Positive Troponin Test Research Articles

Management of massive and submassive pulmonary embolism: focus on recent randomized trials.

Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review. The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results. Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.

Neue Erkenntnisse zur Pathogenese und Ätiologie der koronaren Herzerkrankung

In clinical practice the non-invasive diagnosis of "coronary heart disease" is based on the clinical findings, the detection of ischemia at rest or during exercise, and elevations of cardiac enzymes. However, due to the compensatory enlargement of the vessel diameter at the beginning of plaque growth, the so-called Glagov effect, early stages of plaque development are missed by the angiography. By means of coronary angiography, changes of the coronary arteries become visible only in patients with angiographically recognizable lumen narrowing compared to the reference vessel segment. Thus, early or diffuse stages of atherosclerosis cannot be detected by ECG, stress-tests or coronary angiography. This limitation explains discrepancies, like positive troponin-test and even transmural ischemia, without angiographic visible coronary lumen narrowing. Diagnostic procedures such as intravascular ultrasound, optical coherence tomography, measurements of vasomotion and computed tomography can, in contrast, detect earlier stages of coronary artery disease and thus contribute to clarification in these patients. In addition, plaque rupture and plaque-erosion lead to acute or recurrent microembolism to distal myocardium with subsequent myocardial necrosis. In patients with formerly unexplained cardiovascular events, intravascular ultrasound, optical coherence tomography, and measurements of vasomotion help to understand the underlying pathophysiology. In the report after cardiac catheterization, the term "ruled out coronary heart disease" should be replaced by "No signs of obstructive coronary heart disease" and additional testing should be performed as necessary.

Utility of Neutrophil–Lymphocyte Ratio in Predicting Troponin Elevation in the Emergency Department Setting

There is little data regarding the diagnostic ability of neutrophil-lymphocyte ratio (NLR) in acute coronary syndrome. Therefore, we aimed to assess the predictive value of NLR in the discrimination of troponin-positive patients. We enrolled 244 patients (mean age 61.3 ± 11.7 years, 70.5% male) who presented to the emergency service with acute chest pain. Patients were divided into 2 groups based upon the troponin positivity in the 12- to 24-hour follow-up. The admission NLR was significantly higher in the troponin-positive group (5.49 ± 4.01 vs 2.40 ± 1.36, P < .001). A cutoff point of 2.80 for NLR measured on admission had 79% sensitivity and 73% specificity in predicting follow-up troponin positivity. After multivariate analysis, admission NLR and glucose levels remained significant predictors of follow-up troponin positivity. In conclusion, NLR may be an early diagnostic marker in emergency service for discriminating patients who will have a positive troponin test in the follow-up.

Significant Alteration of Nitrogen Species in Acute Myocardial Infarction Does Not Relate to The Site of Infarction

This study aimed to assess the level of nitrogen species in patients presented with acute myocardial infarction and to relate the levels of nitrogen species to the infarction site. A total number of 113 patients admitted to the intensive care unit at Diyala Teaching Hospital. The patients were presented within 6 hours of pain onset and diagnosed as acute myocardial infarction using electrocardiograph criteria and positive cardiac troponin test. The most common infarction site was anterior followed by inferior and lateral. Serum peroxynitrite level was significantly higher than healthy subjects by 100 folds and serum nitric oxide level is significantly reduced compared with healthy subjects by 50%. There were non significant differences in nitrogen species regarding the infarct sites. Associated risk factors e.g. hypertension, diabetes mellitus and smoking influenced the nitrogen species levels. It concludes that the significant alterations in nitrogen species not related to the site of acute infarction

The relation between ECG changes and troponin test in patients with non ST segment elevation acute coronary syndrome

Objectives: This article focuses on unstable angina and non ST segment elevation myocardial infarction. The objectives are to clarify different ECG pattern, to correlate it with troponin results, and to evaluate the effects of risk factors. Methods: Seventy patients with clinical diagnosis of acute coronary syndrome were collected from coronary care unit in Ibn Sina Teaching Hospital in Mosul, 20 patients with ST segment elevation were excluded, and ECG changes were evaluated. Forty five patients had troponin I test, and the results were compared to their ECG changes. The risk factors and their numbers were studied. Data statistically analyzed using Z- 2 proportion and Chi-square tests. Results: Fifty patients with a mean age 57 year (SD 13.2), including 26 males and 24 females, show (in order of frequency): ST depression (44%), non-specific ECG (24%), T wave inversion (22%), and BBB (10%). Fifteen (33%) had positive troponin test, most of them were males (80%), showed significant association with T wave inversion (p value= 0.05). Specific ECG changes were associated with male gender, diabetes mellitus, hypertension, and old age (p value

Correlation between lipid profile and troponin I test results in patients with chest pain in Nepal

ObjectiveTo study the usefulness of traditional lipid profile levels in screening subjects who had developed chest pain due to cardiac event as indicated by a positive troponin I test. MethodsIn this retrospective study data of the 430 patients presented to the emergency department with symptoms of cardiac ischemia who underwent both troponin and lipid profiles tests were compared with the lipid profiles of 165 normal healthy subjects (controls). The troponin was detected qualitatively when a specimen contains troponin I (cTnI) above the 99th percentile (TnI>0.5 ng/mL). The total cholesterol, high density lipoproteins cholesterol, very low density lipoproteins and triacyl glycerol levels were also analyzed and low density lipoprotein level was calculated using Friedewald's formula. ResultsPatients with chest pain and positive troponin test (with confirmed cardiac event) were found to have significantly elevated levels of total cholesterol, triacyl glycerol levels, low density lipoprotein level and significantly reduced high density lipoproteins cholesterol levels when compared to the patients who experienced only chest pain (negative troponin) and healthy controls. ConclusionsTraditional lipid profile levels is still can be used in screening populations to identify the subjects with high risk of developing cardiac event in case if the laboratory set up has not troponin test facilities.

214: Interpreting troponin elevation in relation to symptom onset in intermediate-risk pulmonary embolism

Troponin elevation in the setting of acute pulmonary embolism (PE) is of small magnitude and short duration and can go unnoticed in pts referred late after symptom onset. Prospective, single-center registry of pts with confirmed intermediate-risk PE, defined as at least 1 echocardiographic finding of right ventricular (RV) dysfunction (endo-diastolic (EDRV)/left ventricular (EDLV) end-diastolic diameter ratio >=1 in the 4-chamber view, paradoxical septal systolic motion or pulmonary hypertension defined as RV/atrial gradient >30mmHg), or positive troponin test. Combined in-hospital endpoint was defined as death, non-fatal recurrent PE, or residual pulmonary vascular obstruction (RPVO) ≥35%. 282 pts were included, age 66±14 years, 59% women, 174 (62%) referred ≤5 days after symptom onset, 108 (38%) after >5 days. Troponin elevation was observed in 126 (72%) treated within ≤5 days, in 60 (56%) treated after >5 days (p=0.004). A significant interaction was observed between time since symptom onset and both troponin elevation and persistence of EDRV/EDLV diameter ratio>1 at 48h. The negative predictive value of troponin elevation was 85% in patients treated within 5 days of symptoms, but fell to 70% in those admitted >5 days after symptom onset (p=0.002). Positive troponin was an independent predictor of adverse outcome (OR=1.43 [1.08-5.56]). ROC curves show that prognostic value of positive troponin test was higher in pts referred ≤5 days than in pts referred >5 days after symptom onset (p=0.01). There is a significant relation between troponin elevation and time since symptom onset in patients with intermediate-risk PE. Negative predictive value of troponin elevation is adequate in pts treated early (≤5 days) but is suboptimal in pts treated >5 days after symptom onset. Table Results <=5 days since symptom onset >5 days since symptom onset p Sensitivity 72% (61.3-82.7) 51% (42.4-59.6) 0.005 Specificity 42% (44.5-49.5) 47% (39.1-54.9) 0.33 PPV 26% (18.4-33.6) 30% (22.2-37.8) 0.81 NPV 85% (78.4-91.6) 70% (63-77) 0.002

Pulmonary embolism hotline 2012

SummaryManagement of acute pulmonary embolism (PE) has advanced considerably in the past year, and progress is expected to continue in 2013. To help determine the optimal management strategy for normotensive patients with intermediate-risk PE, the Pulmonary Embolism Thrombolysis (PEITHO) study completed enrolment of 1006 patients with evidence of right ventricular dysfunction (by echocardiography or computed tomography) plus a positive troponin test. Patients have been randomised to thrombolytic treatment with tenecteplase versus placebo, and the effects on clinical end points (death or haemodynamic collapse) assessed at 7 and 30 days. The results are expected in spring 2013; long-term follow-up is also being performed. The results of a randomised trial on ultrasound- enhanced low-dose catheter-delivered thrombolysis will also become available soon. While optimisation of treatment with vitamin K antagonists incorporating pharmacogenetic testing is still being pursued, new oral anticoagulants are entering the field of PE treatment and secondary prophylaxis. Following the successful use of rivaroxaban as single oral drug therapy in the EINSTEIN-PE trial, the approval of this drug has recently been extended to cover, apart from deep vein thrombosis, PE as well. The apixaban (AMPLIFY) and edoxaban (HOKUSAI) trials have finished recruitment of PE patients, and their results will become available shortly. In the meantime, the AMPLIFY-EXT trial showed that both the therapeutic (5 mg twice daily) and the prophylactic dose (2.5 mg twice daily) of apixaban are effective and safe for longterm secondary prophylaxis after PE. For the extended prophylaxis (after the reommended initial anticoagulation period) of the (few) patients who are unable to tolerate any form of anticoagulation, low-dose asprin may be a safe albeit moderately efficacious option, as indicated by two recent investigator-initiated trials with a total of 1224 patients.

Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain

BackgroundIt is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes.MethodsIn this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes.ResultsThe rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65).ConclusionsIn patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.)

The clinical utility of lipid profile and positive troponin in predicting future cardiac events

Objective To study the usefulness of traditional lipid profile levels in screening subjects who had developed chest pain due to cardiac event as indicated by a positive troponin I (TnI) test. Methods In this retrospective study data of the 740 patients presented to the emergency department with symptoms of cardiac ischemia that underwent both troponin and lipid profiles tests were compared with the lipid profiles of 411 normal healthy subjects (controls). The troponin was detected qualitatively when a specimen contains TnI above the 99th percentile (TnI >0.5 ng/mL). The total cholesterol (TC), high density lipoproteins (HDL), very low density lipoproteins (VLDL), and triacyl glycerol (TG) levels were also analyzed and low density lipoprotein level (LDL) was calculated using Friedewald's formula. Results Patients with chest pain and positive troponin test (with confirmed cardiac event) were found to have significantly elevated levels of TC, TG, LDL and significantly reduced HDL levels when compared to the patients who experienced only chest pain (negative troponin) and healthy controls. Conclusions Traditional lipid profile levels still can be used in screening populations to identify the subjects with high risk of developing cardiac event which is identified by highly sensitive and specific positive troponin test.

Abstract 18214: Interpreting Troponin Elevation in Relation to Symptom Onset in Intermediate-Risk Pulmonary Embolism

Background: Troponin dosage plays an increasingly important role in risk stratification in pulmonary embolism (PE), especially in patients (pts) without hemodynamic compromise. Troponin elevation in the setting of acute PE is of small magnitude and short duration and thus, can go unnoticed in pts referred late after symptom onset. Methods: Prospective, single-center registry of patients with confirmed intermediate-risk PE, defined as at least 1 echocardiographic finding indicating right ventricular (RV) dysfunction (RV/left ventricular end-diastolic diameter ratio * 1 in the 4-chamber view, paradoxical septal systolic motion or pulmonary hypertension defined as a RV/atrial gradient &gt;30 mmHg), or a positive troponin test. We used a combined in-hospital endpoint defined as death, non-fatal recurrent PE, or residual pulmonary vascular obstruction (RPVO) &gt;30% as measured by V/Q scan before discharge. Results: In total, 199 patients were included, average age 69±15, 56% women, 116 (58%) pts referred within ≤5 days after symptom onset, and 83 (42%) after &gt;5 days, of whom 25 were referred after &gt;15 days since symptom onset. All patients had at least 1 sign of RV dysfunction. Troponin elevation was observed in 78/116 pts (67.2%) treated within ≤5 days, and in 40/83 pts (48.2%) treated after &gt;5 days (p=0.03). Sensitivity and specificity of troponin elevation to predict adverse outcome as defined above are shown in the table. Conclusion: Our results show that there is a significant relation between troponin elevation and symptom onset in patients with intermediate-risk PE. Time since symptom onset should be taken into consideration when interpreting troponin elevation in this population. Negative predictive value of troponin elevation is adequate in pts treated early (≤5 days) but is suboptimal in pts treated &gt;5 days after symptom onset.

What is new for emergency physicians in the Heart Foundation's 2011 Addendum to its Guidelines for the management of acute coronary syndromes?

What is new for emergency physicians in the Heart Foundation's 2011 Addendum to its Guidelines for the management of acute coronary syndromes?

The impact of obesity on cardiac troponin levels after prolonged exercise in humans.

Elevated cardiac troponin I (cTnI), a marker for cardiac damage, has been reported after high-intensity exercise in healthy subjects. Currently, little is known about the impact of prolonged moderate-intensity exercise on cTnI release, but also the impact of obesity on this response. 97 volunteers (55 men and 42 women), stratified for BMI, performed a single bout of walking exercise (30–50 km). We examined cTnI-levels before and immediately after the exercise bout in lean (BMI < 25 kg/m2, n = 30, 57 ± 19 years), overweight (25 ≤ BMI < 30 kg/m2, n = 29, 56 ± 11 years), and obese subjects (BMI ≥ 30 kg/m2, n = 28, 53 ± 9 years). Walking was performed at a self-selected pace. cTnI was assessed using a high-sensitive cTnI-assay (Centaur; clinical cut-off value ≥0.04 μg/L). We recorded subject characteristics (body weight, blood pressure, presence of cardiovascular risk) and examined exercise intensity by recording heart rate. Mean cTnI-levels increased significantly from 0.010 ± 0.006 to 0.024 ± 0.046 μg/L (P < 0.001). The exercise-induced increase in cTnI was not different between lean, overweight and obese subjects (two-way ANOVA interaction; P = 0.27). In 11 participants, cTnI was elevated above the clinical cut-off value for myocardial infarction. Logistic regression analysis identified exercise intensity (P < 0.001), but not BMI, body fat percentage or waist circumference to significantly relate to positive troponin tests. In conclusion, prolonged, moderate-intensity exercise results in a comparable increase in cTnI-levels in lean, overweight and obese subjects. Therefore, measures of obesity unlikely relate to the magnitude of the post-exercise elevation in cTnI.

Exercise-Induced Cardiac Troponin Release: Real-Life Clinical Confusion

Exercise training represents a successful and powerful strategy to prevent future cardiovascular disease. Paradoxically, performance of exercise is also associated with an increased risk of acute cardiac events. Accordingly, patients may present to hospital with cardiac symptoms following a bout of unaccustomed physical effort (e.g. exercise). Current guidelines for the identification of an acute myocardial infarction (AMI) importantly depend on the presence of cardiac troponin as a highly sensitive marker of cardiac damage. However, a number of studies have reported elevated cardiac troponin levels in asymptomatic, healthy subjects after endurance exercise (such as a marathon, prolonged cycling or prolonged walking). These observations indicate that elevated cardiac troponin levels can be the result of cardiac ischemia, and subsequent necrosis, but also may be related to strenuous exercise. In this paper, we present three different clinical cases of post-exercise elevations in cardiac troponins, each with a distinct clinical presentation. These case studies emphasize that a detailed assessment of all symptoms and a thorough patient-history are prerequisite for accurate interpretation of a positive cardiac troponin test following exercise.

A case of fulminant type 1 diabetes mellitus accompanied by myocarditis

This report presents the case of a 47-year-old female patient with fulminant type 1 diabetes mellitus and myocarditis. Following a high fever, nausea, vomiting and diarrhea, diabetic ketoacidosis occurred and she was transferred to the hospital. The plasma glucose level was 63.6 mmol/L and HbA1c was 7.0%. C-peptide was undetectable in her plasma. Blood gas analysis showed a pH of 6.99. Antibodies to glutamic acid decarboxylase nor insulinoma associated antigen-2 were not detected. She was diagnosed to have fulminant type 1 diabetes mellitus. Her electrocardiogram showed diffuse ST-segment elevations on the second day of admission, along with a positive troponin test. However coronary angiography revealed neither occlusion nor stenosis of the cardiac arteries. An endomyocardial biopsy revealed hypertrophic cardiomyocytes with a disarrangement of myofibers and the focal accumulation of mononuclear cells in the stroma, thus suggesting myocarditis or mild myocarditic change. Viruses are an important cause of myocarditis and the preceding flu-like symptoms indicate the association of viral infection with myocarditis in this case. The mechanisms by which fulminant type 1 diabetes mellitus occurs is still uncertain, but the presence of islet injury accompanied by myocardial inflammation in the current case suggested that a viral infection accounted for the onset of this type of diabetes.

Safety and efficacy of fondaparinux as an adjunctive treatment to thrombolysis in patients with high and intermediate risk pulmonary embolism

No data are available on the efficacy and safety of a combination of fondaparinux and thrombolysis in the setting of high to intermediate risk pulmonary embolism (PE). Patients submitted to thrombolysis and fondaparinux, presenting with > or =1 of the following criteria were included: (1) cardiogenic shock, (2) syncope, (3) > or =1 proximal thrombo-embolus at CT scan, (4) positive troponin test, (5) echocardiographic findings indicating right ventricular (RV) dysfunction. In-hospital results included death, recurrent PE, persistent RV dysfunction at 48 h echocardiography, bleeding complications. Twenty seven patients were included; 22 received a 2 h infusion of rt-PA and 5 received a 2 h infusion of streptokinase. Ten patients presented with cardiogenic shock (37%), 8 with syncope (30%), all had RV dysfunction. 82% of patients had an uneventful in-hospital course. One patient died during hospital stay from refractory shock. Thrombolysis failed in 2 patients (7%), requiring successful rescue surgical embolectomy. Bleeding events occurred in 2 patients (7%), of whom 1 required blood transfusion. Despite the small sample size, our data suggest that fondaparinux procures adequate tolerability compared to standard current therapy in combination with thrombolysis in high to intermediate risk PE.

Incidence and Significance of a Positive Troponin Test in Bacteremic Patients Without Acute Coronary Syndrome

Background Since the introduction of troponin for the diagnosis of myocardial infarction, several studies have shown additional conditions in which troponin is elevated, including sepsis. The objective of this study was to determine the incidence of an elevated troponin in patients with bacteremia and its significance. Methods This was a prospective, noninterventional study. Patients with a positive blood culture were included. Cardiac troponin I (cTnI) was determined within 4 days of blood culture. A repeat electrocardiogram was obtained in a sample of patients with elevated cTnI and in patients with a negative troponin test. Demographic, clinical, and microbiological data were obtained for all patients. Results A total of 159 bacteremic patients were included. Positive cTnI was detected in 69 patients (43%). Elevated cTnI was associated with a number of underlying diseases, hospitalization ward, severity of the systemic inflammatory condition, and kidney function ( P <.05-.001). A repeat electrocardiogram was performed in 39 patients with a positive cTnI and in 28 patients with a negative cTnI. Two of 39 patients (5%) in the positive cTnI group had ischemic changes and 2 patients (5%) had nonspecific changes, whereas only 1 patient (4%) with a negative cTnI had nonspecific changes. Bivariate analysis revealed a statistically significant association for positive cTnI and mortality; however, on multivariate analysis this was no longer significant. Conclusion Forty-three percent of bacteremic patients had an elevated cTnI. Risk factors for elevated cTnI were severity of the underlying infection, renal function, and underlying cardiac disease. Increased cTnI was found to be a dependent risk factor and a surrogate marker for death.

Multiple postpartal coronary artery dissections and fibromuscular renal artery dysplasia

A 42-year-old postpartal woman presented 5 months after delivery of her second child with sudden onset of chest pain following exercise. The clinical investigation was unremarkable except for a blood pressure of 185/110 mmHg and a positive troponin test. Her past medical history included controlled arterial hypertension and two episodes of a troponin-positive acute coronary syndrome due to spontaneous coronary artery dissection (SCAD) that were treated conservatively. The first episode was not pregnancy associated and was caused by single SCAD of the posterior descending coronary artery. The second episode occurred 2 months after delivery of …

Cardiac Troponin and Outcome in Acute Heart Failure

Cardiac troponin provides diagnostic and prognostic information in acute coronary syndromes, but its role in acute decompensated heart failure is unclear. The purpose of our study was to describe the association between elevated cardiac troponin levels and adverse events in hospitalized patients with acute decompensated heart failure. We analyzed hospitalizations for acute decompensated heart failure between October 2001 and January 2004 that were recorded in the Acute Decompensated Heart Failure National Registry (ADHERE). Entry criteria included a troponin level that was obtained at the time of hospitalization in patients with a serum creatinine level of less than 2.0 mg per deciliter (177 micromol per liter). A positive troponin test was defined as a cardiac troponin I level of 1.0 microg per liter or higher or a cardiac troponin T level of 0.1 microg per liter or higher. Troponin was measured at the time of admission in 84,872 of 105,388 patients (80.5%) who were hospitalized for acute decompensated heart failure. Of these patients, 67,924 had a creatinine level of less than 2.0 mg per deciliter. Cardiac troponin I was measured in 61,379 patients, and cardiac troponin T in 7880 patients (both proteins were measured in 1335 patients). Overall, 4240 patients (6.2%) were positive for troponin. Patients who were positive for troponin had lower systolic blood pressure on admission, a lower ejection fraction, and higher in-hospital mortality (8.0% vs. 2.7%, P<0.001) than those who were negative for troponin. The adjusted odds ratio for death in the group of patients with a positive troponin test was 2.55 (95% confidence interval, 2.24 to 2.89; P<0.001 by the Wald test). In patients with acute decompensated heart failure, a positive cardiac troponin test is associated with higher in-hospital mortality, independently of other predictive variables. (ClinicalTrials.gov number, NCT00366639 [ClinicalTrials.gov].).

Fibromuscular dysplasia of the coronary and renal arteries?

Fibromuscular dysplasia (FMD) involving the coronary arteries has been described pathologically as a cause of myocardial infarction but has not been described antemortem. Unlike renal artery FMD, its clinical manifestations remain poorly characterized. We describe demographic, clinical, and coronary angiographic characteristics of seven women with acute coronary syndromes and unusual coronary anatomy who also had renal artery FMD. All subjects were female caucasians, age 42-56, who presented with prolonged chest pain and positive troponin tests. Two were smokers, two had hypertension, and one had hypercholesterolemia. None was diabetic. There were distinctive angiographic features common to all seven patients. The left anterior descending artery was involved in six, the right posterior descending artery in one. In each case, the proximal vessel appeared normal but in the middle or distal segment there was a well-demarcated abrupt transition to diffuse obliterative disease. In six of the cases, this continued distally for the remainder of the epicardial vessel. In no case was revascularization feasible. Unlike severe diffuse atherosclerotic disease, all other coronary segments were angiographically normal. Ventricular dysfunction, if present, was mild. All seven patients had typical angiographic features of renal FMD, three bilaterally. We have observed a characteristic pattern of well-demarcated obliterative coronary artery disease associated with FMD of the renal arteries. All cases presented as acute coronary syndromes in patients at relatively low risk of coronary artery disease. We propose that these appearances in the epicardial arteries, previously undescribed ante-mortem represent coronary artery fibromuscular dysplasia.