Significant Coronary Artery Narrowing Research Articles

Association between Serum Galectin-3 and Growth Differentiation Factor-15 Levels and Coronary Slow Flow Phenomenon.

Coronary slow flow phenomenon (CSFP) is characterized by delay in the progression of contrast material in the coronary tree that is not accompanied by significant coronary artery narrowing. Pathophysiologic pathways underpinning CSFP still remain poorly understood. To evaluate the relationship between serum galectin-3 (GAL-3) and growth differentiation factor-15 (GDF-15) levels with CSFP. Fifty CSFP patients and 40 subjects with normal coronary arteries were included in this retrospective study. The patients' serum GDF-15 and GAL-3 concentration levels were measured using relevant kits. Thrombolysis in myocardial infarction frame count (TFC) of each patients was determined. We did not find any differences with respect to clinical and demographic features between the two groups. GDF-15 and GAL-3 concentration levels were significantly higher in the patients with CSFP. Moreover GDF-15 and GAL-3 concentration levels were positively correlated with TFC (GDF-15; r = 0.448, GAL-3; r = 0.642, p < 0.001 for both). Multivariate logistic regression showed that GAL-3 and GDF-15 were predictors of the CSFP. Similarly, GDF-15 and GAL-3 were the only predictors of TFC. More specifically, GDF-15 and GAL-3 concentration levels of 182.18 pg/mL and 8.58 ng/mL predicted CSFP with sensitivities of 76% and 87.5%, respectively, and specificities of 84% and 75%, respectively. GDF-15 and GAL-3 levels were increased in the CSFP patients and predicted the presence and severity of CSFP. Thus, these two biomarkers might prove useful in relation to the diagnosis of CSFP.

Incidence and Prognostic Impact of Atrial Fibrillation After Discharge Following Revascularization for Significant Left Main Coronary Artery Narrowing

The incidence, recurrence rate, and prognostic significance of atrial fibrillation or flutter (AF) following hospital discharge after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) are unknown. We sought to determine the 3-year incidence and clinical impact of postdischarge AF in patients with LMCAD treated with PCI or CABG. In the EXCEL trial, 1,905 patients with LMCAD were randomized to PCI versus CABG. We analyzed the occurrence of postdischarge AF through 3 years and its time-adjusted association with adverse outcomes. A total of 1,802 patients without AF at baseline comprised the study cohort. Within 3 years, 227 episodes of AF occurred (29 [12.8%] in the PCI arm and 198 [87.2%] in the CABG arm, p <0.0001); of those, 63 (27.7%) occurred following discharge from the index hospitalization in 57 patients. In-hospital AF predicted postdischarge AF (hazard ratio [HR] 2.94, 95% confidence interval [CI] 1.42 to 6.10, p = 0.004). By multivariable analysis, time-updated postdischarge AF was an independent predictor of 3-year cardiovascular death (HR 4.91, 95% CI 1.92 to 12.60, p = 0.0009), stroke (HR 4.87, 95% CI 1.12 to 21.12, p = 0.035), and the composite outcome of death, stroke or myocardial infarction (HR 3.09, 95% CI 1.56 to 3.6-6.11, p = 0.001). Among patients with postdischarge AF, the rate of the primary composite outcome did not vary according to presence or absence of in-hospital AF (21.0% vs 23.8%, p = 0.78). In conclusion, postdischarge AF following CABG or PCI for LMCAD is associated with increased mortality and stroke. In-hospital atrial fibrillation is an independent predictor of AF following discharge.

Deaths in triathletes: immersion pulmonary oedema as a possible cause.

Background/aimTo address the question as to whether immersion pulmonary oedema (IPO) may be a common cause of death in triathlons, markers of swimming-induced pulmonary oedema (SIPO) susceptibility were sought in triathletes' postmortem examinations.MethodsDeaths while training for or during triathlon events in the USA and Canada from October 2008 to November 2015 were identified, and postmortem reports requested. We assessed obvious causes of death; the prevalence of left ventricular hypertrophy (LVH); comparison with healthy triathletes.ResultsWe identified 58 deaths during the time period of the review, 42 (72.4%) of which occurred during a swim. Of these, 23 postmortem reports were obtained. Five individuals had significant (≥70%) coronary artery narrowing; one each had coronary stents; retroperitoneal haemorrhage; or aortic dissection. 9 of 20 (45%) with reported heart mass exceeded 95th centile values. LV free wall and septal thickness were reported in 14 and 9 cases, respectively; of these, 6 (42.9%) and 4 (44.4%) cases exceeded normal values. 6 of 15 individuals (40%) without an obvious cause of death had excessive heart mass. The proportion of individuals with LVH exceeded the prevalence in the general triathlete population.ConclusionsLVH—a marker of SIPO susceptibility—was present in a greater than the expected proportion of triathletes who died during the swim portion. We propose that IPO may be a significant aetiology of death during the swimming phase in triathletes. The importance of testing for LVH in triathletes as a predictor of adverse outcomes should be explored further.

Clinical & radiological evaluation of atherosclerotic changes in carotid & coronary arteries in asymptomatic & clinically symptomatic individuals as a tool for pre-symptomatic diagnosis of cardiovascular disease.

Background & objectives:An increase in prevalence of atherosclerosis has been noted worldwide with reports of higher incidence of atherosclerotic vascular changes in Asian Indians. There is a need to measure vascular atherosclerotic changes and provide objective parameter to predict cardiac and cerebrovascular adverse events. Atherosclerotic changes in carotids and coronaries are generally accepted as an association. We attempted in this study to relate intimal-luminal changes in carotid arteries to luminal changes in coronary arteries. Our study presents results of high resolution ultra sonographic (HRUS) evaluation of intimal-medial-thickness (IMT) in carotid with luminal changes in coronaries on multidetector-CT (MDCT) in clinically asymptomatic and symptomatic individuals.Methods:In this prospective study, HRUS examination of the carotid bifurcation was performed in 151 individuals to measure IMT in asymptomatic and symptomatic groups. Assessments of coronary arteries of the same group of patients were evaluated by MDCT within a week interval. IMT changes were associated with age, sex, predisposing factors, calcium burden of coronaries and structural atherosclerotic changes in coronary arteries.Results:A linear association of IMT was observed with increasing age. IMT of 0.5-0.69 mm was noted in 50 per cent of patients between 51-56 yr with higher number of symptomatic patients in this group. Linear increases in coronary vascular changes were noted with increasing IMT thickness. Changes were more prevalent in diabetic, hypertensive, treadmill test (TMT) positive and clinically symptomatic patients.Interpretation & conclusions:Age-related progression of atherosclerosis was evident in internal carotid arteries. Significant association was observed in the IMT thickness of right common carotid (RCC) and coronary disease in symptomatic group; whereas IMT of left common carotid and internal carotid arteries did not show any association. RCC IMT between 0.5-0.7mm showed maximal association with significant symptomatic narrowing of coronary arteries. Patients with IMT beyond 0.7mm had no association with symptoms.

Radial artery intima-media thickness predicts major cardiovascular events in patients with suspected coronary artery disease

In the present study, we investigated the prognostic value of radial artery intima-media thickness (rIMT) in patients with suspected coronary artery disease (CAD). Carotid artery intima-media thickness is a well-known surrogate marker of atherosclerosis. Recently, using very high-resolution ultrasound, we showed rIMT can be imaged with great precision and is related to various cardiovascular risk factors. We recruited a total of 416 patients (62 ± 9 years, 44% male) with suspected CAD, referred to myocardial perfusion scintigraphy (MPS). Among these patients, 133 underwent coronary angiography on clinical indication. Two-dimensional images of carotid and radial arteries were acquired bilaterally (using 8 and 55 MHz ultrasound, respectively). All patients were followed regarding major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, stroke, and coronary revascularization. A group of 20 healthy subjects (aged 61 ± 3, 50% male) were recruited for reference. During 3 years of follow-up, 77 MACE occurred. Patients with MACE exhibited significantly thicker rIMT vs. those without (0.35 ± 0.06 vs. 0.32 ± 0.07 mm, P < 0.001). Increased rIMT was associated with an increased occurrence of significant coronary artery narrowing, diagnosed by coronary angiography (P = 0.028). Patients with rIMT values above the median had a nearly three-fold increased risk for MACE (hazard ratio 2.8, 95% confidence interval 1.6-4.8). In multivariate analysis, rIMT (P = 0.011) remained a significant predictor of MACE, along with type II diabetes (P = 0.012), body mass index (P = 0.024), and MPS-verified ischaemia (P < 0.001). Radial artery IMT, assessed by very high-resolution ultrasound, confers prognostic information in patients with suspected CAD.

The favourable effect of Helicobacter pylori eradication therapy in patients with recurrent angina-like chest pain and non-responsive to proton pump inhibitors – a preliminary study

IntroductionThe outcome of Helicobacter pylori (Hp) eradication therapy from the aspect of prevention of chest pain recurrence is still uncertain. The aim of this study was to assess the influence of Hp eradication therapy on the risk of hospitalization due to acute coronary syndrome.Material and methodsThe analysis was carried out in 63 consecutive patients with recurrent retrosternal symptoms: 28 (44%) with significant coronary artery narrowing in coronarography not qualified for revascularization by an invasive cardiologist, and 35 (56%) with no obstructive coronary artery lesions. In 33 (52%) of the patients, Hp infection was found and standard eradication therapy with omeprazole (2 × 20 mg), amoxicillin (2 × 1 g) and metronidazole (2 × 500 mg) was recommended. The mean follow-up period was 977 ±249 days.ResultsChest pain requiring hospitalization because of unstable angina within the follow-up period was observed in 9 (27%) of the Hp-infected individuals and in 15 (50%) subjects in whom a urease test and histology did not confirm this infection (p = 0.055). The recommendation of Hp-eradication treatment was a significant factor prolonging the hospitalization-free period, both in the two Kaplan-Meier curve analyses (Cox’s F test = 1.96; p = 0.049) and the Cox proportional hazard model (beta = –1.18; p = 0.045), but was weaker than the effect of the non-obstructive coronary angiogram (beta = –1.45; p = 0.03).ConclusionsThe recommendation of Hp-eradication therapy may prolong the hospitalization-free period for patients with recurrent chest pain.

Does esophageal dysfunction affect the course of treadmill stress test in patients with recurrent angina-like chest pain?

cardioesophageal reflex may increase severity of chest pain and signs of myocardial ischemia on electrocardiogram (ECG), both in patients with and without significant coronary artery stenosis. the aim of the study was to evaluate the relationships between esophageal pH and pressure and clinical and electrocardiographic signs of myocardial ischemia. in 129 consecutive patients with recurrent chest pain, 77 without significant coronary artery lesions in coronary angiography and 52 with myocardial ischemia, panendoscopy, pH-metry, manometry, and treadmill stress test were performed. The prevalence of esophageal disorders was similar in patients with and without significant coronary artery narrowing. Subjects with significant ST interval depression in the stress test had a higher rate of simultaneous esophageal contractions. There were no differences in the results of the treadmill test between patients with and without esophageal disorders. Forty percent of patients with significant coronary artery lesions, who had to stop the test because of chest pain, did not present significant ST interval depression on ECG; however, such depression was observed in 60% of patients with normal coronary angiography. Patients with exercise-provoked chest pain had more pronounced abnormalities in esophageal pH, together with the amplitude and coordination of esophageal contractions. Demographic and clinical factors associated with chest pain and changes in exercise ECG were not evaluated. esophageal disorders are an important cause of chest pain, potentially affecting the results of the treadmill stress test. However, further research is needed to determine the predictors of the cardioesophageal loop activity.

Efficacy of Fractional Flow Reserve Measurements at Side Branch Vessels Treated With the Crush Stenting Technique in True Coronary Bifurcation Lesions

Measurement of fractional flow reserve (FFR) has been frequently used to optimize the results of coronary stenting in patients with significant narrowing of coronary arteries. There has been a consensus that an FFR value > 0.90 after stenting is a useful surrogate for favorable long-term clinical outcome. We evaluated the efficacy of FFR measurement at side branch vessels of true coronary bifurcation lesions that were treated with the crush stenting technique. This study included 12 patients with significant narrowing in both a main coronary vessel and side branch vessel who underwent the crush stenting procedure. After crush stenting, FFR measurement was performed at the side branch vessel prior to and after kissing balloon angioplasty (KBA). FFR values increased significantly, from 0.94 +/- 0.04 pre-KBA to 0.97 +/- 0.03 post-KBA (P = 0.011). FFR values after crush stenting but prior to KBA already measured > 0.90 in 9 of the 12 patients (75%). FFR values for the remaining 3 patients were 0.88, 0.88, and 0.90, respectively. FFR measurement at side branch vessels of coronary bifurcation lesions treated with crush stenting may not contribute to adequate decision-making for improvement of long-term clinical outcomes. KBA should be strongly considered for patients with bifurcation lesions treated with crush stenting.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

To investigate the relationship between exercise-provoked esophageal motility disorders and the prognosis for patients with chest pain. The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor (PPI). In all, a coronary artery angiography, panendoscopy, 24-h esophageal pH-metry and manometry, as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring, were performed. Thirty-five subjects had no significant coronary artery lesions, and 28 had more than 50% coronary artery narrowing. In patients with hypertensive esophageal motility disorders, a calcium antagonist was recommended. The average follow-up period was 977 ± 249 d. The prevalence of esophageal disorders, such as gastroesophageal reflux or diffuse esophageal spasm, was similar in patients both with and without significant coronary artery narrowing. Exercise prompted esophageal motility disorders, such as a decrease in the percentage of peristaltic and effective contractions and their amplitude, as well as an increase in the percentage of simultaneous and non-effective contractions. In 14 (22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%. Using Kaplan-Meier analysis and the proportional hazard Cox regression model, it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period. In patients with chest pain non-responsive to PPIs, a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.

Exertional esophageal pH-metry and manometry in recurrent chest pain

To investigate the diagnostic efficacy of 24-h and exertional esophageal pH-metry and manometry in patients with recurrent chest pain. The study included 111 patients (54% male) with recurrent angina-like chest pain, non-responsive to therapy with proton pump inhibitors. Sixty-five (59%) had non-obstructive lesions in coronary artery angiography, and in 46 (41%) significant coronary artery narrowing was found. In all patients, 24-h esophageal pH-metry and manometry, and treadmill stress tests with simultaneous esophageal pH-metry and manometry monitoring were performed. During a 24-h examination the percentage of spontaneous chest pain (sCP) episodes associated with acid reflux or dysmotility (symptom index, SI) was calculated. Patients with SI > 50% for acid gastroesophageal reflux (GER) were classified as having GER-related sCP. The remaining symptomatic individuals were determined as having non-GER-related sCP. During the stress test, the occurrence of chest pain, episodes of esophageal acidification (pH < 4 for 10 s) and esophageal spasm with more than 55% of simultaneous contractions (exercise-provoked esophageal spasm or EPES) were noted. Sixty-eight (61%) individuals reported sCP during 24-h esophageal function monitoring. Eleven of these (16%) were classified as having GER-related sCP and 53/68 (84%) as having non-GER-related sCP. The exercise-provoked chest pain during a stress test occurred in 13/111 (12%) subjects. In order to compare the clinical usefulness of 24-h esophageal function monitoring and its examination limited only to the treadmill stress test, the standard parameters of diagnostic test evaluation were determined. The occurrence of GER-related or non-GER-related sCP was assumed as a "gold standard". Afterwards, accuracy, sensitivity and specificity were calculated. These parameters expressed a prediction of GER-related or non-GER-related sCP occurrence by the presence of chest pain, esophageal acidification and EPES. Accuracy, sensitivity and specificity of chest pain during the stress test predicting any sCP occurrence were 28%, 35% and 80%, respectively, predicting GER-related sCP were 42%, 0% and 83%, respectively, and predicting non-GER-related sCP were 57%, 36% and 83%, respectively. Similar values were obtained for exercise-related acidification with pH < 4 longer than 10 s in the prediction of GER-related sCP (44%, 36% and 92%, respectively) and EPES in relation to non-GER-related sCP (48%, 23% and 84%, respectively). The presence of chest pain, esophageal acidification and EPES had greater than 80% specificity to exclude the GER-related and non-GER-related causes of recurrent chest pain.

Relationship between carotid intima-media thickness and coronary angiographic findings: a prospective study

BackgroundSince cardiovascular diseases are associated with high mortality and generally undiagnosed before the onset of clinical findings, there is a need for a reliable tool for early diagnosis. Carotid intima-media thickness (CIMT) is a non-invasive marker of coronary artery disease (CAD) and is widely used in practice as an inexpensive, reliable, and reproducible method. In the current study, we aimed to investigate prospectively the relationship of CIMT with the presence and extent of significant coronary artery narrowing in patients evaluated by coronary angiography for stable angina pectoris.MethodsOne hundred consecutive patients with stable angina pectoris and documented ischemia on a stress test were included in the study. The patients were divided into two groups according to the result of the coronary angiography: group 1 (39 patients) without a noncritical coronary lesion, and group 2 (61 patients) having at least one lesion more than 50% within the main branches of the coronary arteries. All of the patients underwent carotid Doppler ultrasound examination for measurement of the CIMT by a radiologist blinded to the angiographic data.ResultsThe mean CIMT was 0.78 ± 0.21 mm in Group 1, while it was 1.48 ± 0.28 mm in Group 2 (p = 0.001). The mean CIMT in patients with single vessel disease, multi-vessel disease, and left main coronary artery disease were significantly higher compared to Group 1 (1.2 ± 0.34 mm, p = 0.02; 1.6 ± 0.32 mm, p = 0.001; and 1.8 ± 0.31 mm, p = 0.0001, respectively). Logistic regression analysis identified CIMT (OR 4.3, p < 0.001) and hypertension (OR 2.4, p = 0.04) as the most important factors for predicting CAD.ConclusionsThe findings of this study show that increase in CIMT is associated with the presence and extent of CAD. In conclusion, we demonstrated the usefulness of carotid intima-media thickness in predicting coronary artery disease but large-scale studies are required to define its role in clinical practice.

Positive Remodeling of the Coronary Arteries Detected by Magnetic Resonance Imaging in an Asymptomatic Population: MESA (Multi-Ethnic Study of Atherosclerosis)

The purpose of this study was to assess coronary arterial remodeling as a marker of subclinical atherosclerosis using coronary wall magnetic resonance imaging (MRI) in an asymptomatic population-based cohort.In early atherosclerosis, compensatory enlargement of both the outer wall of the vessel as well as the lumen, termed compensatory enlargement or positive remodeling, occurs before luminal narrowing.One hundred seventy-nine participants in the MESA (Multi-Ethnic Study of Atherosclerosis) trial were evaluated using black-blood coronary wall MRI. Coronary cross-sectional area (vessel size), lumen area, and mean wall thickness of the proximal coronary arteries were measured.Men had a greater vessel size, lumen area, and mean wall thickness than women (38.3 +/- 11.3 mm2 vs. 32.6 +/- 9.4 mm2, 6.7 +/- 3.2 mm2 vs. 5.3 +/- 2.4 mm2, and 2.0 +/- 0.3 mm vs. 1.9 +/- 0.3 mm, respectively, p < 0.05). No significant coronary artery narrowing was present by magnetic resonance angiography. Overall, coronary vessel size increased 25.9 mm2 per millimeter increase in coronary wall thickness, whereas lumen area increased only slightly at 3.1 mm2 for every millimeter increase in wall thickness (difference in slopes, p < 0.0001). Adjusting for age and sex, participants with an Agatston score >0 were more likely to have wall thickness >2.0 mm (odds ratio: 2.0, 95% confidence interval: 1.01 to 3.84).Coronary wall MRI detected positive arterial remodeling in asymptomatic men and women with subclinical atherosclerosis.

Latent left ventricular outflow tract obstruction induced by abnormal hypertrophic papillary muscle caused myocardial ischemia

Left ventricular outflow tract (LVOT) obstruction is a typical recognized feature in hypertrophic cardiomyopathy. However, it has been shown in other clinical scenarios such as acute ischemia. In some patients, LVOT obstruction may only be detectable with provocation testing such as exercise stress. Accurate and timely diagnosis, therefore, relies on recognizing an echocardiographic substrate in which LVOT obstruction may occur, such as ventricular hypertrophy. This report describes the case of a patient presenting with effort ECG and signs of myocardial ischemia, with no significant narrowing of coronary arteries but with latent LVOT obstruction due to the presence of an abnormal hypertrophic papillary muscle instead of a typical ventricle hypertrophy.

Comparison of Lipoprotein(a) Levels between Elderly and Middle‐Aged Men with Coronary Artery Disease

Lipoprotein(a) [Lp(a)] is known to be a risk factor for atherosclerotic disease in middle-aged men, but the role of Lp(a) in women and in the elderly is less clear. In most studies, excess Lp(a) is not associated with increased risk for persons >65 years of age. This study examined the strength of association of a number of risk factors to coronary artery disease (CAD) in groups of men <65 years (n = 108) and >65 of age (n = 66) with angiographically documented significant narrowing of coronary arteries. Serum Lp(a) concentrations were determined; elevated Lp(a) is positively associated with CAD for men <65 years (adjusted OR: 2.45, P <0.05) but not for men >65 of age (adjusted OR: 0.56, P = NS). For middle-aged men, elevated Lp(a) appears to be an independent risk factor for premature CAD, and the importance of Lp(a) as a risk factor appears to decrease with age. These data suggest that the utility of Lp(a) lipoprotein levels in predicting the risk of CAD in older men is limited. Factors, such as age; sex; levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides; carotid-wall thickness; smoking status; the presence or absence of diabetes and systolic and diastolic hypertension; body mass index (BMI); and other traditional risk factors, must be evaluated together to determine the risk of CAD for the entire population.

Das „Broken Heart”-Syndrom - Ein seltenes klinisches Phänomen

A clinical entity that mimics acute coronary syndrome with reversible left ventricular systolic dysfunction and is triggered by emotional stress was identified in 6 patients by screening a database of > 1000 patients with the ICD-10 coding of acute coronary syndrome. The search criteria were acute coronary syndrome, normal coronary anatomy, absence of coronary lesions and transient left ventricular dysfunction, triggered by emotional stress. We analyzed 6 patients, who fulfilled the criteria of (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing on angiography, (3) systolic dysfunction with abnormal regional wall motion ("apical ballooning") in the context of (4) severe psychological stress immediately before and triggering the cardiac events. The primary diagnosis for all 6 acutely ill patients accorded with the ICD-code of acute coronary syndrome. All patients had survived and eventually recovered with an LV ejection fraction of 60 +/- 5 %; P = 0.03 and had had recovered normal levels of physical activity at hospital discharge. Of note is the number of women of postmenopausal age. A transient cardiomyopathy triggered by major emotional stress may mimic an acute coronary syndrome but without significant coronary artery disease. This condition is characterized by reversible cardiac dysfunction and may be more frequent in women. It has a favorable clinical outcome.

Acute and Reversible Cardiomyopathy Provoked by Stress in Women From the United States

A clinical entity characterized by acute but rapidly reversible left ventricular (LV) systolic dysfunction and triggered by psychological stress is emerging, with reports largely confined to Japan. Over a 32-month period, 22 consecutive patients with this novel cardiomyopathy were prospectively identified within a community-based practice in the Minneapolis-St. Paul, Minn, area. All patients were women aged 32 to 89 years old (mean 65+/-13 years); 21 (96%) were > or =50 years of age. The syndrome is characterized by (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing by angiography; (3) systolic dysfunction (ejection fraction 29+/-9%), with abnormal wall motion of the mid and distal LV, ie, "apical ballooning"; and (4) profound psychological stress (eg, death of relatives, domestic abuse, arguments, catastrophic medical diagnoses, devastating financial or gambling losses) immediately preceding and triggering the cardiac events. A significant proportion of patients (37%) had hemodynamic compromise and required vasopressor agents and intra-aortic balloon counterpulsation. Each patient survived with normalized ejection fraction (63+/-6%; P<0.001) and rapid restoration to previous functional cardiovascular status within 6+/-3 days. In 95%, MRI identified diffusely distributed segmental wall-motion abnormalities that encompassed LV myocardium in multiple coronary arterial vascular territories. A reversible cardiomyopathy triggered by psychologically stressful events occurs in older women and may mimic evolving acute myocardial infarction or coronary syndrome. This condition is characterized by a distinctive form of systolic dysfunction that predominantly affects the distal LV chamber and a favorable outcome with appropriate medical therapy.

Frequency and clinical implications of fluid dynamically significant diffuse coronary artery disease manifest as graded, longitudinal, base-to-apex myocardial perfusion abnormalities by noninvasive positron emission tomography.

Diffuse coronary atherosclerosis is the substrate for plaque rupture and coronary events. Therefore, in patients with mild arteriographic coronary artery disease without significant segmental dipyridamole-induced myocardial perfusion defects, we tested the hypothesis that fluid dynamically significant diffuse coronary artery narrowing is frequently manifest as a graded, longitudinal, base-to-apex myocardial perfusion abnormality by noninvasive PET. In this study, 1001 patients with documented coronary artery disease by coronary arteriography showing any visible coronary artery narrowing underwent rest-dipyridamole PET perfusion imaging. Quantitative severity of dipyridamole-induced, circumscribed, segmental PET perfusion defects was objectively measured by automated software as the minimum quadrant average relative activity indicating localized flow limiting stenoses. Quantitative severity of the graded, longitudinal, base-to-apex myocardial perfusion gradient indicating fluid dynamic effects of diffuse coronary artery narrowing was objectively measured by automated software as the spatial slope of relative activity along the cardiac longitudinal axis. In patients with mild arteriographic disease without statistically significant dipyridamole-induced segmental myocardial perfusion defects caused by flow-limiting stenoses compared with normal control subjects, there was a graded, longitudinal, base-to-apex myocardial perfusion gradient significantly different from normal control subjects (P=0. 001) that was also observed for moderate to severe dipyridamole-induced segmental perfusion defects (P=0.0001), indicating diffuse disease underlying segmental perfusion defects; 43% of patients with or without segmental perfusion defects demonstrated graded, longitudinal, base-to-apex perfusion abnormalities beyond +/-2 SD of normal control subjects, indicating diffuse coronary arterial narrowing by noninvasive PET perfusion imaging.

Iodine-123 Metaiodobenzylguanidine Cardiac Imaging to Identify and Localize Vasospastic Angina Without Significant Coronary Artery Narrowing

Objectives. We assessed the ability of iodine-123 metaiodobenzylguanidine (MIBG) imaging to identify and localize coronary spasm and determined the most useful method of MIBG analysis in vasospastic angina without significant coronary narrowing.Background. Various noninvasive methods have been used to detect vasospastic angina, but they are not very sensitive in patients with sporadic attacks. MIBG imaging has recently been proposed as a useful tool for detecting vasospastic angina.Methods. Normal limits of both visual and quantitative analysis of two-dimensional polar maps (bull’s-eyes) for MIBG imaging were at first established in 59 normal subjects. For optimal criteria of visual analysis, we established regional differences in abnormal MIBG defect scores. An abnormal region of the bull’s-eye was defined as an area >2 SD below normal. An abnormal regional washout rate was defined as <0%. Using these criteria, we prospectively evaluated 104 patients with suspected vasospastic angina. Visual, bull’s-eye and regional washout rate analyses were compared for overall detection of the disease and for individual vessel involvement.Results. Overall sensitivity by these methods was 30%, 42% and 76%, respectively. Washout rate analysis showed a significantly higher sensitivity than the other two methods. Specificity was 78%, 72% and 87%, respectively. The sensitivity of detecting spasm-induced coronary artery with washout rate analysis was 82% for the left anterior descending (LAD), 76% for the right (RCA) and 69% for the circumflex (Cx) coronary arteries. The sensitivity of visual analysis was 29%, 15% and 35%, respectively; that for bull’s-eye analysis was 34%, 54% and 41%, respectively. Washout rate analysis showed a significantly higher sensitivity for LAD spasm than for the other two methods and a higher sensitivity for RCA and Cx spasms than for visual analysis.Conclusions. Regional washout rate analysis of MIBG imaging is a highly accurate technique for determining the presence and location of coronary artery spasm.

Detection of myocardial ischemia: value of combined myocardial perfusion and cineangiographic MR imaging.

Established noninvasive methods for assessing myocardial ischemia have limitations that might be overcome by MR imaging. We investigated MR myocardial perfusion imaging and MR ventriculography, before and after dipyridamole-induced stress, to determine whether the superior spatial and temporal resolution of MR imaging has advantages for the evaluation of myocardial ischemia. Eighteen patients with symptoms suggestive of myocardial ischemia were examined by use of MR perfusion imaging and MR cineangiography before and during dipyridamole-induced stress. Multiplanar gradient-echo MR cineangiography and cardiac gated fast low-angle shot (turbo-FLASH) MR imaging during injection of gadopentetate dimeglumine were used. Results were compared with findings from perfusion scintigraphy and coronary arteriography. The accuracy of the combination MR technique for detecting myocardial ischemia was similar to that of scintigraphy. No significant difference was found between the MR technique and scintigraphy for detecting segments of myocardium supplied by stenosed coronary arteries (> 70% reduction in diameter, as determined by coronary arteriography). The sensitivity of the combination MR technique for angiographically detecting significant coronary artery narrowing was 92%, and the specificity was 100%. For scintigraphy, the sensitivity was also 92% and the specificity was 100%. Initial results indicate that a combination of stress MR myocardial perfusion imaging and MR ventriculography is feasible and that this technique can detect myocardial ischemia with an accuracy similar to that of scintigraphy. This technique may make more complete noninvasive assessment of myocardial ischemia possible.

Relation of coronary artery disease in women

After age 40 years, coronary artery disease (CAD) is the leading cause of death in both women and men, yet in women the factors associated with, or leading to, CAD have been less extensively studied. This study examined the strength of association of a number of risk factors to CAD in groups of women <60 years of age with (n = 108) and without (n = 66) angiographically documented significant narrowing of coronary arteries. In univariate analyses, there were significant differences between control subjects and patients with regard to age (49 ± 6 vs 52 ± 7 years) and total lipids and apolipoproteins measured. The relative frequency of cigarette smoking and diabetes was higher and that of estrogen replacement therapy lower in patients with CAD than in control subjects. In multivariate analysis the following factors were independently associated with CAD (adjusted odds ratios and 95% confidence intervals): total cholesterol to high-density lipoprotein (HDL) cholesterol (1.91; 1.56 to 2.34); lipoprotein (a) (10.66; 3.51 to 32.35); estrogen replacement (0.24; 0.11 to 0.54); age (1.12; 1.04 to 1.18); and smoking (1.50; 0.98 to 2.29). The nonadjusted odds ratio of CAD, based on combined tercile values of lipoprotein (a) serum level and total cholesterol to HDL cholesterol ratio, was very low (0.15; 0.06 to 0.36) when both values were within the first tercile, but very high (16.63; 3.54 to 78.07) when both were in the third tercile. In conclusion, the serum lipoprotein (a) level and the total cholesterol to HDL cholesterol ratio were the risk factors most closely associated to CAD in women, and the determination of lipoprotein (a) should complement the measurement of classic lipids in the screening and the diagnostic workup of that disease.