Obstructive Coronary Atherosclerosis Research Articles

Ten-year mortality after treating obstructive coronary atherosclerosis with contemporary stents in patients with or without concomitant peripheral arterial disease

Background and aimsPrevious studies in percutaneous coronary intervention (PCI) patients showed a higher 3-year adverse event risk, including all-cause mortality, in those with concomitant peripheral arterial disease (PADs). Ten-year data of mortality and causes of death are scarce. This analysis assessed PCI patients, treated with contemporary drug-eluting stents, the impact of concomitant PADs on very long-term mortality, and causes of death. MethodsWe assessed PCI all-comers from our center who participated in the TWENTE and DUTCH PEERS trials (clinicaltrials.gov:NCT01066650, NCT01331707), comparing patients with versus without PADs. Life status was checked in the Dutch Personal Records Database; causes of death were obtained from medical records. ResultsOf 2705 study patients, 668 (24.7%) died during follow-up: 88/212 (41.5%) patients with PADs and 580/2493 (23.1%) without PADs. In PADs patients, the 10-year rate of all-cause mortality was about twice as high as in patients without PADs (41.5% vs.23.1%, HR: 2.05, 95%-CI: 1.64–2.57, p<0.001). For both groups, the rates of patients dying from various causes of death were: cardiac (14.1% vs.6.8%), vascular (2.8% vs. 1.1%), non-cardiovascular (17.4% vs. 9.8%), and unclear causes (7.1% vs. 5.3%), without a statistically significant between-group difference. When multivariate analysis was adjusted for between-group differences in cardiovascular risk profile, PADs remained predictor of all-cause mortality (adjusted HR: 1.38, 95%-CI: 1.08–1.75, p=0.01). ConclusionsThe 10-year all-cause mortality rate in PCI patients with concomitant PADs was almost twice as high as in those without PADs. Age and other traditional cardiovascular risk factors were higher in patients with PADs, but after correction for these confounders PADs still accounted for almost 40% increase in mortality.

Cerebral Embolism and MINOCA Secondary to Left Atrial Myxoma after Occlusion of Atrial Septal Defect by Amplatzer Occluder: A Case Report.

Primary heart tumors are rare, with atrial myxomas being the most common type. Atrial myxomas can lead to embolisms, heart obstruction, and systemic symptoms. Herein, we report a case of 72-year-old woman who presented with a left atrial myxoma at the atrial septal defect occluder, a new acute cerebral infarction, and MINOCA (myocardial infarction with no obstructive coronary atherosclerosis). Left atrial myxoma is a common primary cardiac tumor; however, left atrial myxomas arising after percutaneous atrial septal defect occlusion are rare. Additionally, the patient presented with a new case of multiple systemic emboli. The patient underwent surgical resection of a left atrial myxoma, occluder, and left atrium, and atrial septal repair, and was discharged with good recovery for outpatient follow-up. The possibility of a cardiac tumor, especially an atrial myxoma, which can lead to a series of complications, should be considered at the closure site after percutaneous atrial septal closure. Therefore, active surgical treatment and long-term follow-up are warranted in such cases.

Инфаркт миокарда у молодых женщин

The low alertness of physicians and women due to the rare incidence of myocardial infarction in young women, often atypical clinical presentation, and frequent lack of obstructive coronary artery disease accounts for the issue of timely diagnosis. According to Russian researchers, the incidence of acute myocardial infarction in women aged 35–44 years in Russia in 2014 was 0.2%. Foreign studies have shown that slightly over half of young women with ST-elevation myocardial infarction experience typical chest pain. Our case reports highlight the challenges in diagnosing myocardial infarction in young women, and the impact of both gender-related and non-gender-related risk factors Although there is no obstructive coronary atherosclerosis, myocardial infarction in young women can have a severe course and lead to complications such as cardiac aneurysms and chronic heart failure KEYWORDS: myocardial infarction, young women, spontaneous coronary artery dissection FOR CITATION: Khar'kov E.I., Tsibul'skaya N.Yu., Ryabkov E.I., Karaev E.B. Myocardial infarction in young women. Russian Medical Inquiry. 2024;8(1):37–41 (in Russ.). DOI: 10.32364/2587-6821-2024-8-1-6.

Follow-Up of Post Myocardial Infarction Using Telemedicine: Stakeholders’ Education, Results and Customer Satisfaction

Background. There are few studies about post myocardial infarction follow-up using telemedicine. We organized a post-discharge telemedicine service with a dedicated team. To do this, it was necessary that all stakeholders involved in the organization and use of the telemedicine service were properly educated and informed. Methods. We designed a theoretical–practical mini-course to train healthcare personnel and increase skills, with excellent learning outcomes and satisfaction. Thereafter, we enrolled patients affected by acute myocardial infarction with ST elevation (STEMI), MINOCA (myocardial infarction with no obstructive coronary atherosclerosis), Takotsubo syndrome or spontaneous coronary dissection, and high-risk acute myocardial infarction without ST elevation (NSTEMI). At discharge, the cardiology technician performed counselling for the patient, using regional platforms, such as televisit, at 1 and 4 months, allowed us to monitor major adverse cardiac events (MACE), heart failure, arrhythmias, unstable angina and non-cardiovascular events, therapy adherence, target therapy and customer satisfaction. Results. Between November 2021 and February 2023, we enrolled 110 patients: 72% affected by STEMI, 22% by NSTEMI. At the 1-month follow up, 12 patients did not reach the pressure target and 23 patients did not reach the LDL target. We observed three patients requiring hospital readmission, three requiring hospital visits for further investigation, and one death. To date, a four month follow up was performed for 54 patients. No readmissions or deaths occurred. We detected a rate of 96% of customer satisfaction. Conclusions. A health coordination center with a dedicated team makes televisit safe as a follow-up for post-myocardial infarction patients. Beforehand, it is fundamental for healthcare professionals to acquire theoretical knowledge and updates, and the acquisition of manual, technical and practical skills.

Single-Cell RNA Sequencing of Coronary Perivascular Adipose Tissue From End-Stage Heart Failure Patients Identifies SPP1+ Macrophage Subpopulation as a Target for Alleviating Fibrosis.

Perivascular adipose tissue (PVAT) is vital for vascular homeostasis, and PVAT dysfunction is associated with increased atherosclerotic plaque burden. But the mechanisms underlining coronary PVAT dysfunction in coronary atherosclerosis remain elusive. We performed single-cell RNA sequencing of the stromal vascular fraction of coronary PVAT from 3 groups of heart transplant recipients with end-stage heart failure, including 3 patients with nonobstructive coronary atherosclerosis, 3 patients with obstructive coronary artery atherosclerosis, and 4 nonatherosclerosis control subjects. Bioinformatics was used to annotate the cellular populations, depict the cellular developmental trajectories and interactions, and explore the differences among 3 groups of coronary PVAT at the cellular and molecular levels. Pathological staining, quantitative real-time polymerase chain reaction, and in vitro studies were performed to validate the key findings. Ten cell types were identified among 67 936 cells from human coronary PVAT. Several cellular subpopulations, including SPP1+ (secreted phosphoprotein 1) macrophages and profibrotic fibroadipogenic progenitor cells, were accumulated in PVAT surrounding atherosclerotic coronary arteries compared with nonatherosclerosis coronary arteries. The fibrosis percentage was increased in PVAT surrounding atherosclerotic coronary arteries, and it was positively associated with the grade of coronary artery stenosis. Cellular interaction analysis suggested OPN (osteopontin) secreted by SPP1+ macrophages interacted with CD44 (cluster of differentiation 44)/integrin on fibroadipogenic progenitor cells. Strikingly, correlation analyses uncovered that higher level of SPP1 in PVAT correlates with a more severe fibrosis degree and a higher coronary stenosis grade. In vitro studies showed that conditioned medium from atherosclerotic coronary PVAT promoted the migration and proliferation of fibroadipogenic progenitor cells, while such effect was prevented by blocking CD44 or integrin. SPP1+ macrophages accumulated in the PVAT surrounding atherosclerotic coronary arteries, and they promoted the migration and proliferation of fibroadipogenic progenitor cells via OPN-CD44/integrin interaction and thus aggravated the fibrosis of coronary PVAT, which was positively correlated to the coronary stenosis burden. Therefore, SPP1+ macrophages in coronary PVAT may participate in the progression of coronary atherosclerosis.

Characteristics of patients with recurrent acute myocardial infarction after MINOCA

BackgroundMyocardial infarction (MI) with non-obstructed coronary arteries (MINOCA) is an increasingly recognized condition with challenging management. Some MINOCA patients ultimately experience recurrent acute MI (re-AMI) during follow-up; however, clinical and angiographic factors predisposing to re-AMI are still poorly defined. MethodsIn this retrospective multicenter cohort study we enrolled consecutive patients fulfilling diagnostic criteria of MINOCA according to the IV universal definition of myocardial infarction; characteristics of patients experiencing re-AMI during the follow-up were compared to a group of MINOCA patients without re-AMI. Results54 patients (mean age 66 ± 13) experienced a subsequent re-AMI after MINOCA and follow-up was available in 44 (81%). Compared to MINOCA patients without re-AMI (n = 695), on first invasive coronary angiography (ICA) MINOCA patients with re-AMI showed less frequent angiographically normal coronaries (37 versus 53%, p = 0.032) and had a higher prevalence of atherosclerosis involving 3 vessels or left main stem (17% versus 8%, p = 0.049).Twenty-four patients (44%) with re-AMI underwent a new ICA: 25% had normal coronary arteries, 12.5% had mild luminal irregularities (<30%), 20.8% had moderate coronary atherosclerosis (30–49%), and 41.7% showed obstructive coronary atherosclerosis (≥50% stenosis).Among patients undergoing new ICA, atherosclerosis progression was observed in 11 (45.8%), 37.5% received revascularization, only 4.5% had low-density lipoprotein cholesterol (LDL_C) under 55 mg/dL and 33% experienced a new cardiovascular disease (CVD) event (death, AMI, heart failure, stroke) at subsequent follow-up. ConclusionsIn the present study, only a minority of MINOCA patients with re-AMI underwent a repeated ICA, nearly one out of two showed atherosclerosis progression, often requiring revascularization. Recommended LDL-C levels were achieved only in a minority of the cases, indicating a possible underestimation of CVD risk in this population.

Features of coronary pathology and its relationship with myocardial fibrosis markers in patients with resistant hypertension

Aim. To evaluate the severity of coronary atherosclerosis and its association with biochemical markers of fibrosis in patients with coronary artery disease (CAD) and resistant hypertension (RHT).Material and methods. The study included 39 patients with CAD and RHT. All patients underwent 24-hour blood pressure (BP) monitoring, office BP numbers were measured. Laboratory diagnostics included routine tests, as well as determination of serum lipocalin, plasma concentration of matrix metalloproteinases 2 and 9 (­MMP-2, MMP-9), tissue inhibitor of matrix metalloproteinases-1 (TIMP 1). Coronary atherosclerosis in patients was assessed retrospectively according to medical records with an assessment of the protocols of invasive coronary angiography and multislice computed tomography, performed no more than a year ago from the moment of inclusion in the study with no clinical signs of CAD progression. Obstructive atherosclerosis was considered a coronary artery narrowing by more than 50%.Results. Considering the results of previous coronary angiography, the patients were divided into two groups. In the first group (n=20), coronary artery stenosis was &lt;50%, in the second (n=19) &gt;50% (p&lt;0,05). The compared groups of patients were comparable in sex, age, duration of hypertension, blood pressure level, and the number of antihypertensive drugs taken. There were no differences in blood lipid profile, basal glycemia, uric acid levels, and the frequency of previous cerebral accidents. However, the incidence of diabetes in group 2 was significantly higher (p&lt;0,05). Additionally, there was a significant difference in serum levels of lipocalin and MMP-2 with higher values of these indicators in patients with coronary atherosclerosis stenosis (p=0,02).Conclusion. In patients with RHT with symptoms and signs of myocardial ische­­mia, the incidence of obstructive coronary atherosclerosis according to coronary angiography is 50%. Diabetes in this category of patients indicates a more frequent obstruction of coronary bed. An increase in the level of MMP-2 and lipocalin in this category of patients is associated with more severe coronary damage and can be considered as an indirect indicator of obstructive coronary atherosclerosis.

Prevalence of angina pectoris and association with coronary atherosclerosis in a general population

ObjectiveTo assess the contemporary prevalence of, and factors associated with angina pectoris symptoms, and to examine the relationship to coronary atherosclerosis in a middle-aged, general population.MethodsData were based on the...

P158 REMOTE FOLLOW–UP OF ISCHEMIC HEART DISEASE AFTER MYOCARDIAL INFARCTION: PRELIMINARY RESULTS OF A TELEVISIT PROJECT IN THE CARDIOLOGY OF G.B. GRASSI HOSPITAL IN ROME

Abstract Introduction In literature there are few studies reported on follow–up of post infarction using telemedicine. Objective and Methods Considering recent pandemic and thanks to the development of digital also in its regulations, it was decided to organize a televisit service with a dedicated team (cardiologist, nurse, cardiology technician) for patients (pt) discharged after a myocardial infarction. The platform of Regione Lazio SISMED has been used to carry out all the necessary procedures (dematerialised recipe, booking, videoconference, digital signature reporting and sending to FSE). We selected pt with: ST elevation myocardial infarction (STEMI), myocardial infarction with no obstructive coronary atherosclerosis (MINOCA) or Takotsubo syndrome, non ST elevation myocardial infarction (NSTEMI) with high–risk, providing a follow–up to 1 and 4 months to monitor cardiovascular events, adherence to therapy, achievement of therapeutic targets and level of satisfaction. An Access file was designed for reporting and data collection. Results From 23–11–21 to 2–11–22, we followed 58 pt (average age 64±10 years, 73% males). Figure 1 represents the cardiovascular risk factors and Figure 2 the type and location of the myocardial infarction; at discharge (average stay 7±2 days), the ejection fraction of the left ventricle was 53±9%. At the televisit control at 1 month, 5 pt reported symptoms (4 dyspnea, 1 cardiopalm), all continued the antiaggregant therapy; Figure 3 shows those who have reached the target for LDL cholesterol (average 56±34 mg/dl), blood pressure (average 124±10 mmhg) and blood sugar level (average 107±19 mg/dl); 6 pt had no target LDL cholesterol (three stopped hypolipidaemic therapy). One pt showed intense pallor, asthenia and reduced hemoglobin (6 g/dl): after hospitalization, we found colon diverticulosis with bleeding (he took oral anticoagulant due to prior atrial fibrillation, suspended, with benefit). The 4–month follow–up was performed for 42 pt, with overlapping results, without reospedalizations. No pt died. Conclusions The televisit showed itself safe as an option in the follow–up of these pt, with a high approval rating. This was possible through the structuring of a health coordination center with a dedicated team, which also supported pt in the new path.

FREQUENCY OF SIGNIFICANT CORONARY ARTERY DISEASE IN CASES WITH ST SEGMENT DEPRESSION DURING RECOVERY PHASE OF EXERCISE

Coronary Artery Disease (CAD) imposes physical, social, and economic burden. It is amongst the leading causes of mortality and morbidity. Exercise-induced ST segment depression is considered reliable ECG finding for the diagnosis of obstructive coronary atherosclerosis. Exercise testing has an excellent safety record. The aim of the study is to determine the frequency of significant coronary artery disease in cases with ST-segment depression during recovery phase of exercise tolerance test. This descriptive case series was carried out at the Department of Cardiology, Rehmatul-Lil-Alamin Institute of Cardiology, Lahore, from 11-01-2021 to 10-07-2021. A total of 89 patients were taken in this study. Conventional coronary angiography via femoral or radial route was performed. Lesions were quantified by QCA technique in addition to visual assessment. Significant CAD was labelled as per operational definition. Patients ranged between 30-70 years of age with mean age of 51.8±10.8 years. There were 56 males (62.9%) while remaining 33 (37.1%) were females. History of diabetes mellitus was reported in 31 patients (34.8%), hypertension in 38 patients (42.7%) and smoking 51 (57.3%). Family history of CAD found in 46 patients (51.7%). Hyperlipidemia reported in 38 patients (42.7%). Significant CAD was observed in 76 patients (85.4%). Stratification for age, gender, diabetes mellitus, hypertension and smoking were carried out and found no association with significant CAD. In conclusion, 85.4% frequency rate of significant coronary artery disease in cases with ST segment depression during recovery phase of exercise tolerance test was observed. Thus, careful evaluation of ST segment depression occurring in recovery phase may add significantly to the clinical information derived from the results of ETT.

509 RECURRENCE OF ACUTE MYOCARDIAL INFARCTION AFTER MINOCA: INSIGHTS FROM A MULTICENTRE NATIONAL REGISTRY

Abstract Background Myocardial infarction with non-obstructed coronary arteries (MINOCA) is an increasingly recognized condition with challenging management. Prognosis of this patients could be of concern, in particular for those who experienced recurrent acute myocardial infarction (re-AMI). Moreover, there are limited data on characteristics of re-AMI among MINOCA patients. Methods In this retrospective multicentre cohort study involving seven Hub Hospitals across Italy we enrolled consecutive patients 18 years and older discharged with diagnosis of MINOCA according to the IV universal definition of myocardial infarction who experienced hospitalization for re-AMI during follow-up. Results A total of 54 patients were included (mean age 66±13). Compared to MINOCA patients without re-AMI (n=695), on first angiography MINOCA patients with re-AMI showed less frequently angiographically normal coronaries (37 versus 53%, p=0,032) and had higher prevalence of atherosclerosis involving 3 vessels or left main stem (17% versus 8%, p=0,049). Twenty four patients (44%) with re-AMI underwent a new coronary angiography and 25% had normal coronary arteries, 12% had mild luminal irregularities (&amp;lt;30%), 21% had moderate coronary atherosclerosis (30-49%), and 42% showed obstructive coronary atherosclerosis (≥50%). Among patients undergoing new angiography, only 4% had LDL cholesterol under 55 mg/dL, atherosclerosis progression was observed in 11 (46%), 38% received revascularization and 33% experienced a new cardiovascular event (death, AMI, heart failure, stroke) at subsequent follow-up. Conclusions In the present study near one out of two patients with re-AMI after MINOCA showed angiographic atherosclerosis progression requiring revascularization in the majority of cases. These patients rarely presented with recommended LDL cholesterol levels and are at risk for further cardiovascular events, indicating a possible underestimation of cardiovascular risk in this population.

Consensus of European Experts on the Management of Patients with Ischemia with Non-Obstructive Coronary Arteries with Chronic Coronary Syndrome: Possibilities for Use in Outpatient Clinical Practice in Russia

In 2020, a consensus document of the European Society of Cardiology on the management of patients with myocardial ischemia with non-obstructive coronary arteries was released. The main provisions of the new document are aimed at identifying a special group of patients with chronic coronary syndrome and suspected vasospastic or microvascular angina in order to rationalize and personalize the approach to their management. Most patients with established myocardial ischemia do not have obstructive coronary arteries when undergoing coronary angiography. Coronary microvascular dysfunction and epicardial vasospasm, alone or in combination with obstructive coronary artery atherosclerosis, are the causes of myocardial ischemia. In this case, microvascular dysfunction is considered as a significant provoking factor in the pathogenesis of refractory angina pectoris. Diagnosis of such conditions is often difficult, and therefore the correct therapy is not prescribed for such patients. As a consequence, these patients have a poor quality of life, which leads to hospital readmissions, poor cardiovascular outcomes in the short and long term, and a significant burden on health care resources. The article discusses the possibilities of applying new recommendations and consensus in the diagnosis and management of such patients in outpatient clinical practice in Russia. At the initial stages of diagnosis, priority is given to non-invasive research methods; in-depth examination, carried out using invasive methods with a pharmacological testing. Patient management uses a stepwise strategy depending on the specific clinical situation. Calcium channel blockers or beta blockers remain the first line anti-ischemic therapy.

Dapagliflozin improves myocardial flow reserve in patients with type 2 diabetes: the DAPAHEART Trial: a preliminary report

ObjectiveCardiovascular (CV) outcome trials have shown that in patients with type 2 diabetes (T2D), treatment with sodium-glucose cotransporter-2 inhibitors (SGLT-2i) reduces CV mortality and hospital admission rates for heart failure (HF). However, the mechanisms behind these benefits are not fully understood. This study was performed to investigate the effects of the SGLT-2i dapagliflozin on myocardial perfusion and glucose metabolism in patients with T2D and stable coronary artery disease (coronary stenosis ≥ 30% and < 80%), with or without previous percutaneous coronary intervention (> 6 months) but no HF.MethodsThis was a single-center, prospective, randomized, double-blind, controlled clinical trial including 16 patients with T2D randomized to SGLT-2i dapagliflozin (10 mg daily) or placebo. The primary outcome was to detect changes in myocardial glucose uptake (MGU) from baseline to 4 weeks after treatment initiation by [(18)F]2-deoxy-2-fluoro-D-glucose (FDG) PET/CT during hyperinsulinemic euglycemic clamp. The main secondary outcome was to assess whether the hypothetical changes in MGU were associated with changes in myocardial blood flow (MBF) and myocardial flow reserve (MFR) measured by 13N-ammonia PET/CT. The study was registered at eudract.ema.europa.eu (EudraCT No. 2016-003614-27) and ClinicalTrials.gov (NCT 03313752).Results16 patients were randomized to dapagliflozin (n = 8) or placebo (n = 8). The groups were well-matched for baseline characteristics (age, diabetes duration, HbA1c, renal and heart function). There was no significant change in MGU during euglycemic hyperinsulinemic clamp in the dapagliflozin group (2.22 ± 0.59 vs 1.92 ± 0.42 μmol/100 g/min, p = 0.41) compared with the placebo group (2.00 ± 0.55 vs 1.60 ± 0.45 μmol/100 g/min, p = 0.5). Dapagliflozin significantly improved MFR (2.56 ± 0.26 vs 3.59 ± 0.35 p = 0.006 compared with the placebo group 2.34 ± 0.21 vs 2.38 ± 0.24 p = 0.81; pint = 0.001) associated with a reduction in resting MBF corrected for cardiac workload (p = 0.005; pint = 0.045). A trend toward an increase in stress MBF was also detected (p = 0.054).ConclusionsSGLT-2 inhibition increases MFR in T2D patients. We provide new insight into SGLT-2i CV benefits, as our data show that patients on SGLT-2i are more resistant to the detrimental effects of obstructive coronary atherosclerosis due to increased MFR, probably caused by an improvement in coronary microvascular dysfunction.Trial registration EudraCT No. 2016-003614-27; ClinicalTrials.gov Identifier: NCT03313752

Spasm, inflammation, coronary microcirculation and metabolism: how big is the iceberg under the stenosis

Ischemic heart disease (IHD) is a leading global cause of death and coronary artery disease has long been considered the main determinant of inducible ischemia and symptoms. However, after the performance of hundreds of thousands of percutaneous coronary revascularizations (PCI) worldwide, outcome analysis suggests that the direct relationship between chronic obstructive coronary atherosclerosis and ischemic heart disease (IHD) may represent a too simplified view of IHD; growing evidence has demonstrated the importance of a number of other underlying mechanisms. The purpose of this review is to highlight the multiple mechanisms responsible of myocardial ischemia.

Clinical outcomes of patients with coronary microvascular dysfunction in absence of obstructive coronary atherosclerosis.

Up to 50% of patients presenting with stable, mainly exercise-induced, chest pain and 10-20% of those admitted to hospital with chest pain suggesting an acute coronary syndrome show normal or near-normal coronary arteries at angiography. Coronary microvascular dysfunction (CMD) is a major cause of symptoms in these patients. However, controversial data exist about their prognosis. In this article, we critically review characteristics and results of the main studies that assessed clinical outcome of patients with angina chest pain and nonobstructive coronary artery disease presenting with either a stable angina pattern or an acute coronary syndrome. Published data indicate that the patients included in most studies are heterogeneous and a major determinant of clinical outcome is the presence of atherosclerotic, albeit not obstructive, coronary artery disease. Long-term prognosis seems instead excellent in patients with totally normal coronary arteries and a syndrome of CMD-related stable angina (microvascular angina). On the other hand, the prognostic impact of CMD in patients presenting with an acute coronary syndrome needs to be better assessed in future studies.

Focal ST-segment elevation without coronary occlusion: myocardial infarction with no obstructive coronary atherosclerosis associated with COVID-19-a case report.

BackgroundWhile it is understood that coronavirus disease 2019 (COVID-19) is primarily complicated by respiratory failure, more data are emerging on the cardiovascular complications of this disease. A subset of COVID-19 patients present with ST-elevations on electrocardiogram (ECG) yet normal coronary angiography, a presentation that can fit criteria for myocardial infarction with no obstructive coronary atherosclerosis (MINOCA). There is little known about non-coronary myocardial injury observed in patients with COVID-19, and we present a case that should encourage further conversation and study of this clinical challenge.Case summaryAn 86-year-old man presented to our institution with acute hypoxic respiratory failure and an ECG showing anteroseptal ST-segment elevation concerning for myocardial infarction. Mechanic ventilation was initiated prior to presentation, and emergent transthoracic echocardiography reported an ejection fraction of 50–55%, with no significant regional wall motion abnormalities. Next, emergent coronary angiography was performed, and no significant coronary artery disease was detected. The patient tested positive for COVID-19. Despite supportive management in the intensive care unit, the patient passed away.DiscussionWe present a case of COVID-19 that is likely associated with MINOCA. It is crucial to understand that in COVID-19 patients with signs of myocardial infarction, not all myocardial injury is due to obstructive coronary artery disease. In the case of COVID-19 pathophysiology, it is important to consider the cardiovascular effects of hypoxic respiratory failure, potential myocarditis, and significant systemic inflammation. Continued surveillance and research on the cardiovascular complications of COVID-19 is essential to further elucidate management and prognosis.

Case report of a COVID-19-associated myocardial infarction with no obstructive coronary arteries: the mystery of the phantom embolus or local endothelitis

BackgroundSince the first documented outbreak of a novel severe acute respiratory syndrome inducing Coronavirus in China at the end of 2019 the virus has spread to all continents, leading the WHO to declare a pandemic in March 2020. While this virus primarily targets the alveoli in the lungs, multiple authors have described an increased rate of thrombo-embolic events in affected patients. We present this case of a myocardial infarction with no obstructive coronary atherosclerosis in an otherwise healthy 48-year-old patient.Case summaryA 48-year-old female, presenting with chest pain radiating to her left shoulder with no cardiovascular risk factors other than genetic predisposition, was screened for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and tested positive. Although computed tomography angiography excluded obstructive coronary heart disease, cardiac magnetic resonance imaging showed an acute myocardial infarction with no obstructive coronary arteries of the inferior wall. The patient was treated with dual anti-platelet therapy, an angiotensin-converting-enzyme inhibitor and a statin, and assigned to a cardiac rehabilitation program.ConclusionWe report a serious thrombo-embolic event during an oligosymptomatic SARS-CoV-2 infection in a healthy, young patient. While these two diseases may have occurred simultaneously, by chance, it is possible that the pro-thrombotic effects of the SARS-CoV-2 infection facilitated the infarction. This case further demonstrates the significant cardiovascular morbidity potentially caused by SARS-CoV-2.

Long-Term Prognostic Significance of High-Sensitive Troponin I Increase during Hospital Stay in Patients with Acute Myocardial Infarction and Non-Obstructive Coronary Arteries.

Background and Objectives: A topic already widely investigated is the negative prognostic value regarding the extent of high sensitive troponin I (hs-TnI) increases among patients with myocardial infarction (MI) and obstructive coronary atherosclerosis compared to a group of patients with MI and non-obstructive coronary atherosclerosis (MINOCA). Thus, the aim of this study was to evaluate the prognostic value concerning the extent of hs-TnI increase on clinical outcomes among patients with a MINOCA working diagnosis. Materials and Methods: We selected 337 consecutive patients admitted to hospital with a working diagnosis of MINOCA. The patients were divided in three groups according to the extent of hs-TnI increase during hospitalization (increase ≤5-times above the limit of the upper norm, >5 and ≤20-times, and >20-times). The study endpoints included all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE; cerebral stroke and transient ischemic attacks, MI, coronary artery revascularization, either percutaneous coronary intervention or coronary artery bypass grafting and all-cause mortality). Results: During the mean follow-up period of 516.1 ± 239.8 days, using Kaplan–Meier survival curve analysis, significantly higher mortality rates were demonstrated among patients from the group with the greatest hs-TnI increase compared to the remaining groups (p = 0.01) and borderline values for MACCE (p = 0.053). Multivariable cox regression analysis did not confirm hs-TnI among factors related to increased MACCE or all-cause mortality rates. Conclusion: While a relationship between clinical outcomes and the extent of the hs-TnI increase among patients with a MINOCA working diagnosis remains, it does not seem to be not as strong as it is in patients with obstructive coronary atherosclerosis.

Coronary CT Angiography In Patients With Clinical Suspicion For Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of coronary obstruction but the diagnosis remains difficult. Given that the optimal management of SCAD may differ from treatment of obstructive coronary atherosclerosis, further improvement in non-invasive diagnosis is necessary. We therefore investigated the diagnostic yield of coronary computed tomographic angiography (CTA) in patients with clinical suspicion of SCAD.

Natural course of coronary artery calcium progression in Asian population with an initial score of zero

BackgroundWe aimed to investigate the natural course of coronary artery calcium progression in an Asian population with a baseline coronary artery calcium (CAC) score of zero, and to determine subclinical coronary atherosclerosis.MethodsFour hundred fifty-nine subjects with at least two CAC scans with an initial score of zero were included. CAC progression (+) was defined by the development of any CAC (i.e., CAC > 0) during subsequent CT scans. Clinical characteristics and Framingham risk profiles were also recorded.ResultsAmong 459 subjects, 106 (23.09%) experienced CAC progression during the average follow-up period of 5.71 ± 2.68 years. Older age, male gender, HDL-C, total cholesterol and higher Framingham risk score were independently associated with CAC progression. Framingham risk score had the better discriminative ability (AUC = 0.660) to predict CAC progression compared to the other parameters with a sensitivity of 75.24% and specificity of 53.95%. For the double zero score with coronary artery atherosclerosis prediction, older age, triglycerides, hypertension, and Framingham risk score were significantly associated with these events. Among these parameters, Framingham risk score may be a relatively acceptable parameter with high negative predictive (NPV = 96.4%) value to rule out double zero score with obstructive coronary artery atherosclerosis scenario with an optimum cut-off value of <16.9 (AUC =0.652, sensitivity of 57.69%; specificity of 68.82%).ConclusionsA baseline zero CAC score in asymptomatic Chinese population with low to intermediate risk have a low incidence for CAC progression within the 5-years period. For CAC progression prediction, Framingham risk score with the cutoff < 11.1 may help confirm subjects at low risk to improve cardiovascular risk stratification and reclassification in the field of preventive cardiology.