Presence Of Coronary Occlusion Research Articles

The lipid profile of the young patient with ischemic heart disease. Do these patients meet the goals?

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Virgen Macarena Introduction Ischemic heart disease is becoming increasingly common in young individuals, with dyslipidemia being an important risk factor for developing acute coronary syndrome (ACS). Recently, new analytical parameters of the lipid profile have been described, which are associated with a higher cardiovascular risk. Purpose The aim of the study was to analyse characteristics, lipid profile and, whether LDL goals are achieved in young patients with ACS admitted to our Coronary Care Unit (CCU). Methods Retrospective cohort of all patients with ACS minor than 45 years admitted to a CCU between January 2010 and February 2023. The LDL goals were established according to the European clinical practice guidelines (<70 mg/dL or <55 mg/dL after 2019). Results A total of 287 patients were included, with 82.6% being male and an average age of 41 years. 77% were smokers and 9% were ex-smokers. The prevalence of classic cardiovascular risk factors at admission was as follows: dyslipidemia 105 (37%), overweight 74 (26%), obesity 70 (25%), hypertension 87 (30%), and diabetes 29 (10%). Lipid profile’s results are showed in picture 1. Smoking, gender, as well as obesity or overweight were not significantly associated with a worse lipid profile. Significant differences were also not found based on the extent of coronary involvement (analyzing the number of affected vessels or the presence of coronary occlusion) or the reason for admission (NSTEMI vs. STEMI). As for secondary prevention, 70% of patients completed the cardiac rehabilitation program. The percentage of patients who achieved the LDL goal was 62.4% at 6 months (with an average of 61 mg/dL) and 52.4% at one year (with an average of 72 mg/dL). The majority of patients (74%) who did not meet the goals at 6 months still did not achieve them at one year. A higher initial LDL-C level was associated with a lower likelihood of achieving the goals at 6 months and one year, although it did not reach statistical significance at one year (p = 0.05 and 0.08, respectively). No other predictors of success were found, although participation in a Cardiac Rehabilitation Program was associated with a non-significant trend towards goal attainment, likely due to the small sample size (45% vs. 65%, p = 0.09). Conclusion Young patients with ACS have a good short-term and long-term prognosis, which is why secondary prevention becomes particularly important. However, a significant percentage of patients still do not achieve the recommended LDL-C goals, leaving room for improvement in reducing morbidity and mortality in this population. Larger patient series are needed to gain a better understanding of this population.Table 1.Lipid profile'sLDL and Lipoprotein (a) at admission

Abstract 12628: Evaluation of Time From Pre-Hospital Symptom Onset to Angiography on Coronary Artery Occlusion Status and Outcomes in Patients Presenting With NSTE-ACS

Introduction: Current guidelines for invasive coronary angiography (ICA) in patients presenting with NSTE-ACS outline two treatment pathways: early (within 24 hours [hrs]); or late (>24 hrs). Time of hospital admission is used as the start time, however, we hypothesize that pre-hospital time of symptom onset may be a more optimal starting time. This study was designed to test optimal symptom onset-to-angiography time (OAT) and its association with the presence of coronary occlusion and adverse outcomes. Methods: Secondary data analysis in NSTE-ACS patients (pre-COVID-19) who underwent ICA. We tested the optimal cutoff point of OAT in classifying coronary occlusion using Youden-index analysis. We tested the association of OAT and in-hospital complication (i.e., myocardial infarction [MI] after admission, unplanned transfer to the cardiac intensive care unit, pulmonary edema, cardiogenic shock, dysrhythmia with intervention) and hospital length of stay [LOS]) using regression models. Results: In 163 patients: 124 (76%) had an occluded artery; 37 (23%) had an in-hospital complication. Overall, the mean OAT was 26±22 hrs (24±22 vs. 31±21, with and without occluded artery, respectively), and the median LOS was 55 hrs. The Youden-index optimum OAT cutoff point was 13.4 hrs. In the two logistic models, the adjusted OAT was associated with the presence of coronary occlusion (Figure A). OAT, as a continuous variable, was associated with LOS ( β =0.64, 95% CI 0.08-1.21, p =0.025), no other in-hospital complications were significant (Figure B). Conclusions: In patients presenting with NSTE-ACS, OAT at both 13.4 and <24 hrs is a significant predictor of the presence of coronary artery occlusion. Every hour of delayed OAT was associated with a prolonged hospital LOS 0.64 hrs (38 min). Symptom onset appears to be an important starting point in determining optimal timing of ICA in patients with NSTE-ACS, but requires further study with a large sample of patients.

ECG analysis in patients with acute coronary syndrome undergoing invasive management: rationale and design of the electrocardiography sub-study of the MATRIX trial

BackgroundThe twelve‑lead electrocardiogram (ECG) has become an essential tool for the diagnosis, risk stratification, and management of patients with acute coronary syndromes (ACS). However, several areas of residual controversies or gaps in evidence exist. Among them, P-wave abnormalities identifying atrial ischemia/infarction are largely neglected in clinical practice, and their diagnostic and prognostic implications remain elusive; the value of ECG to identify the culprit lesion has been investigated, but validated criteria indicating the presence of coronary occlusion in patients without ST-elevation are lacking; finally, which criteria among the multiple proposed, better define pathological Q-waves or success of revascularisation deserve further investigations. MethodsThe Minimizing Adverse hemorrhagic events via TRansradial access site and systemic Implementation of AngioX (MATRIX) trial was designed to test the impact of bleeding avoidance strategies on ischemic and bleeding outcomes across the whole spectrum of patients with ACS receiving invasive management. The ECG-MATRIX is a pre-specified sub-study of the MATRIX programme which aims at analyzing the clinical value of ECG metrics in 4516 ACS patients (with and without ST-segment elevation in 2212 and 2304 cases, respectively) with matched pre and post-treatment ECGs. ConclusionsThis study represents a unique opportunity to further investigate the role of ECGs in the diagnosis and risk stratification of ACS patients with or without ST-segment deviation, as well as to assess whether the radial approach and bivalirudin may affect post-treatment ECG metrics and patterns in a large contemporary ACS population.

Novedades en el electrocardiograma de los síndromes coronarios agudos. De los patrones conocidos a las manifestaciones inusuales

Within the context of an acute coronary syndrome (ACS), the electrocardiogram (ECG), provides proper classification and risk stratification. Early ECG changes detection is crucial in diagnosing acute complete coronary obstruction. Persistent ST segment elevation is usually the clue for urgent reperfusion. Nevertheless, there are situations where even in presence of coronary occlusion we can not find the expected ST segment elevation. Furthermore, there are unusual ECG patterns related with significant risk. To recognise these situations is a real challenge for care providers.

Limitation of Infarct Size and the Open Artery Hypothesis: A Conversation With Eugene Braunwald, MD.

Eugene Braunwald received an MD from the New York University School of Medicine. He completed an internal medicine residency at Johns Hopkins Hospital and cardiology fellowships at Mount Sinai Hospital, Columbia University, and the National Heart Institute. He served as chief of cardiology and subsequently clinical director of the institute. From 1968 to 1972, he was the founding chair of medicine at the University of California, San Diego. From 1972 to 1996, he served as chair of medicine at the Brigham and Women’s Hospital. In 1975, he was elected to the National Academy of Sciences. He is now the Distinguished Hersey Professor of Medicine at Harvard Medical School and a senior investigator of the TIMI Study Group, which he founded in 1984. Dr Braunwald replies: I became aware of the importance of AMI in 1951 during an elective in cardiology during my senior year at the New York University School of Medicine. At the time, AMI was by far the most common cause of death in adults in the United States. Of the patients who survived to be admitted to hospitals (no one knew how many AMI patients failed to reach hospital emergency departments), about one third died before discharge, either suddenly, presumably from an arrhythmia, or secondary to pump failure. Of the patients who were discharged alive, about one quarter died within a year, most frequently as a consequence of heart failure or recurrent MI. Pathologists had taught that AMI was usually associated with coronary thrombosis. Indeed, during my cardiology elective, Herrick’s classic article describing AMI was required reading. Its title, “Clinical Features of Sudden Obstruction of the Coronary Arteries,” showed how these 2 conditions (coronary occlusion and AMI) were intertwined.1 My direct involvement in the care of several patients who did not survive the acute event left …

An update on interventional cardiology: management of CTO, performance of absorbable scaffolds, coronary vasomotion after DES, and antithrombotics

In spite of all the progress made over the last decades,1 coronary artery disease remains the most important cause of morbidity and mortality in Western countries2 as well as in the developing world. Atherosclerotic plaques, the underlying cause of the disease, can lead to stenosis or occlusion of epicardial coronary arteries, resulting in ischaemia and angina.3 Acute plaque rupture leads to occlusion and ST-segment myocardial infarction,4 while patients with slowly developing plaques may develop collaterals5 and will therefore present with stable angina rather than infarction even in the presence of coronary occlusion. ![Graphic][1] Coronary chronic total occlusions are commonly encountered in patients undergoing coronary angiography, and their current management is updated in a timely review entitled ‘ Appropriateness of percutaneous revascularization of coronary chronic total occlusions: an overview ’ by Alfredo Galassi and colleagues from the Cannizzaro Hospital in Catania, Italy.6 Observational studies have demonstrated that successful revascularization of chronic total occlusions is associated with improved quality of life and better outcomes.7–9 However, in the absence of randomized trials, its prognostic benefit remains debatable. Over the past decade, important developments in dedicated equipment and techniques10 have resulted in higher success and lower complication rates. Both European and American guidelines have assigned a class IIa (level of evidence B) recommendation for the percutaneous revascularization of coronary chronic total occlusions. The authors, all experienced operators, stress the importance of appropriate patient selection, and provide a critical assessment of the … [1]: /embed/inline-graphic-1.gif

DIABETUS MELLITUS AND SURGICAL TREATMENT OF CORONARY HEART DISEASE

Nearly 40-year experience of surgical treatment of coronary heart disease testifies to higher coronary heart disease (CHD) morbidity and mortality rates among diabetes mellitus patients in comparison to non-diabetic patients. At the same time, comparative study of CHD treatment methods efficacy in diabetes mellitus patients has shown that surgery is preferred to angioplasty, especially in the most severe cases--in presence of coronary occlusion, insulin-dependent diabetes and left-ventricle dysfunction. More inferior results of coronary bypass surgery in diabetic patients in comaparison to non-diabetic were conditional on a more pronounced arterial calcinosis and diffuse distal arterial involvement, as well as more severe aortal ateromatosis, flebopathy and more often wound infection occurrence. In the department of cardio-vascular surgery in Russian cardiologic scientific productive complex a quarter of all patients waiting for the coronary bypass surgery are diabetic. Selection algorithm, preoperation preparation, peculiarities of surgical technique and principles of postoperative supervision of these patients were specially designed. With adequate preparation, remission of diabetes and use of microsurgery, postoperative prognosis for these patients (both stratified and real) is comparative to that for the main group of patients. One-year follow up after the bypass surgery data testifies to the low difference in autovenous and autoarterial shunt patency in diabetic and non-diabetic patients. Long-term (10 years) survival rate is significantly lower in the group of diabetic patients. Proposed cardioprotective postoperative strategy is designed to improve both short and long-term efficacy ofsurgical revascularization in CHD patients with concomitant diabetes mellitus.

The Use of Low-Molecular Weight Heparins in Acute Coronary Syndromes

Acute coronary syndrome (ACS) comprises of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). ACS is the consequence of a sudden rupture of the coronary artery plaque and the immediate formation of thrombosis around the plaque. The presence of coronary occlusion and thrombus might result in cardiac muscle damage and loss of effective cardiac output, leading to cardiac failure. Anticoagulants, therefore, play an important role in medical management for ACS. This article assesses the role of low molecular weight heparin (LMWH) in ACS based on current available data in clinical trials and clinical practice guidelines from the American College of Cardiology (ACC)/the American Heart Association (AHA) and the American College of Chest Physicians (ACCP) antithrombotic and thrombolytic therapy consensus guidelines. Overall, the use of enoxaparin is generally preferred over other LMWHs when LMWH is indicated, and there is strong support for its role across the continuum of treatment for ACS patients.

Ultrasound energy improves myocardial perfusion in the presence of coronary occlusion

We evaluated whether ultrasound improves myocardial tissue perfusion in 14 animals with coronary artery occlusion. A recent study demonstrated that low-frequency ultrasound improves tissue perfusion in the rabbit ischemic limb, but there are no data on ultrasound enhancement of myocardial perfusion. Fourteen animals (9 dogs, 5 pigs) underwent thoracotomy and occlusion of a diagonal branch of the left anterior descending coronary artery. Myocardial tissue perfusion units (TPUs) and pH were measured before coronary occlusion, after occlusion, and after direct exposure of the ischemic myocardium in the presence of fixed occlusion to low-frequency ultrasound (27 kHz). The TPU decreased from 100.9 +/- 13 at baseline to 71.1 +/- 13 (p < 0.01) after 60 min occlusion but rose by 19.7% to 85.1 +/- 8 (p < 0.01) after ultrasound exposure for 60 min. After 60-min coronary occlusion, myocardial pH fell from 7.43 +/- 14 to 7.05 +/- 0.15 (p < 0.01) but then improved to normal (7.46 +/- 0.32) after ultrasound for 60 min. Administration of L-Nomega-nitro-arginine methyl esther (L-NAME), an inhibitor of nitric oxide synthase, before ultrasound exposure, blocked improvement in myocardial tissue perfusion and pH by ultrasound. Quantitative histomorphology showed a significant increase in the capillary area of myocardium exposed to ultrasound versus non-exposed myocardium (16.2 +/- 7.9 vs. 8.2 +/- 2.1, p < 0.02). Low-frequency, low-intensity ultrasound improves myocardial tissue perfusion and pH in the presence of a fixed coronary artery occlusion.

938-56 Myocardial Contrast Echocardiography: What is the Meaning of Regional Perfusion Abnormalities After Release of Temporary Coronary Occlusions?

Myocardial contrast echocardiography (MCE) has been used to demonstrate regional perfusion abnormalities (RPA) in the presence of coronary occlusions, severe coronary stenosis, and myocardial infarctions (MI). We have observed such abnormalities following the release of a temporary occlusion in the absence of MI. To further define this, we studied 54 open-chest dogs. Temporary coronary occlusions were performed (Group A = 15 minutes; Group B = 30 to 360 minutes), followed by release of the occlusions and by the administration of dobutamine IV (10 μg/kg/min). Myocardial contrast echocardiography was performed with aortic root injections of sonicated albumin (Albunex ® ) during occlusion and following reperfusion with and without dobutamine. Postmortem TTC staining (+ stain = viable myocardiuml was used to determine the presence/absence of MI All Group A dogs (n = 14) showed no evidence of MI. In Group B (n = 40), 14 dogs showed no evidence of MI, whereas the other 26 did (12 papillary muscle, 7 subendocardial, and 7 transmural). The presence of RPA in all groups is shown below: Occlusion Reperfusion Reperfusion+ Dobutamine Group A 13/14 2/14 2/14 Group B 35/40 17/39 20/39 • No MI 11/14 7/13 8/13 • Papillary MI 10/12 3/12 5/12 • Subendocardial MI 7/7 3/7 3/7 • Transmural MI 7/7 4/7 4/7 In conclusion, the presence of a RPA following the release of coronary occlusions most likely indicates abnormal coronary reserve rather than the presence of myocardial necrosis.

Selective dopamine-1 receptor agonist augments regional myocardial blood flow: Comparison of fenoldopam and dopamine

A new class of vasodilators exhibiting selective dopamine-1 receptor agonist activity is being introduced into clinical practice. Inasmuch as various vasodilators either augment or decrease myocardial blood flow (“coronary steal”) depending on their pharmacologic action, the goal of this study was to assess the effects of fenoldopam (selective dopamine-1 receptor agonist) and dopamine (nonselective dopamine-1 receptor agonist) on regional myocardial blood flow in the presence of coronary occlusion. Accordingly, in 16 dogs anesthetized with pentobarbital, the left anterior descending coronary artery was occluded. Cardiovascular and renal hemodynamic effects were measured before and after intravenous infusion of renal equipotent doses of either fenoldopam ( n = 9, 0.1 μg/kg/min) or dopamine ( n = 7, 1 μg/kg/min). Both fenoldopam and dopamine caused a significant and comparable increase in renal blood flow. Fenoldopam but not dopamine significantly decreased the calculated peripheral vascular resistance and subsequently increased cardiac output. Dopamine had no effect on regional myocardial blood flow. In contrast, fenoldopam augmented transmural myocardial blood flow in normal (from 114 ± 10 to 188 ± 27 ml/100 gm/min, p < 0.02) and ischemic border myocardium (from 45 ± 5 to 68 ± 11 ml/100 gm/min, p < 0.03 and p < 0.02 vs dopamine). There was a significant increase in blood flow to both the endocardial and epicardial layers of normal and ischemic border myocardium. These changes were accompanied by a significant reduction in coronary vascular resistance in the normal myocardium. In addition, with fenoldopam increments in myocardial blood flow in normal and ischemic border myocardium showed a significant correlation with changes in renal blood flow ( r = 0.76, p < 0.01 and r = 0.80, p < 0.01, respectively). No such correlation was observed after dopamine. In conclusion, low-dose infusion of selective (fenoldopam) and nonselective (dopamine) dopamine-1 receptor agonists resulted in comparable increases in renal blood flow but divergent effects on regional myocardial perfusion. Fenoldopam but not dopamine resulted in improved perfusion in normal and ischemic border myocardium. It is postulated that these findings may have important clinical implications in the treatment of patients with heart failure, renal dysfunction, and concomitant ischemic heart disease.

Response of the coronary vasculature to myocardial hypertrophy

Cardiac hypertrophy is often characterized by abnormalities in myocardial perfusion, including decreased coronary reserve, increased minimal coronary vascular resistance, underperfusion of the subendomyocardium during conditions of high oxygen demand and increased risk of infarction in the presence of coronary occlusion. Two major anatomic variables may cause these perfusion deficits. First, the coronary resistance vessels may not grow in proportion to the magnitude of the cardiac enlargement. Second, the luminal diameter of resistance vessels may become reduced as a consequence of medial hypertrophy, hyperplasia or fibrosis. A luminal narrowing coupled with a lack or inadequate numeric proliferation of resistance vessels can markedly limit maximal myocardial perfusion.However, not all models of cardiac hypertrophy are characterized by perfusion abnormalities. A substantial growth of arterioles and capillaries has been documented in exercise- and thyroxine-induced left ventricular hypertrophy. Moreover, at least in some models, angiogenesis occurs when the duration of the ventricular hypertrophy is sufficient. The hypothesis that coronary angiogenesis is stimulated by increased blood flow or prolongation of diastole appears to have support from a number of experimental studies. However, the cascade of events underlying angiogenesis and the numerous variables that characterize the various models of hypertrophy are complex and require elucidation.

Efficiency of cardioplegia in the presence of coronary occlusion.

Myocardial tissue pH and temperatures (MT) were continuously measured in dogs on total cardio-pulmonary bypass (CPB) after acute distal coronary artery occlusion. Measurements were performed in a collateralized area with myocardial blood flow (MBF) ranging from 20 to 80 ml/100 g-min (microspheres). Immediately after coronary artery occlusion the aorta was clamped and the heart perfused with a cardioplegic solution (Bretschneider HP, 41 ml/kg, 4 degrees C). Prolonged regional fibrillation was observed and MT fell to 20 degrees C in 10 min in the low perfusion area (LPA) and in 2 min in the control area (CA). Whereas MTs were practically identical 15 min after termination of cardioplegic perfusion the magnitude of H+ accumulation continued to be greater in the LPA. During blood reperfusion with the coronary snare released MBF was significantly lower in the LPA as opposed to the CA indicating a microcirculatory derangement. Accordingly the bipolar ECG revealed signs of regional ischemia even after 30 min of reperfusion. We conclude that myocardial protection may be inadequate in areas located distal to coronary occlusion. This is true not only in cases of acute severe ischemia but also when collateral resistance is sufficiently high to impede the flow of cold viscous cardioplegic solutions. Results derived from intermittent MT measurements may be erroneous because intramyocardial heat equilibration may mask the inhomogeneous cardioplegic perfusion.

Effects of Drugs and of Counterpulsation on Myocardial Oxygen Consumption

A series of investigations on the determinants of myocardial oxygen consumption were reviewed and their relevance to the survival and function of ischemic tissue in the presence of coronary occlusion pointed out. Tension development, contractile state of the myocardium, and heart rate are the most important factors influencing cardiac oxygen consumption, and drugs commonly used in the treatment of patients with acute myocardial infarction appear to influence oxygen consumption by acting upon these three determinants. Thus, digitalis glycosides and sympathomimetic agents tend to increase myocardial oxygen requirements, since they improve the heart's inotropic state. However, this influence may be offset in the enlarged heart in which end-diastolic volume and tension are reduced. Agents which depress the heart exert the opposite effect. Electrocardiographic changes reflecting myocardial ischemia are intensified when isoproterenol is administered following coronary ligation. Synchronized arterial counterpulsation reduces myocardial tension development and therefore oxygen consumption. An augmentation of myocardial oxygen needs in the presence of coronary occlusion may be expected to increase the size of the necrotic zone and to impair the function of the ischemic zone, while a reduction of oxygen consumption may be expected to exert the opposite effect.

EFFECT OF EXPERIMENTAL CARDIAC INFARCTION ON RESPONSE TO DIGITALIS

In 1925 a study was published by one of us (Dr. Gold¹) on the tolerance of the cat to ouabain in the presence of coronary occlusion. It was found that within periods up to twenty-four hours after extensive ligation of coronary vessels animals required on the average as much ouabain to cause death as did normal animals. These results were confirmed in a recent study (1934) by Bellet, Johnston and Schecter,²in which the drug was digitalis, the interval between the ligation and the testing was thirty minutes and the animal used was the dog. These authors extended their study to include chronic experiments, and from them they found that four days after the ligation the tolerance to digitalis had diminished by about 23 per cent of normal but that in from six weeks to six months some recovery of tolerance had taken place (tolerance being reduced about