Occlusion Of Right Coronary Artery Research Articles

Evaluation of Previous ECG Algorithms for Identifying the Culprit Artery in Inferior STEMI

Abstract Background ST elevation myocardial infarction (STEMI) is the leading cause of cardiovascular related mortality. In the context of Inferior STEMI, the culprit artery is whether the right coronary artery (RCA) or left circumflex coronary artery (LCx). An accurate prediction of culprit artery prior to primary percutaneous coronary intervention (PCI) could improve the door-to-balloon time and could prevent contrast-induced-nephropathy. However algorithms established for that purpose were not evaluated within the Tunisian population. We aimed then to assess their performance in our population Methods We conducted a single-center hostorical cohort study from January 2014 to December 2022 on patients admitted at Sahloul university hospital Sousse Tunisia for PCI following an inferior STEMI. We analyzed the ST segment deviations at the J-point and 80 ms after the J-point then evaluated the performance of previous algorithms. Results We collected data from 156 patients, of which 130 (83.3%) hada RCA occlusion, and 26 (16.7%) a LCx occlusion. We evaluated 19 published algorithms. The criterion of zimetbaum et al (ST elevation in III> II and I and/or VL <-1 mm) had the highest AUC 0.77[0.66 - 0.88] YI = 52 accuracy = 0.81. The criterion of Herz et al (ST III > II) had AUC ROC of 0.71 [0.58 - 0.83] YI = 0.41 accuracy = 0.78, the algorithm of Tierala et al: AUC = 0.70[0.58 - 0.83] YI = 0.40 accuracy = 0.78. The algorithm og Fiol et al: AUC = 0.79 [0.58-0.83] YI = 0.59 accuracy = 0.73. Conclusions The Zimetbaum criterion had the highest performance in predicting the culprit artery and Fiol’s algorithm was the most specific to the LCx occlusion in our population. Further study on the impact of these algorithms on patients outcome is necessary. Key messages • The prediction of the culprit artery in inferior STEMI is challenging. • The criterion of Zimetbaum et al had a good performance for that regard.

Successful percutaneous coronary intervention in a congenital single right coronary artery with acute myocardial infarction: A case report and literature review.

Single coronary artery (SCA) is a rare coronary artery malformation. SCA combined with atherosclerotic plaques can cause severe and widespread myocardial ischemia and infarction, leading to hemodynamic instability and even sudden death. A 48-year-old Chinese man was admitted for treatment of persistent chest tightness and panic for 5 hours. The patient was a lorry driver with high work intensity and mental stress, with body mass index of 33.78, history of smoking and alcohol consumption, but no history of hypertension and diabetes. Admission examination showed Troponin was 183.083 µg/L and CK-MB value was >300 µg/L. The patient was diagnosed with a congenital single right coronary artery (RCA) with acute myocardial infarction (AMI) by coronary angiography (CAG). Due to atherosclerotic plaques rupture, a complete occlusion of the proximal RCA with thrombolysis in myocardial infarction grade 0 of distal blood flow were found. The patient was treated with thrombus aspiration and thrombolytic therapy by percutaneous coronary intervention under the support of intra-aortic balloon pump. Postoperative the chest tightness and panic were relieved, and CAG revealed that the proximal thrombus of the RCA was reduced, and distal blood flow was restored to thrombolysis in myocardial infarction grade 3. After 2 weeks of intensive antithrombotic and lipid-regulating drug therapy, the patient was successfully discharged. Follow-up for 6 months, the patient was able to live and work normally without experiencing chest tightness and chest pain. Computed tomography angiography (CTA) confirmed a congenital single RCA with patent lumen and no severe stenosis. The congenital single RCA is very rare, and it is fatal in conjunction with acute coronary syndrome. Early detection and appropriate treatment is critical for AMI patient with single RCA. CAG is the gold standard for diagnosis of single RCA, and CTA is a necessary to describe the anatomical course of abnormal coronary arteries.

Determinants of right coronary artery occlusion in patients with inferior wall myocardial infarction: A cross-sectional study from Western India

ABSTRACT Introduction: In acute inferior wall myocardial infarction (IWMI) and occlusion of the right coronary artery (RCA), the most important element is to recognize the culprit artery and the location and size of the infarct, which is essential in the treatment. Adequate knowledge about clinical determinants can aid in prompt and effective management. Materials and Methods: A cross-sectional study was conducted to find determinants of RCA occlusion among 103 subjects with IWMI from rural western India. Results: About 86.4% of subjects were male. Females experienced IWMI at a later age than males (62.4 ± 10.3 vs. 58.6.1 ± 11.8 years). Bradycardia was more prevalent than tachycardia (44.66% vs. 15.53%). Males had a 5.17 times higher odds of having RCA involvement in IWMI. Subjects with deranged lipid profiles had 2.37 times higher odds of involvement of RCA. RCA involvement was significantly associated with bradycardia (P = 0.006, aOR = 15.31, 95% confidence interval [CI] = 2.21–105.7) but not with tachycardia (P = 0.903). Proximal site occlusion was significantly associated (P = 0.027; aOR = 0.103; 95% CI = 0.013–0.772) with bradycardia compared to distal sites. Triple-vessel disease had significantly (P < 0.05) 12.9 times higher odds than single-vessel disease. Total occlusion of RCA was 2.9 times higher than obstructive coronary artery disease. Conclusion: These findings suggest determinants associated with RCA involvement in IWMI, including gender, lipid profile, cardiac rhythm disturbances (particularly bradycardia), and the extent and site of coronary artery occlusion. Incorporating these factors into clinical practice, clinicians can better predict the underlying pathophysiology of IWMI, anticipate its hemodynamic and electrophysiologic consequences, and tailor management strategies accordingly.

A collateral channel from the bronchial artery in chronic total occlusion of proximal right coronary artery.

A collateral channel from the bronchial artery in chronic total occlusion of proximal right coronary artery.

Evaluation of Coronary Circulation by 13N-Ammonia Myocardial Perfusion Positron Emission Tomography in Patients with Right Coronary Artery Occlusion Due to Kawasaki Disease.

Although occlusion of the right coronary artery (RCA) is common in the remote stages of Kawasaki disease, revascularization of the RCA is challenging in children and is usually managed by observation without intervention. Using adenosine-stress 13N-ammonia myocardial perfusion positron emission tomography, we evaluated coronary circulation in 14 patients (12 males) with RCA occlusion to identify ischemia (myocardial flow ratio < 2.0) in the RCA region and examined hemodynamics, cardiac function, and coronary aneurysm diameter. These variables were also compared in patients with/without RCA segmental stenosis (SS). There were five cases of ischemia in the RCA region. RCA myocardial blood flow (MBF) at rest was higher in patients with ischemia than in those without ischemia, but the difference was not significant (1.27 ± 0.21 vs. 0.82 ± 0.16 mL/min/g, p = 0.2053). Nine patients presented with RCA SS, and age at onset of Kawasaki disease tended to be lower in those with SS. The maximum aneurysm diameter of RCA was significantly smaller in patients with SS (10.0 ± 2.8 vs. 14.7 ± 1.6, p = 0.0239). No significant differences in other variables were observed between patients with/without ischemia and SS. At rest, MBF in the RCA region was relatively well preserved, even in patients with RCA occlusion, and there was no progressive deterioration in cardiac function. Adenosine stress showed microcirculatory disturbances in only half of the patients, indicating that it is reversible in children with Kawasaki disease.

Percutaneous Coronary Intervention in a Saphenous Vein Graft Failure: A Case Report

Abstract: Recent published data from the Society of Thoracic Surgery (STS) national database displayed that among patients aged &gt;65 years old who survived following an initial coronary artery bypass graft (CABG) operation, rates of repeat revascularization at 1, 5, 10, and 18 years were 2%, 8%, 16%, and 25%, respectively. The most preferred mode of revascularization was percutaneous coronary intervention (PCI). While remain the most frequently used conduits beside left internal mammary artery (LIMA), saphenous vein grafts (SVGs) have high failure rates. Percutaneous coronary intervention in SVGs is associated with an increased risk of distal coronary embolization, commonly resulting in periprocedural MI. We reported a 79-year-old male patient admitted due to progressive symptoms of chronic coronary syndrome. The patient had a history of hypertension and a CABG surgery in 2012. Electrocardiogram showed ischemia and old myocardial infarction (OMI) in inferior leads as well as poor R wave progression in the precordial leads. Transthoracic echocardiogram displayed a normal ejection fraction but impaired left ventricular (LV) diastolic relaxation. Diagnostic coronary angiography revealed a 70% tubular stenosis in proximal part of SVG supplying posterior descending artery, patent LIMA graft to left anterior descending artery, and complex lesion on native vessel (chronic total occlusion in mid right coronary artery). Implantation of drug eluting stent in SVG-posterior descending artery was performed. Direct-stenting PCI technique using undersized-stent was done to prevent any complications. In conclusion, despite the high risk of complications, vein graft intervention was successfully performed without any complications. Since the high rates of in-stent restenosis following PCI in SVGs, long-term dual antiplatelet therapy should be commenced in this patient. Keywords: saphenous vein graft; vein graft intervention; percutaneous coronary intervention

Right Ventricular Myocardial Infarction: A Mono-Centric Retrospective Study

Coronary heart disease is one of the world's leading causes of morbidity and mortality. Much is known about left ventricular myocardial infarction. It was not until much later (1974) that right ventricular myocardial infarction was studied as a distinct entity [1]. Isolated VD MI is rare [2,3,4]. It is often associated with infero-posterior MI (in a third of patients) [2,5], with higher morbidity and in-hospital mortality due to hemodynamic and rhythmic complications [4]. The culprit lesion is often occlusion of the proximal right coronary artery [2,4,6,7]. However, the VD is relatively resistant to infarction and recovers even after prolonged occlusion [8]. In this work, we will study the epidemiological, clinical, electrical, echocardiographic and angiographic aspects of MDI with extension to the VD, as well as its complications and therapeutic modalities.

A tale of two culprits: a case report

Acute thrombotic closure of more than one coronary artery causing STEMI is an infrequent finding in coronary angiography during primary angioplasty in myocardial infarction (PAMI). We presented a case of 37 years old male with acute inferior wall myocardial infarction (IWMI) with complete heart block (CHB) with left ventricular failure (LVF). Coronary angiography showed thrombotic occlusion in right coronary artery (RCA) and circumflex arteries. Clinical condition improved only after percutaneous transluminal coronary angioplasty (PTCA) of both arteries. Given this unique presentation, the best management is not standardized. Further studies are needed to better predict outcomes and guide future management.

Isolated Right Ventricular Infarction without Right Ventricular Dysfunction: A Case Report

BACKGROUND: Myocardial infarction is the leading cause of the occlusion of the coronary artery. Meanwhile, right ventricular myocardial infarction (RVMI) is usually associated with inferior left ventricular infarction in 10–50% of cases. We presented isolated RV infarcts which are rare cases that happen in only 3% of total myocardial infarction. CASE PRESENTATION: We presented a case of a 67-year-old man with sudden chest pain, shortness of breath, and a history of diabetes mellitus. From his 12 lead electrocardiogram, there is no specific ST elevation yet elevation in V3R and V4R and elevated troponin I highly sensitive value. The patient developed junctional bradycardia and early percutaneous coronary intervention backup temporary pacemaker showed total occlusion in the proximal right coronary artery (RCA) CONCLUSION: The RVMI commonly occurs in the dominant RCA that also supplies the sinoatrial node and atrioventricular node. Therefore, due to its location that passed through the RCA, bradycardia to complete heart block may happen. Isolated right ventricular (RV) infarction may happen because either RV marginal as the predominant location is occluded, or non-dominant RCA occluded by thrombus. RV infarction may impair RV contractility causing a decrease in RV stroke volume and this condition leads to hypotension, shock, and severe hemodynamic derangement. Meanwhile, acute proximal RCA occlusions do not result in significant RV necrosis, one of the reasons is collateral flow from the left coronary system further protects from RV dysfunctions in our patient.

A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.

Right ventricle injury in RCA occlusion: Exploration using precordial bipolar leads and surrogate vectorcardiograms.

Precordial Bipolar Leads (PBL) provide new electrocardiographic information derived from standard 12‑lead ECG recordings. To explore the usefulness of PBL in patients with acute right coronary artery (RCA) occlusion. Sixteen patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA) were studied before and after RCA occlusion and their data were processed with new methods based on PBL. The findings were: 1. In PBL V2-V1, strong systolic currents of injury moving in the left to right direction coexist with those directed towards leads II, III and aVF. 2. Changes in the time of the peaks of the QRS waves do not alter the duration of the QRS. 3. The QRS loops of the surrogate VCG generated show that, during ischemia, the time changes in the peak of the QRS waves displayed in one axis are the consequence of an increase in the amplitude of the waves observed in the perpendicular axis. 4. The use of two simultaneous dimensions (transverse and frontal planes) facilitates the location of the J-point. 5. In the surrogate VCGs of this group of patients, J-point and ST segment shifts produced an image that reminded the Greek letter omega (Ω). 6. The QRS wave changes, in time and amplitude, explained the rotational changes and the ischemic distortions of the surrogate VCG loops. Computerized processing of ECG data appears to provide new and valuable diagnostic data in patients with acute RCA occlusion. The loops revealed important information related to systolic currents of injury. Because these methods use routine 12‑lead ECG data, the procedure is based only in software applications.

Correlation between echocardiographic and primary percutaneous coronary intervention for proximal right coronary artery in inferior-wall myocardial infarction

Abstract Background Diagnosing myocardial infarction (MI) of the right ventricle (RV) is difficult. ECG remains the main tool for diagnosis of acute RVMI. For accurate diagnosis of RVMI, angiography can be done to enforce RVMI diagnosis. The physiology of the RV makes it less likely to suffer muscle infarction, but this can happen in cases of acute severe right coronary-artery (RCA) occlusion. Echocardiographic parameters have proven their efficacy in predicting proximal RCA infarction, including annular velocity and tricuspid annular-plane systolic excursion. Aim Assessment of the value of RV echocardiographic parameters in the diagnosis of early acute inferior RVMI in relation to coronary angiogram of proximal RCA. Patients and methods This prospective study was conducted on 125 patients diagnosed with inferior MI. ECG, echocardiographic RV parameters, and primary percutaneous coronary-intervention technique for proximal RCA were performed for all included patients at the Cardiovascular Medicine Department Tanta University Hospitals from June 2019 to December 2019. Results RV infarction occurred mostly in cases of proximal RCA occlusion and few cases with mid-segment of RCA lesion. This was reported by echocardiography using tricuspid annular-plane systolic excursion and S-wave tissue Doppler. Few cases showed impairment in RV function in left circumflex-artery occlusion as culprit vessel reported by echocardiography and the impairment occurred only with S wave. RV function was not affected with left circumflex-artery occlusion as culprit lesion. Conclusion Echocardiographic parameters of RV are useful in predicting RVMI due to proximal RCA occlusion.

A very rare interarterial communication: total occlusion of right coronary artery with antegrade collateral supply from left circumflex artery through conus branch.

The purpose of the present case report is to describe an extremely rare and unusual coronary interarterial communication. A 65-year-old female patient admitted with acute coronary syndrome underwent a coronary angiography performed with Judkins technique to obtain standard angiographic views. We have demonstrated a very rare interarterial communication traversing an unusual retroaortic path between the body of left circumflex artery and the conus branch of the right coronary artery. Coronary interarterial communications are rarely encountered; however, may fulfill important tasks in the coronary circulation. Therefore, invasive cardiologists and cardiovascular surgeons should be aware of their presence.

P192 POSTINFARCTION VENTRICULAR SEPTAL DEFECT: MANAGEMENT AND A NEW SURGICAL OPTION FOR CLOSURE

Abstract Postinfarction ventricular septal defect is a rare mechanical complication of myocardial infarction, with difficult management, debated closure timing and high mortality rates. Standard repair techniques – infarcectomy and infarct exclusion through a left ventriculotomy – are surgically challenging and have high risk of operative mortality and frequently suboptimal results. We report the case of a 66–year–old patient with a 1.4 cm septal rupture developed after a sub–acute STEMI. At the admission, he had chest pain and moderate dyspnoea, EKG showed inferior STEMI with increased myocardial necrosis markers. Echocardiography showed a preserved ejection fraction, akinesia of the inferior, posterolateral walls and of the posterobasal septum, with septal rupture at this level and 1.5 Qp/Qs ratio. A total occlusion of proximal right main coronary artery was found at coronary angiography. After the heart team meeting, we performed a new modified closure, in urgent setting, using two hand–made composite patches (Fig. 1) parachuted through a transversal aortotomy and a right atriotomy, without left ventriculotomy (Fig. 2). In the 7th postoperative day a second septal rupture was detected at the echocardiographic control. After two weeks follow–up in optimized medical therapy, we decided to complete the closure of the later developed septal rupture percutaneously using an Amplatzer device. Six months after the event, the patient is still asymptomatic and echocardiography documents a 50% ejection fraction, with trivial residual left–to–right shunt and normal valve function. Computed tomography scans confirmed optimal surgical result. Timing, management and surgical strategy are still on debate. Our technique is effective, simple, reproducible and provides good result (Fig. 3) and can be perfectly integrated in a hybrid approach.

P131 ACUTE RIGHT HEART FAILURE: MASSIVE PULMONARY EMBOLISM OR RIGHT INFARCTION?

Abstract Right ventricular infarction is often unrecognized. Rarely isolated, it complicates up to 50% of inferior infarction, conditioning morbidity and mortality. Clinical presentation, characterized by hypotension, and echocardiografic features, with right ventricular involvement, can often mimic high risk pulmonary embolism. This case report focuses on an 85–years–old woman who called 118 for chest pain and asthenia. The patient is in shock, when accepted into the emergency room. ECG reveals a third–degree AV block with escape rhythm at rate of 35bpm and ST segment elevation in inferior leads, requiring temporary transvenous pacemaker placement. Bedside echo shows a borderline LV systolic function (EF 50%) with inferior wall akinesis and a dilated and hypokinetic right ventricle (TAPSE 15mm). In emergency we perform a coronary angiogram, that reveals a total occlusion of the ostial right coronary artery, treated by PCI 2 DES. During clinical course, no complications occur. At hospital discharge, the patient is hemodynamically compensated, without neurological sequelae and with cardiac enzymes in decrease (Trp I HS peak 94 000pg/ml). The aim of this case report is to focus cardiologist’s attention on right ventricular infarction, knowing its clinical presentation and its laboratory, electrocardiographic and echocardiographic features.

Importance of the Multimodality Evaluation of a Double-chambered Right Ventricle for Surgical Indications on Admission for Acute Myocardial Infarction.

We treated a female patient known to have a double-chambered right ventricle (DCRV) who presented with symptoms of an acute myocardial infarction (AMI). Emergent coronary artery catheterization revealed acute right coronary artery (RCA) occlusion and proximal left anterior descending (LAD) stenosis. We performed percutaneous coronary intervention (PCI) for the RCA occlusion. Right heart catheterization revealed a pressure gradient across the mid-RV of 58 mmHg. Computed tomography and magnetic resonance imaging revealed no other congenital cardiac abnormalities. She underwent surgical repair of the RV stenosis and coronary artery bypass surgery for LAD stenosis.

An unusual giant coronary artery aneurysm mimicking mediastinal mass.

A 55-year-old woman was admitted with complaints of recurrent chest pain for eight days. She had a history of intermittent chest tightness and pain for 5 years. Laboratory test showed increased hypersensitive cardiac troponin I of 0.14 μg/L. The ECG showed ST segment depression in leads V1, V2, V3, and V4. Acute non-ST segment elevation myocardial infarction was diagnosed. Echocardiography revealed a hypoechoic mass (8.9 × 7.0 cm) (asterisk, Panel A, see Supplementary material online, Video S1) in front of the right side of the heart. The right atrium (RA) and right ventricle (RV) were compressed and deformed. A cystic cavity (13 mm wide) can be observed in the mass (arrowhead, Panel B, see Supplementary material online, Video S2), which was connected to the dilated right coronary artery (RCA). Enhanced chest CT showed the obviously enhanced RCA entered into the mass (asterisk, Panels C and D), the distal of which was occlusive and dilated like ‘gallbladder’ (arrowhead, Panel C, D and E). Coronary artery aneurysm (CAA) was suspected. Coronary angiography showed abnormal neoplastic dilatation in the proximal segment of the RCA and complete occlusion in the middle segment (arrowhead, panel F, see Supplementary material online, Video S3). The left coronary artery provided collateral circulation to the RCA (see Supplementary material online, Video S4). The patient underwent resection of the mass. The giant mass was observed between RA and RV (panel G) with numerous thrombi inside (panels H and I). Coronary artery bypass surgery was performed successfully after CAA resection.

1112 DOUBLE RUPTURE OF INTERVENTRICULAR SEPTUM AFTER MYOCARDIAL INFARCTION

Abstract Ventricular septal rupture (VSR) is a mechanical complication of acute myocardial infarction (MI). VSR and early surgical repair is associated with a high mortality rate and suboptimal results with frequent postoperative residual shunt. Rapid diagnosis and proper management are critical. We present the case of a 73-year-old patient who came to our Emercency Room (ER) reporting oppressive chest pain and profuse sweating . The physical examination showed a 4/6 L rude holosystolic murmur in right parasternal location. Electrocardiogram (ECG) showed inferior MI. Hematochemicals tests detected an increase of myocardial necrosis markers. Two-dimensional and three-dimensional transthoracic echocardiography (TTE) showed normal-sized left ventricle with akinesia of inferior and posterolateral walls and akinesia of posterior basal septum with ventricular septal rupture at this level. Coronary angiography showed total occlusion in mid right coronary artery (RCA). An intra-aortic balloon pump (IABP) was inserted to promote hemodynamic stability of the patient and as a bridge. Afterload was reduced using vasodilatators. A preoperative transesophageal echocardiography (TOE) showed the presence of an additional septal rupture into middle posterior interventricular septum. The role of echocardiographic assessment in VSR, therapeutic management, IABP use and timing of surgery are discussed.

279 LAYERED PLAQUES: NOT ALL ARE HEALED

Abstract Layered plaques are the effect of a previous plaque event. They are associated with coronary spasm and found in more than 50% of patients with stable angina and a quarter of those with an acute coronary syndrome. Nevertheless, it is not clear whether their presence is indicative of a healing process or rather is predictive of an increased risk of future events. A 71-year-old male, heavy smoker and hypertensive, presented with episodes of angina at rest that resolved spontaneously in less than 5 minutes, with evidence of ST-segment elevation (STE) in the lower leads during one of these episodes. Coronary angiography showed an intermediate stenosis at the end of the mid segment of the dominant right coronary artery (RCA) (Figure A). Optical coherence tomography (OCT) revealed a layered plaque, consisting of high backscattering layers alternated with low reflection layers (Figures A1-3). Given the minimum luminal area of 3.65 mm2 and the absence of other criteria for plaque instability (erosion, thin-cap, etc.), we treated the patient conservatively with medical therapy alone, consisting of a single antiplatelet agent and a high-dose statin with ezetimibe. A non-dihydropyridine calcium antagonist and a long-acting nitrate were started given the suspicion of coronary spasm. Four months later the patient returned to the emergency department for persistent oppressive chest pain unresponsive to sublingual nitrates with evidence of STE in the lower leads. Emergency coronary angiography showed an acute occlusion of RCA with TIMI 0 flow in correspondence to the layered plaque highlighted 4 months earlier on OCT (Figure B). Antegrade flow was restored with manual thrombus aspiration (Figure C) and OCT showed lesion progression with many new layers, together with a cavity suggestive of plaque rupture (Figures C1-3). A 3.5×38 mm everolimus eluting stent was deployed – based on OCT sizing – and post-dilated with a 4.0×8 mm non-compliant balloon, obtaining an excellent angiographic result with TIMI 3 flow (Figure D). Low-reflecting layers within layered plaques are generally considered to be lipid deposits, but they could also represent intraplaque haemorrhages, generated by coronary spasm. The haematoma can be reorganised within the plaque to create a new layer, leading to lesion progression without necessarily requiring a loss of endothelial integrity. The progressive increase of the haematoma may lead to plaque rupture when the pressure exceeds the resistance of superficial layers. This case reveals a new possible mechanism of plaque progression in patients with coronary spasm and explains how layered plaques can be ambivalently considered to be either stable or vulnerable. Their treatment should be meticulously tailored not only based on classical criteria of plaque instability but also according to the underlying trigger mechanism.

Identifying the culprit artery via 12-lead electrocardiogram in inferior wall ST-segment elevation myocardial infarction: Ameta-analysis.

Inferior wall ST-segment elevation myocardial infarction (STEMI) is mostly caused by acute occlusion of right coronary artery (RCA) and left circumflex artery (LCX). Several methods and algorithms using 12-lead ECG were developed to localize the lesion in inferior wall STEMI. However, the diagnostic properties of these methods remain under-recognized. The aim of this meta-analysis is to compare the diagnostic properties among the methods of identifying culprit artery in inferior wall STEMI using 12-lead ECG. We performed a meta-analysis to calculate the pooled sensitive, specificity, area under the curve (AUC) and diagnostic odds ratio (DOR) of each method. Thirty-three studies with 4414 participants were included in the analysis. Methods using double leads had better diagnostic properties, especially ST-segment elevation (STE) in III > II [with pooled sensitivity 0.89 (0.84-0.93), specificity 0.68 (0.57-0.79), DOR 17 (9-32), AUC 0.88 (0.85-0.91)], ST-segment depression (STD) in aVL > I [with pooled sensitivity 0.82 (0.72-0.90), specificity 0.69 (0.48-0.86), DOR 11 (4-29), AUC 0.85 (0.81-0.88)], and STD V3/STE III ≤1.2 [with pooled sensitivity 0.88 (0.78-0.95), specificity 0.59 (0.42-0.75), DOR 12 (5-27), AUC 0.82 (0.78-0.85)]. Diagnostic algorithms, including Jim score[pooled sensitivity 0.70 (0.55-0.85), specificity 0.88 (0.75-0.96)], Fiol's algorithm [pooled sensitivity 0.54 (0.44-0.62), specificity 0.92 (0.88-0.96)] and Tierala's algorithm [pooled sensitivity 0.60 (0.49-0.71), specificity 0.91 (0.86-0.96)], were not superior to these simple methods. Our meta-analysis indicated that diagnostic methods using double leads had better properties. STE in III > II together with STD in aVL > I may be the most ideal method, for its accuracy and convenience.