Significant Obstructive Coronary Artery Research Articles

An observational study on global longitudinal strain in acute coronary syndrome and its correlation with coronary angiogram

Background: Coronary angiography (CA) is crucial for diagnosing acute coronary syndrome (ACS) and assessing coronary artery disease (CAD), enabling healthcare providers to determine treatment options and assess the risk of cardiovascular events. Global longitudinal strain (GLS) is a sensitive marker of cardiac function. This study aimed to determine the correlation between GLS in ACS and CA findings. Methods: This prospective observational study was conducted at the cardiology department of the Salem government medical college. The study involved transthoracic echocardiography (TTE) to assess LV volumes, ejection fraction (EF), and LVGLS and strain analysis using 2D echocardiography to measure regional longitudinal peak systolic strain in different LV segments. CA was performed to visualise the coronary vessels and detect significant CAD. Results: The study population consisted predominantly of male patients (n=93, 62%), with notable smoking (n=48, 32%) and alcohol consumption (n=36, 24%). A significant majority of the patients (n=111, 74%) exhibited ECG abnormalities. Obstruction was present in 82% of the patients (n=123), with those showing impaired myocardial function compared to those without obstruction. GLS values below 13.95 were more common in patients with obstruction (n=8 out of 11), indicating reduced myocardial deformation. The GLS demonstrated excellent diagnostic performance for detecting significant coronary artery obstruction, with a high sensitivity of 88.89%, specificity of 90.63%, and overall accuracy of 90.24%. Conclusions: Our study revealed a strong correlation between reduced GLS and CAD, highlighting its importance in CAD assessment and risk stratification in ACS. GLS demonstrated excellent diagnostic performance for detecting significant CAD, showing high sensitivity and specificity.

MINOCA: A Pathophysiological Approach of Diagnosis and Treatment-A Narrative Review.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical entity characterized by the absence of significant coronary artery obstruction in epicardial arteries (<50%) on coronary angiography in the setting of acute myocardial infarction (AMI). This article aims to provide a narrative review of the pathophysiological mechanisms, diagnostic challenges, and prognosis associated with MINOCA based on pathophysiology regarding the atherosclerotic and non-atherosclerotic causes. Etiological factors, including thromboembolism, coronary artery spasm, spontaneous coronary artery dissection, coronary microvascular disease, and supply-demand mismatch, are addressed. Imaging modalities such as echocardiography, advances in coronary angiography like intravascular ultrasound (IVUS) and optical coherence tomography (OCT), cardiac magnetic resonance (CMR), and coronary computed tomography angiography (CCTA) are also analyzed. MINOCA patients have a better short-term prognosis compared to those with obstructive coronary artery disease but face significant long-term risks, underscoring the need for precise diagnosis and management strategies. Elevated inflammatory markers and specific genetic predispositions are also associated with adverse outcomes in MINOCA. This review focused on MINOCA from a pathophysiological perspective on the diverse underlying mechanisms, the challenges in achieving accurate diagnosis, the importance of a tailored therapeutic approach and the necessity for further investigation of clinical outcomes.

Abstract P350: Circulating Endothelial microRNAs in Patients with INOCA and Diabetes Mellitus

Ischemia with no obstructive coronary artery (INOCA) is a common cause of hospitalizations, resulting in poor outcomes and diminished quality of life. A key element in the pathophysiology of INOCA is endothelial dysfunction, which leads to myocardial ischemia despite the absence of significant coronary artery obstruction. Effective management of endothelial dysfunction is essential for alleviating symptoms and preventing cardiovascular events in INOCA patients. Recent studies have highlighted diabetes mellitus (DM) as a significant contributor to INOCA complications by exacerbating endothelial impairment and coronary microvascular dysfunction. MicroRNAs (miRNAs), which are known to regulate gene expression, have emerged as potential biomarkers and therapeutic targets in various biological processes, including endothelial dysfunction and cardiovascular diseases. However, there is a lack of research evaluating miRNA biomarkers specifically in INOCA patients. In our study, we examined a panel of circulating miRNAs associated with the regulation of endothelial function in INOCA patients with and without DM. Using RT-qPCR, we analyzed miRNA expression in a cohort of consecutive patients undergoing percutaneous coronary intervention (PCI) who were confirmed to have INOCA. We measured the expression levels of a previously validated panel of miRNAs in INOCA patients with DM compared to those without DM. Specifically, we observed an increased expression of several miRNAs previously associated with endothelial dysfunction and decreased expression of miRNAs known to protect endothelial function. Further analyses revealed that among these miRNAs, miR-363-5p was significantly downregulated (P&lt;0.001) and miR-92a-3p was significantly upregulated (P&lt;0.001) in INOCA patients with DM compared to those without DM, as illustrated in the volcano plot in Figure 1 . Taken together, our findings demonstrated significant dysregulation of miR-363-5p and miR-92a-3p in INOCA patients with DM compared to those without DM, indicating their potential role as biomarkers for endothelial dysfunction in INOCA.

A Broken Heart Coexisting with Obstructive Coronary Artery Disease: Double Trouble

Background. Takotsubo is a syndrome characterized by transient regional systolic dysfunction of the left ventricle (LV). The most common clinical presentation mimics acute myocardial infarction without angiographic evidence of obstructive coronary artery disease or acute plaque rupture.1-3 The diagnosis and management became a challenge when it presented as atypical symptoms and significant obstructive coronary artery. Thus, this case report highlights the diagnosis and management of Takotsubo Cardiomyopathy with obstructive coronary artery disease.Case illustration. A 71 years old woman came to the emergency room with a chief complaint of dyspnea from one week ago and worsened in the last three days. The initial electrocardiogram showed slight ST-elevation, and thorax Rontgen showed the congestion and elongation of the aorta. Increased high-sensitive Cardiac Troponin T and The NT-Pro BNP levels were present, along with apical ballooning of the LV and reduced RV function. Physiological stress was found to be the death of her husband one week ago. Although the left ventriculography of this patient was classically depicted as the octopus trap, we did find obstructive coronary artery disease in the left anterior descending artery.&#x0D; Keywords: Takotsubo Cardiomyopathy, Uncommon presentation, Coronary artery disease, apical ballooning, acute heart failure

Clinical Features and Long-Term Outcomes in Very Young Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries

Background and Aim: The most common cause of acute coronary syndrome (ACS) is the erosion causing the development of atherosclerotic plaque. There is, however, a subset of individuals with ACS-like symptoms but no significant coronary artery obstruction characterized as myocardial infarction with non-obstructive coronary arteries (MINOCA). The purpose of the present study was to assess the clinical features and long-term outcome of young MI patients with non-obstructive coronary arteries. Patients and Methods: This prospective observational study was carried out on 926 patients underwent coronary angiographies in the Cardiology Department of Medical Teaching Institute (MTI) Lady Reading Hospital, Peshawar from January 2019 to December 2022. All the patients (age ≤45 years) with suspected acute coronary syndrome were enrolled. Participants were categorized into three groups: Group-I [obstructive coronary artery disease (o-CAD)], Group-II (MINOCA diagnosed patients), and Group-III [control (non-coronary artery disease)]. Demographic details, clinical features, and outcomes of patients were recorded. Results: Of the total 926 patients underwent coronary angiographies, about 122 (13.2%) patients were ≤45 years old. Out of 122 patients, the incidence of o-CAD, MINOCA, and control (non-coronary artery disease) was 60.7% (n=74), 13.1% (n=16), and 26.2% (n=32) respectively. Chest pain was the most prevalent symptom found in 95.1% (n=116) group-I, 93.8% (n=15) in group-II, and 81.3% (n=26) respectively. MINOCA patients had similar high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol levels with o-CAD patients, however, the triglyceride values was significantly higher (180.8±90.6) than control (136.2±82.8). Conclusion: The present study found that MINOCA and o-CDA group patients had similar long-term poor outcomes. Triglyceride levels, depression, BMI &gt;30 kg/m2, and family history of CAD are significant risk factors for MINOCA during follow-up. Secondary preventive initiatives are required in these patients to avoid recurrences and enhance outcomes. Keywords: CAD, MINOCA, Young patients, Clinical features, Long-term outcomes

The utility of a fully automated cardiac magnetic resonance post-processing tool and radiomics algorithm to non-invasively classify patients with or without significant coronary artery stenosis

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Research Institute of the McGill University Health Centre. Background Oxygenation-Sensitive Cardiac Magnetic Resonance (OS-CMR) has emerged as a powerful tool to investigate the underlying physiology of a number of disease states through the assessment of tissue oxygenation status with myocardial oxygenation reserve and functional kinetics of the myocardium with strain. Recently, the analysis of CMR scans with radiomics algorithms has demonstrated to have superior diagnostic accuracy over standard analysis and reporting methods. As up to half of patients undergoing coronary angiography are found to have ischemia with no significant coronary artery obstruction, a non-invasive diagnostic test that can help to more accurately stratify patients presenting with symptoms of ischemia as having significant or no significant coronary artery disease (CAD) would be of great clinical use. Methods We analyzed 49 patients (38 with significant and 15 without significant obstructive CAD) with a positive stress test and coronary angiography. All participants underwent a non-contrast CMR exam on a clinical 3T MRI system (Magnetom Skyra™, Siemens Healthineers, Erlangen, Germany) within one week of the coronary angiography. Long axis cine CMR for ventricular morphology, volumes, function including strain, and short axis OS-CMR images were acquired (total image acquisition time less than 15min). The images were imported and analyzed with a fully automated analysis package including an advanced machine learning algorithm (cvi42™ Cardiom prototype (Circle Cardiovascular Imaging, Alberta, Canada). Per participant, 602 discrete data points per participant are extracted. A 75% or higher degree of coronary artery stenosis on Quantitative Coronary Angiography (QCA) was used as the ground truth and classified as either 1 vessel disease (VD), 2VD, 3VD, or no significant coronary artery obstruction. Results Fig. 1 shows the top discriminative features as identified by the algorithm: OS-CMR derived marker: 1) myocardial oxygen saturation (LV SVO2), 2) myocardial oxygenation in response to hyperventilation stress (MORS), and 3) epicardial myocardial oxygenation reserve (MORE). Other predictive markers were: Peak Systolic Radial Strain, treatment with calcium channel blockers, presence of cerebrovascular disease, and hypertension. The algorithm showed a 73% classification accuracy of identifying patients with or without obstructive coronary artery stenosis. Conclusion In this proof-of-concept analysis, a fully automated post-processing tool and radiomics algorithm has demonstrated the potential to accurately predict clinical classification in patients with and without significant CAD with a non-invasive, contrast-free CMR protocol. Further training and refinement of analysis algorithms are likely to further enhance the predictive value.

Long-term clinical outcomes in patients with a working diagnosis of myocardial infarction with non-obstructed coronary arteries (MINOCA) assessed by cardiovascular magnetic resonance imaging

BackgroundMyocardial infarction with non-obstructed coronary arteries (MINOCA) is a distinct entity among patients presenting with troponin-positive acute chest pain. We have previously reported on the incremental diagnostic capability of cardiovascular magnetic resonance (CMR) in this cohort. There is paucity of evidence on the long-term (> 5 years) clinical outcomes of these patients as graded by their acute CMR diagnosis. Methods and resultsA total of 229 patients with a working diagnosis of MINOCA who underwent CMR assessment during the acute admission (2010–2017) were prospectively studied. The primary endpoint was major adverse cardiac events (MACE) defined as a composite of all-cause mortality and cardiovascular readmissions, identified from hospital and primary care records. CMR performed at a median of 6 days (IQR 2, 8) from presentation provided a diagnosis in 85% of the patients (38% myocarditis, 28% acute myocardial infarction and 19% Takotsubo cardiomyopathy). Over a median follow-up of 7.1 years (IQR 3.7, 8.2), 56 (24%) patients experienced a MACE. We found a strong association between CMR diagnosis and MACE (log rank 30.47, p < 0.001). In multivariate analysis, age (hazard ratio = 1.07; 95% confidence interval = 1.05, 1.10; p < 0.001) and CMR diagnosis of acute myocardial infarction (hazard ratio = 8.87; 95% confidence interval = 2.58, 30.4; p = 0.001) were independent predictors of MACE. ConclusionsIn a large cohort of patients with a working diagnosis of MINOCA, one in four suffer a MACE during long-term clinical follow-up. CMR diagnosis of acute myocardial infarction and age were significant predictors of MACE even in the absence of significant coronary artery obstruction.

Long-term outcome after the arterial switch operation: 43 years of experience.

OBJECTIVESThe objective of this study was to assess our 43-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) by analysing cardiac outcome measures (hospital and late mortality, reoperations and catheter interventions, significant coronary artery obstruction) and to identify risk factors for reoperation and catheter interventions. METHODSA total of 490 patients who underwent ASO for TGA from 1977 to 2020 were included in this retrospective, single-centre study. Data on reoperation and catheter intervention of hospital survivors were estimated by the Kaplan–Meier method and compared using a long-rank test. Risk factors for reoperation and/or catheter intervention were assessed by multivariate Cox regression analysis.RESULTSHospital mortality occurred in 43 patients (8.8%), late death in 12 patients (2.9%) and 43 patients were lost to follow-up. Median follow-up time of 413 hospital survivors was 15.6 (interquartile range 7.0–22.4) years. Reoperations were performed in 83 patients (117 reoperations). Neoaortic valve regurgitation with root dilatation was the second most common indication for reoperation (15/83 patients, 18.1%) after right ventricular outflow tract obstruction (50/83 patients, 60.2%). Risk factors for any reoperation on multivariable analysis were: TGA morphological subtype [TGA with ventricular septal defect: hazard ratio (HR) = 1.99, 95% confidence interval (CI) 1.18–3.36; P = 0.010 and Taussig-Bing: HR = 2.17, 95% CI 1.02–4.64; P = 0.045], aortic arch repair associated with ASO (HR = 3.03, 95% CI 1.62–5.69; P = 0.001) and a non-usual coronary artery anatomy (HR = 2.41, 95% CI 1.45–4.00; P = 0.001). One hundred and one catheter interventions were performed in 54 patients, usually for relief of supravalvular pulmonary stenosis (44/54 patients, 81.5%) or arch obstruction (10/54 patients, 18.5%). Main risk factor for catheter intervention on multivariable analysis was aortic arch repair associated with ASO (HR = 2.95, 95% CI 1.37–6.36; P = 0.006). Significant coronary artery stenosis was relatively uncommon (9/413 patients, 2.2%) but may be underrepresented.CONCLUSIONSPatients after ASO typically have good long-term clinical outcomes but reoperations and interventions remain necessary in some patients. Neoaortic valve regurgitation with root dilatation is the second most common indication for reoperation after right ventricular outflow tract obstruction and an increasing need for neoaortic valve and root redo surgery in future is to be expected.

Long-term clinical outcomes of troponin-positive chest pain and unobstructed coronary arteries assessed by cardiovascular magnetic resonance imaging

Abstract Background and introduction Troponin-positive chest pain with unobstructed coronary arteries is a distinct entity with different pathophysiological causes. We have previously reported on the incremental diagnostic capability of cardiovascular magnetic resonance (CMR) in this cohort. However, there is paucity of literature on the long-term clinical outcomes of these patients assessed with CMR. Objectives Using the unique cohort of patients previously studied, we sought to assess the long-term clinical outcomes in patients with troponin-positive chest pain and unobstructed coronary arteries, as graded by their acute CMR presentation. Methods A total of 122 consecutive patients with troponin-positive chest pain and unobstructed coronary arteries undergoing CMR assessment during the acute admission (2010–2014) were studied. The primary endpoint was major adverse cardiac event (MACE), defined as a composite of all-cause mortality and cardiovascular readmissions (heart failure, acute myocardial infarction [AMI], atrial or ventricular arrhythmia and stroke). Patients were grouped into 4 categories based on their initial CMR findings: AMI, acute myocarditis, Takotsubo cardiomyopathy and normal CMR. Results The mean age of the study cohort was 55.6±16.5 years and 56.5% were women. CMR (performed at a median of 6 days from presentation) provided a diagnosis in 87% of the patients (38% myocarditis, 28% Takotsubo cardiomyopathy and 21% AMI). Patients with a diagnosis of AMI were prescribed guideline recommended medical therapy. Over a median follow-up of 2524 days (6.9 years), 32 (26.2%) patients experienced a MACE. The all-cause mortality was 2.5%. The most common indication for cardiovascular readmissions in this cohort was heart failure (12.3%) and AMI (9%). In multivariate analysis, a CMR diagnosis of AMI (hazard ratio = 2.6; 95% confidence interval = 1.2, 5.7; p=0.019) and peak troponin (hazard ratio = 1.0003; 95% confidence interval = 1.00003, 1.0006; p=0.028) were significantly associated with MACE after adjusting for age and gender. In addition, CMR diagnosis of AMI was significantly associated with a lower event-free survival rate compared with a diagnosis of non-AMI (adjusted hazard ratio = 2.57, p=0.019) (Figure). Conclusions The long-term prognosis of patients with troponin-positive chest pain and unobstructed coronary arteries is not benign. CMR diagnosis of AMI is a significant predictor of MACE even in the absence of significant coronary artery obstruction and despite guideline recommended post AMI therapy. Figure 1 Funding Acknowledgement Type of funding source: None

Correlation of coronary microvascular function and diastolic dysfunction

Abstract Background Coronary microvascular dysfunction (CMD) is an important mechanism for heart failure with preserved ejection fraction (HFpEF) which is closely related with diastolic dysfunction on transthoracic echocardiography (TTE). Purpose The aim of this study was to evaluate the association of CMD with echocardiographic parameters of diastolic dysfunction. Methods Total 385 patients with chest discomfort in the absence of significant coronary artery obstruction were enrolled to this study and underwent invasive coronary physiologic assessment including index of microcirculatory resistance (IMR), and coronary flow reserve (CFR). Echocardiographic parameters for diastolic dysfunction - left atrial volume index (LAVI) and left ventricular filling pressure (E over e') were compared in patients with true CMD (CFR&amp;lt;2.5 with IMR ≥20), mismatched CMD (CFR≥2.5 with IMR ≥20 or CFR&amp;lt;2.5 with IMR &amp;lt;20), and no CMD (CFR≥2.5 with IMR &amp;lt;20). Results Among the study population, 55 patients (14.3%) were true CMD, 162 patients (42.1%) were mismatched CMD and 168 patients (43.6%) were no CMD. Age (62.9±10.5 vs. 61.1±9.9 vs. 61.7±10.5, p=0.522) and left ventricular ejection fraction (63.9±8.1 vs. 63.9±6.2 vs. 63.0±6.7, p=0.414) was not different between groups. Patients with true CMD showed significantly larger left atrial size (LAVI: 34.7±18.2 mL/m2 vs. 26.8±10.7 mL/m2, p=0.005) and trend towards higher LV filling pressure (E/e': 10.8±3.5 vs. 9.9±3.5, p=0.073) compared with no CMD. In subgroup analysis, younger patients showed more pronounced increase of LAVI (Age &amp;lt;65: 39.6±22.6 vs. 26.1±11.6, p=0.003; Age ≥65: 28.0±9.13 vs. 28.8±8.2, p=0.266; p for interaction 0.043) in true CMD compared to no CMD. Non-diabetic patients also showed more pronounced increase of E/e' in true CMD (Non-diabetes: 10.2±2.7 vs. 9.2±2.6, p=0.002; Diabetes: 12.1±4.5 vs. 11.9±5.1, p=0.197; p for interaction 0.015). Conclusions Coronary microvascular dysfunction is significantly related with echocardiographic parameters of diastolic dysfunction. The effect of CMD on diastolic dysfunction is more prominent in low-risk patients. Figure 1 Funding Acknowledgement Type of funding source: None

Value of Pulsed Tissue Doppler Imaging in Predicting the Presence of Significant Coronary Artery Insufficiency

Background: Coronary artery disease (CAD) is a paramount cause of death. Global and regional left ventricular (LV) systolic function is an important non-invasive marker of CAD. We can use tissue Doppler imaging (TDI) to measure the low velocities generated by myocardium which are: S'-wave, E'-wave, and A'-wave. We aimed to examine the value of the S'-wave dispersion of TDI across mitral valve annular velocities to predict angiographically significant coronary artery obstruction. Patients and Methods: We included 100 patients with symptoms suggesting CAD. All patients had undergone full history taken and clinical examination; ECG, echocardiographic with assessment of LV function, and Doppler derived mitral valve velocities; TDI with measuring of S'-wave and coronary angiography. Lesions with ≥70% or more stenosis in major epicardial artery or ≥50% stenosis in the left main coronary artery were considered significant. Patients were classified into two groups according to the presence or absence of significant coronary stenosis. Results: Clinical and conventional echocardiographic and Tissue Doppler measures were comparable between the two groups; there was statisticallysignificant difference between Group I and Group II (P value ; patients with significant coronary arteries lesions have higher S' wave dispersion as compared with patients with normal or mild significant coronary lesions. Conclusion: S'-wave dispersion may consider a good predictor of angiographically significant coronary artery disease.

Foreword

Non-ST elevation-acute coronary syndrome (NSTE-ACS) includes NSTE myocardial infarction and unstable angina. This patient population forms approximately two-thirds of all hospital admissions for ACS in the United States each year and is associated with an in-hospital mortality of 5%. NSTE-ACS is primarily due to an acute change in the supply and demand balance of coronary perfusion and myocardial oxygen consumption, because of the significant coronary artery obstruction presenting as plaque rupture or erosion. Nevertheless, nonobstructive causes may lead to that same phenomenon by excessive myocardial oxygen demand or reduced coronary supply from hypotension, anemia, or sepsis, including transient coronary vasospasm and endocardial dysfunction. The recent clinical application of high-sensitivity troponin biomarker assays and computer tomography angiography shows promise for improving the diagnosis and the risk stratification of patients with angina symptoms.Implementation of recent updates to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on NSTE-ACS, especially regarding the selection and duration of antiplatelet therapy, have led to improvement in management and outcomes of this disease. Additionally, new adjunctive therapies and approaches to diagnosis and treatment are discussed. Despite the progress made in recent years in the diagnosis and management of NSTE-ACS, morbidity remains high and mortality is significant. Such a fact suggests that future research targeting prevention, early diagnosis, and intervention in these patients is warranted. This article provides a detailed overview of the most recent information on the pathophysiology, diagnosis, treatment, and prognosis of NSTE-ACS.

Takotsubo Syndrome: Does the Octopus Trap Hide Dangers?

Takotsubo syndrome (TTS) is a recently identified acute heart syndrome, characterized by regional wall motion abnormalities not justified by the presence of significant coronary artery obstruction. Clinically, TTS closely resembles acute coronary syndromes (ACS) and therefore differential diagnosis may be an important obstacle for its correct clinical management. The prevalence of TTS is estimated to be around 2% of acute myocardial infarctions, and the number of diagnoses has increased in recent years, possibly reflecting our growing understanding of this condition. Given the similarities between TTS and ACS, clinical presentation in these patients is equivocal. However, numerous peculiar traits have been observed, such as the greater prevalence in postmenopausal women and the presence of stressful triggers. Many pathogenetic hypotheses for TTS, such as catecholamine overload and microvascular dysfunction, have been proposed. None of these have been capable of independently explaining the underlying mechanisms. The diagnostic criteria proposed by the Heart Failure Association of the European Society of Cardiology represent a novel attempt to introduce semiquantitative parameters, yet further scientific validation is needed. Contrary to previous opinions, TTS is not always benign, considering the relatively high prevalence of acute complications, an estimated in-hospital mortality similar to that of acute myocardial infarction (1–8%), and a significant rate of recurrences and persistence of symptoms. Clinical management of TTS has been largely based on empirical experience related to ACS, and therefore pharmacological strategies are partially overlapping. An issue of the utmost importance is the lack of randomized prospective data validating diagnostic criteria, risk stratification, and specific therapeutic approaches.

Myocardial Infarction with Non-obstructive Coronary Arteries-MINOCA

Myocardial Infarction with Non-obstructive Coronary Arteries-MINOCA is a clinical syndrome that encompasses a subgroup of heterogeneous patients who present with myocardial infarction yet do not have any significant coronary artery obstruction on angiogram. From several studies it is understood that MINOCA has a 8.8% prevalence of all Myocardial Infarction (MI) presentations, with no characteristic distinguishing clinical features when compared with MI-CAD( Coronary artery disease), except for patients being younger with a female preponderance &amp; less likely to have hyperlipidemia. The prognosis is extremely variable, depending on the causes of MINOCA. Clinical history, echocardiography, coronary angiography, and left ventriculography represent the first-level diagnostic investigations.&#x0D; Ibrahim Card Med J 2015; 5 (1&amp;2): 61-66

Non-ST Elevation Acute Coronary Syndromes: A Comprehensive Review

Non-ST elevation-acute coronary syndrome (NSTE-ACS) includes NSTE myocardial infarction and unstable angina. This patient population forms approximately two-thirds of all hospital admissions for ACS in the United States each year and is associated with an in-hospital mortality of 5%. NSTE-ACS is primarily due to an acute change in the supply and demand balance of coronary perfusion and myocardial oxygen consumption, because of the significant coronary artery obstruction presenting as plaque rupture or erosion. Nevertheless, nonobstructive causes may lead to that same phenomenon by excessive myocardial oxygen demand or reduced coronary supply from hypotension, anemia, or sepsis, including transient coronary vasospasm and endocardial dysfunction. The recent clinical application of high-sensitivity troponin biomarker assays and computer tomography angiography shows promise for improving the diagnosis and the risk stratification of patients with angina symptoms.Implementation of recent updates to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on NSTE-ACS, especially regarding the selection and duration of antiplatelet therapy, have led to improvement in management and outcomes of this disease. Additionally, new adjunctive therapies and approaches to diagnosis and treatment are discussed. Despite the progress made in recent years in the diagnosis and management of NSTE-ACS, morbidity remains high and mortality is significant. Such a fact suggests that future research targeting prevention, early diagnosis, and intervention in these patients is warranted. This article provides a detailed overview of the most recent information on the pathophysiology, diagnosis, treatment, and prognosis of NSTE-ACS.

Takotsubo Cardiomyopathy: Case Series and Literature Review.

Although originally considered to be uncommon, Takotsubo cardiomyopathy is becoming increasingly visible, annually comprising an increasing portion of suspected diagnoses of acute coronary syndrome. This condition is characterized by reversible left ventricular akinesis without significant coronary artery obstruction. This case study presents five patients diagnosed with Takotsubo cardiomyopathy, as confirmed by echocardiogram and angiography. All of the patients presented with classic myocardial chest pain and elevated troponins. Following diagnosis, they were treated with supportive measures, particularly angiotensin-converting enzyme inhibitors, and beta-blockers. All patients made a full recovery. Though the mechanism of Takotsubo has not been fully elucidated, hypotheses suggest it may be related to excessive catecholamine levels causing either myocardial stunning or coronary vasospasm. Recognition and understanding of this unusual pathology are essential because it can lead to improved clinical management.

Abstract 14772: Routine Coronary Angiography Prior to Pulmonary Thromboendarterectomy in Patients With Chronic Thromboembolic Pulmonary Hypertension

Introduction: At UC San Diego Health System, routine coronary angiography has been performed in men &gt;40 years and women &gt;45 years (or earlier in those with significant cardiovascular risk factors) prior to pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH). However, the prevalence of significant coronary artery disease (CAD) in this population has not been evaluated, and the optimal screening strategy has not been systematically established. Hypothesis: We hypothesized that the current approach of routine age-based coronary angiography in screening candidates for PTE may be better optimized based on cardiac risk factors. Methods: The study included 349 consecutive patients (51.3% male) with CTEPH undergoing preoperative coronary angiography for PTE between January 1, 2007 and November 7, 2014. Charts were reviewed for baseline demographic and medical information. Major cardiac risk factors included: diabetes, hypertension, hyperlipidemia, obesity (BMI ≥25 kg/m2), tobacco use, and family history of CAD. Coronary angiography reports and PTE operative reports were reviewed for significant CAD (≥50% obstruction) and revascularization. Results: Significant CAD was found in 43 (12.3%) of the 349 patients who underwent routine preoperative coronary angiography. The subset with significant CAD included 14 (8.2%) of 170 women and 29 (16.2%) of 179 men. Significant CAD was present in only 5.6% of patients ≤50 years of age, compared to 14.6% of patients &gt;50 years of age. The absence of major cardiac risk factors was a key indicator in excluding significant CAD in patients ≤50 years: no patient ≤50 years without risk factors for CAD was found to have significant coronary artery obstruction. Furthermore, in patients ≤50 years, significant CAD was found only among those with ≥3 major risk factors. Conclusions: In patients ≤50 years with CTEPH, the prevalence of significant CAD was low, and omitting preoperative coronary angiography in this subset of men and women may be reasonable when no cardiac risk factors are present. Routine preoperative coronary angiography is reasonable in individuals &gt;50 years, as well as those ≤50 years with significant risk factors or clinical suspicion of CAD.

Stress-induced Cardiomyopathy Precipitated by Triathlon Competition: A Case Report

Stress-induced cardiomyopathy in post-menopausal women is transient and typically precipitated by severe emotional or physical stress. We report a rare case of stressinduced cardiomyopathy mimicking acute coronary syndrome in a middle-aged female triathlete. The initial presentation included chest tightness and dyspnea; however, acute pulmonary edema and cardiogenic shock developed shortly after admission. Electrocardiography showed non-specific ST-T changes and echocardiography revealed severe left ventricular dysfunction with regional wall motion abnormalities. Coronary angiography did not reveal significant coronary artery obstruction. The patient was placed on ventilatory support and administered diuretics and an angiotensin-converting enzyme inhibitor. Follow-up echocardiography on day 3 showed nearly normal left ventricular wall motion with a 54% ejection fraction, and follow-up radiography of the chest revealed no evidence of pulmonary edema. The endotracheal tube was removed on the third day of hospitalization and the patient was discharged two days later without complications.

Takotsubo Cardiomyopathy: A Challenging Diagnosis for Emergency Service Clinicians!

Takotsubo cardiomyopathy (TTC) is a clinical entity characterized with transient left ventricular wall dysfunction without significant culprit obstructive coronary artery disease. For definitive diagnosis ventriculography and invasive coronary angiography are gold standard techniques. We present a case with TTC, who was first diagnosed as anterior STEMI (ST elevated myocardial infarction) in our emergency service.

The value of serum osteoprotegerin levels in patients with angina like chest pain undergoing diagnostic coronary angiography

Osteoprotegerin (OPG) is a member of the tumor necrosis factor superfamily.Recent evidence supports a relationship between serum OPG level and atherosclerosis. The aim of this study was to evaluate the possible association of OPG with the presence of coronary artery disease (CAD), its severity and prognosis in patients with chest pain and suspected coronary stenosis. In this cross-sectional analytic study, 180 candidates of elective coronary artery angiography were recruited. Serum level of OPG was measured by ELISA method in all patients and its relation with presence and severity of CAD based on a coronary atherosclerosis score (CAS) was assessed. Patients were followed for a mean period of about 24 ± 3.2 months and the relationship between OPG levels and future cardiac events were evaluated. The mean serum level of OPG was 1637 ± 226 pg/mL in those with CAD and 1295 ± 185 pg/mL (nonparametric p = 0.001) in those without it. There was a significant direct correlation between the level of serum OPG and CAS (rho = 0.225, p = 0.002). The optimalcut-off point for predicting a significant coronary artery obstruction was a serum level of≥ 1412 pg/mL with a sensitivity and specificity of 60% and 57.8%, respectively. Major adversecardiac events (MACE) including cardiovascular death, admission with acute coronary syndrome,or heart failure, was significantly higher in those with higher OPG levels (22 [34.3%]vs. 15 [16%], p = 0.012). There was a direct and significant correlation between the serum level of OPG and CAS. MACE occurred more commonly in those with higher baseline OPG levels.