicardial coronary arteries

BackgroundTo detect ischemia in patients with angina and normal coronaries frequently represents a complex diagnosis. MethodsTo investigate whether left ventricular mechanical dyssynchrony by phase analysis contributes in the evaluation of patients with chest pain and normal coronaries, gated-SPECT myocardial perfusion imaging (MPI) at rest and 30 minutes post-stress was performed in 218 patients with normal epicardial coronaries, who were divided into two groups: those with summed difference score (SDS) ≥ 4 (54 patients, Group 1), and those with SDS < 4 (164 patients, Group 2). Intraventricular synchronism-phase standard deviation (PSD) and histogram bandwidth (HBW)—was evaluated by phase analysis. ResultsWomen were significantly more frequent in Group 2 (those without ischemia in SPECT MPI): 113 (69%) vs 25 (46%), P = .00001. In males, left ventricular ejection fraction (LVEF) and ventricular volumes were not significantly different between patients with or without ischemia. However, ischemic females showed significantly higher ventricular volumes, minor post-stress LVEF and more negative delta LVEF (− 3.9 vs 0.34, P = .0008) than the non-ischemic ones. There was a significant post-stress increase of PSD and HBW among males, although not among females. According to SSS (≥ 4, with ischemia/necrosis; < 4, without ischemia/necrosis), post-stress PSD and HBW significantly increase both in male and female, and PSD and HBW were significantly higher in females with SSS ≥ 4 compared to those with SSS < 4 (PSD rest: 19.04° vs 11.72°, P < .0001; HBW rest: 58.85° vs 38.21°, P < .0001). PSD and HBW were also higher among males with SSS ≥ 4 compared to those with SSS < 4, although not significantly. ConclusionHigher ventricular volumes in females and dyssynchrony are associated with inducible ischemia in MPI in patients with chest pain and normal coronaries. Stress-induced ischemia increases degree of dyssynchrony.

Angiographic profiles in patients of persistent non-valvular atrial fibrillation from a tertiary care center in north india

Abstract Funding Acknowledgements Type of funding sources: None. Background The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established. Atrial ischemia due to obstructive CAD has been identified as one of the key risk factors, leading to AF. However, sufficient evidence exists as to the presence of myocardial ischemia on stress imaging, even without the presence of obstructive CAD in AF patients. Slow flow and coronary tortuosity on angiogram can lead to downstream myocardial ischemia independent of CAD. Purpose We aimed to delineate the angiographic profiles in AF patients with attention to slow flow and tortuosity leading to ischemia in those without obstructive CAD. Methods The study was a nonrandomised, prospective, single-centre observational study of consecutive patients of persistent non valvular AF. Symptomatic patients despite optimal medical therapy (OMT) for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with known CAD or prior history of myocardial infarction were excluded. Further angiographic analysis was done in those without obstructive CAD to determine incidence of slow flow (&amp;gt;27 corrected TIMI frame count) and tortuosity (presence of ≥3 fixed bends in an epicardial artery). Results A total of 70 patients were recruited and followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49). Hypertension (74%) was the commonest comorbidity followed by obesity (35%) and diabetes (30%). At CAG, 32/70 (45%) had obstructive CAD, 17/70 (24%) had non obstructive (&amp;lt;50-70% stenosis) CAD and 21/70 (30%) had normal coronaries without atherosclerosis. Amongst patients without obstructive CAD (n = 38) slow flow was seen in 16/38 (42%) and coronary tortuosity in 11/38 (29%) patients. There ware no differences in terms of death, HF and FVR hospitalisations or stroke at follow up between the obstructive CAD vs no obstructive CAD. However in patients without obstructive CAD, hospitalisations for FVR was significantly increased in those having slow flow on CAG, 9/12 (75%) vs 7/26 (27%) in those without slow flow (p value = 0.005). The mean TIMI frame count was also significantly higher in those with FVR hospitalisations 35.3 ± 11 vs 25.8 ± 8.9 (p value = 0.005). TIMI frame count &amp;gt;31 had a sensitivity of 83% and a specificity of 69% for predicting hospitalisations for FVR on ROC curve(AUC = 0.71). Conclusions CAD is closely related to AF and majority (70%) of our patients had evidence of atherosclerotic CAD on CAG in our study. A large proportion of patients with no evidence of obstructive CAD on CAG had slow flow or coronary tortuosity. Significantly increased hospitalisation for FVR seen in the slow flow group shows its significance and may lead to newer treatment modalities in future. Further larger studies looking at these aspects on CAG may give further insight as to the nature and prognosis of these entities.

Graves’ Thyrotoxicosis and Fulminant Myopericarditis: A Clinical Dilemma!

Abstract Myocarditis is a rare presentation of Graves’ disease, fulminant myocarditis is even rarer. We report a woman with Graves’ disease with fulminant myopericarditis as the presenting clinical feature. A 23-year-old healthy woman presented with acute onset pleuritic chest pain, palpitations, diaphoresis, heat intolerance, and dyspnea. There was no history of fever, upper respiratory tract infection, diarrhea, or weight loss. Physical exam revealed sinus tachycardia and palpable non-tender thyroid. Blood work was pertinent for TSH &amp;lt;0.01uIU/ml(0.3-4.5), free T4 2.8ng/dl(0.6-1.5), free T3 &amp;gt; 32.6pg/ml (2.4-4.2) and positive TSI (thyroid-stimulating immunoglobulin) 12.4 IU/L (&amp;lt;0.54). She had a diffusely enlarged vascular thyroid on ultrasound, all findings consistent with hyperthyroidism due to Graves’ disease. Electrocardiogram showed sinus tachycardia with diffuse PR depression and ST-segment elevation, troponin was 0.85 which increased to 17.5 within 12 hours, an echocardiogram showed normal ejection fraction (EF) with mild pulmonary hypertension but no pericardial effusion. She improved symptomatically with beta-blockers, methimazole, and colchicine but unfortunately had a witnessed ventricular fibrillation cardiac arrest in the next 12 hours with return to spontaneous circulation achieved after 90 minutes of bystander cardiopulmonary resuscitation. Coronary angiogram revealed normal coronaries with post-cardiac arrest EF of 5%. She subsequently developed acute respiratory distress syndrome secondary to massive pulmonary hemorrhage requiring extracorporeal mechanical support for worsening cardiogenic shock, succumbing to her illness a few hours later. Graves’ disease affects 0.5% of the population and causes hyperthyroidism in 50-80% of cases. Thyrotoxicosis may be associated with supraventricular arrhythmias and cardiomyopathy due to long-standing untreated hyperdynamic heart failure, but myopericarditis is an unusual presentation of Graves’ thyrotoxicosis with fulminant myopericarditis being even rarer. Fulminant myocarditis can present with ventricular tachyarrhythmias and can rapidly deteriorate into shock which may be difficult to distinguish from other causes of cardiogenic shock such as acute coronary syndromes or stress-induced cardiomyopathy. Myopericarditis associated with Graves’ is thought to be due to autoimmunity against functional TSH receptors identified in human cardiomyocytes. Fulminant myocarditis is a common cause of sudden cardiac death in young healthy adults, which is also the same population that gets Graves’ disease. It is critical to recognize the unusual presenting features of Graves’ disease such as fulminant myopericarditis, as timely aggressive intervention can reduce the risk of sudden cardiac death.

Role of multimodality imaging in a case of heart failure with preserved ejection fraction

A man in his 80s with hypertension presented with progressive shortness of breath and pitting oedema of lower limbs from the last 6 months. He was admitted twice to an...

Pitfalls in comparison of coronary artery measurements of Indian population with different geographical area studies

IntroductionCoronary artery disease (CAD) is the most common cause of morbidity and mortality especially in the developing countries. Coronary artery measurements (CAM) are the most important factor affecting the procedure and outcome of coronary angioplasty (PCI) as well as coronary by-pass operations (CABG). In this study, we aimed to establish a database for the normal CAM as well as for gender difference among the Indian population using quantitative coronary angiography (QCA) with an objective of assessing normal coronary vessel morphology of patients with normal coronaries. Materials and methodsFour thousand angiograms from patients of Indian origin were studied prospectively after procuring the sanction for the same from the ethical committee of the pre-selected hospitals of four states in India. Informed consents were obtained. Post CABG, post PCI patients and patient being diabetic for ≥5 years were also excluded from the study. ResultsTen segments from right and left coronary arteries were taken for diameter measurements. These coronary diameters were indexed to body surface area (BSA) (mean diameter mm/m2 BSA). Among, 4000 patients, 933(23.3%) [M:F-521:412] had normal coronaries and 3067 (76.7%) were diseased. Discussion and conclusionThe dimensions of the coronary artery segments of Indians were smaller (in BSA indexed and non-indexed data), compared to studies from other continents which can be due to their smaller BSA.

Ischemia of Non-Obstructive Coronary Artery Disease: Need to Address in our Patient Population

Ischemia of non-occlusive coronary artery disease (INOCA) not an uncommon phenomenon, exist in our patient population which did not address well. Many of the stable angina and or unstable angina patient, whose coronary angiogram revealed significant coronary stenosis (&gt;70%) are being treated by PCI with drug eluting stent. On the contrary, quite a significant proportion of patient, who are found to have non-significant coronary lesion (&lt;50%) or essentially normal epicardial coronaries. These group of patients with angiographic evidence of non-occlusive CAD, remain undiagnosed of their exact etiology of angina. As a result, recurrence of anginal chest pain leading to repeat hospitalization impaired quality of life and the expenditure. Women are significant number in this category, labelled as syndrome X. Many of the scientific literature, has labeled it as Ischemia of Non obstructive Coronary artery Disease. Notably, Microvascular angina is due to ischemia driven mismatch of demand and supply in the myocardium. Microvascular Dysfunction (MVD) and Coronary vascular spasm or Vasospastic Angina (VSA) are the main pathogenic causes of INOCA. With the advent of Imaging physiology, and its availability in Bangladesh, many of the center can assess INOCA and its severity by FFR, iFR, DFR and transthoracic Doppler study of the coronaries. Therefore, we recommend evaluating INOCA patient by available technical assistance and to address the issue and patients suffering with repeated hospitalization and financial expenditure.&#x0D; Cardiovasc. j. 2021; 13(2): 217-222