Significant Obstructive Lesions Research Articles

Offline Assessment of the Quantitative Flow Ratio: Is it Useful in Clinical Practice?

Fractional flow reserve (FFR) has been established as the gold standard in the physiological assessment of coronary obstructions severity. However, the need to insert an intracoronary pressure guidewire is a factor that limits its use. Quantitative flow ratio (QFR) is a method that infers the value of FFR from 3-dimensional quantitative coronary angiography (3D-QCA), eliminating the use of a pressure wire and coronary hyperemia. The present study aims to evaluate the diagnostic accuracy of QFR and 3D-QCA in comparison with FFR for the identification of significant obstructive coronary lesions (FFR ≤.80) and the feasibility to assess QFR in a cohort of patients without dedicated angiographic acquisition. Consecutive patients with coronary angiography with moderate obstructive lesions that had previous FFR measurement were evaluated. Validation of QFR was assessed by the area under the curve (AUC) and other statistical tools, using FFR as the reference method. Seventy-five arteries from 69 patients were evaluated. The accuracy of the QFR to detect FFR ≤.80 was 84.0% (95% confidence interval, 75.6-92.4). The correlation and agreement between FFR and QFR were r=0.54 (P<.01) and mean difference was -0.02 ± 0.09 (P=.09), respectively. The AUC of QFR and 3D-QCA identifying stenosis >50% was 0.854 and 0.755, respectively (P=.09). QFR demonstrated good accuracy compared with FFR for the assessment of moderate obstructive coronary lesions in an unselected clinical practice population. However, many patients were excluded from the analysis and there was no statistical difference between the receiver operator characteristic curves of the QFR and percent diameter stenosis.

Management of myocardial infarction and ischemia without obstructive coronary arteries: insights from a case series

Acute coronary syndromes typically result from the formation of atherosclerotic lesions in a large epicardial vessel, which restrict blood flow either partially or completely. These lesions can be identified through angiography, an invasive imaging technique that enables visualization of the coronary arteries. However, a small percentage of patients, usually ranging from 5% to 10%, experience symptoms and/or signs of myocardial ischemia, either acute or chronic, without significant obstructive coronary lesions visible on angiography. This condition is particularly prevalent in young women and is characterized by two distinct forms: myocardial infarction with no obstructive coronary arteries (MINOCA) and myocardial ischemia with no obstructive coronary arteries (INOCA). MINOCA can be caused by a variety of heterogeneous mechanisms, including coronary vascular spasm, microvascular disease, spontaneous coronary dissection, and plaque rupture or erosion. Conversely, coronary vasospasm and microvascular dysfunction account for the majority of patients with INOCA. We here present three cases of MINOCA/INOCA that were evaluated using optical coherence tomography, coronary flow reserve, index of microcirculatory resistance, and acetylcholine provocative test. These diagnostic tests allowed us to identify a specific condition and adopt a targeted treatment for each patient.

CLINICAL AND ANGIOGRAPHIC SPECTRUM AMONG CASES WITH LEFT MAIN CORONARY ARTERY DISEASE

Objective: Left main coronary artery disease (LMCA) is a significant threat factor for amplified morbidity and mortality in the analysis and treatment plan of coronary artery disease. Multivessel disease of other coronary arteries is seen in 80% of patients with left main disease. With drug-eluting stents and advances in percutaneous coronary intervention, the management of this disease is not purely surgical. Hence, angiographic profile of patients with left main coronary artery stenosis was evaluated. Methods: A total of 700 cases of significant coronary arterial disease clinical and those underwent coronary angiography were studied and their coronary angiogram was analyzed with respect to pattern of involvement. Results: Of these cases, 72 patients have LMCA disease of those 24 cases have obstructive and 48 cases have non-obstructive disease and among them, 63.9% were diabetic; 55.5% were hypertensive, 44.4% have dyslipidemia, and 48.6% were smokers. Mean age was 56.5 years and mode of presentation was non-ST-elevation myocardial infarction (STEMI) in 59.7%; CSA in 30.5%, and STEMI in 9.7% cases. Distal left main was most common involvement in 79.2% cases of which 61.1% have bifurcation and 18.1% have non-bifurcation lesions. Isolated ostial involvement is seen only in 6 patients. 93% had involvement of other coronary arteries, 9.7% had SVS; 22% had DVD; and 61% had TVD. Conclusion: Overall, the incidence of LMCA disease was 10.2% and 3.4% had only significant obstructive lesion. Distal bifurcation was the most common form of involvement and TVD was reported to be the most common association.

Aumento do Trabalho Miocárdico Desperdiçado como Indicador de Lesão Coronariana Significativa

Introduction: The assessment of global myocardial work indices under baseline conditions may be useful for the clinical stratification of patients with suspected coronary obstruction. Objective: To correlate the value of global myocardial work indices and the presence of significant obstructive coronary lesions. Method: Cross-sectional study, with patients referred for elective coronary angiography. An echocardiogram was performed to obtain measurements to calculate the value of myocardial work and evaluated the presence or presence of significant obstructive coronary lesions at coronary angiography. Results: The sample consisted of 30 patients, with a mean age of 64.2±12.8 years, the majority being male (63.3%), of which 68.4% had significant obstructive coronary lesions. The global myocardial work indices was 1,876mmHg%±253.8 in the group with significant obstructive coronary lesions and 2,054.2mmHg%±417.3 in those without significant lesions (p=0.089). Global constructive myocardial work in patients without significant obstructive coronary lesions was higher (2,329.3mmHg%±462.9) than in those with significant obstructive coronary lesions (2,109.5mmHg%±332.3; p=0.064). Global wasted myocardial work was higher in patients with significant obstructive coronary lesions (103.7mmHg%±47.1 versus 68.3mmHg%±33.8; p=0.038). The cutoff point of 115 mmHg% was the one with the best area under the curve (0.625), with a sensitivity of 83.3%. Conclusion: The increase in global wasted myocardial work correlated with the presence of significant obstructive coronary lesions in our sample.

Abstract 9140: Validity of Coronary Angiography-Based Physiology in Clinical Practice

Introduction: The invasive physiological assessment of the severity of coronary obstruction is performed by hyperemic (FFR) and non-hyperemic (iFR) indices. However, the need to insert an intracoronary pressure guidewire are factors that limit its use. Quantitative flow ratio (QFR) is a method that infers the value of FFR, eliminating the use of a pressure wire and coronary hyperemia. Objectives: Evaluate the diagnostic accuracy of the QFR, diameter stenosis percentual (DS%) and area stenosis percentual (AS%) in comparison with the FFR, for identification of significant obstructive coronary lesions (FFR ≤ 0.80) and the feasibility to assess QFR in cohort of patients without dedicated angiographic acquisition. Methods: Consecutive patients with moderate obstructive lesions in coronary angiography that had previous FFR measurement were evaluated. Validation of QFR was assessed by accuracy, area under the curve (AUC), sensitivity, specificity, correlation coefficient and Bland-Altman plot, using FFR as reference method. Results: Out of 102 patients and 143 arteries assessed by the FFR, only 69 (67%) patients and 75 (52%) arteries were possible to be calculated by QFR. The accuracy of the QFR to detect an FFR ≤ 0.80 was 84.0% (95% CI: 75.6% to 92.4%), with a sensitivity of 67.9% (95% CI: 47.6% to 84.1%) and specificity of 93.6% (95% CI: 82.5% to 98.7%). The correlation and agreement between FFR and QFR were r = 0.54, p &lt; 0.01 and mean difference = -0.02 ± 0.09; p = 0.0874, respectively. The AUC to QFR, DS% and AS% comparison are represented in the attached figure. Conclusions: QFR demonstrated good accuracy and agreement, compared to the FFR, with moderate correlation in an unselected population of clinical practice. QFR and DS% demonstrated AUC greater than AS%. However, the high rate of exclusion in offline evaluations of angiograms recorded without dedicated acquisition protocol considerably limits the use of this tool in clinical practice.

Microvascular Angina : A Diagnosis Hidden in Plain Sight

Background: Patients who are initially suspected of having ischemic heart disease, but in whom normal coronaries are discovered at angiography, are frequently believed to have pain of a non-cardiac aetiology. Micro vascular angina is hardly ever diagnosed save in peri-menopausal women. Physicians traditionally tend to view coronary microvascular disease and obstructive coronary artery disease as two separate entities. Notwithstanding, recent studies have begun to focus on endothelial dysfunction as being a key component in all cardiovascular diseases, with or without obstructive coronary lesions. Hypothesis: Patients suspected of having obstructive coronary disease associated with a significant risk factor burden, but in whom normal coronaries are found at angiography, in reality possess microvascular dysfunction. Objectives: • To determine the prevalence of normal coronaries at elective angiography compared to subjects with significant obstructive lesions. • To examine the influence of risk factor burden in patients who present normal coronaries in comparison with those who demonstrate obstructive lesions at angiography. • To suggest endothelial dysfunction as the common nexus underlying the disparities in cardiovascular morbidity observed among population samples. Methods: A group of 90 patients were randomly selected from clinical files of those who underwent elective coronary angiography between January, 2013 and May, 2017. The study cohort was comprised of 55 males and 35 females between the ages of 43 to 84 years. All subjects presented chest pain suspected of being coronary in origin. Coronary risk factors were recorded for each patient and the results were compared with findings at coronary angiography and then correlated with those encountered in medical literature. Results: Normal coronary angiograms were more prevalent in the African-Caribbean population (54.16%), than within the Mestizo-Mayan population (37.5%) Conversely, the finding of an obstructive lesion was more common in the Mestizo-Mayan population (56.25%), than within the African-Caribbean group (31.25%). The African-Caribbean group generally possessed a greater risk factor burden than their Mestizo-Mayan counterparts. Mayan counterparts. The percentage of women with normal coronaries (52.94%) showed a slight increase over that of men (47.05%). Males possessed a prevalence for obstructive disease of almost 4 times greater (79.48% vs. 20.5%) than females, yet females demonstrated a greater risk factor burden than males in most risk parameters. Hypertension was the most prevalent risk factor followed by dyslipidaemia and diabetes mellitus but these factors were more commonly encountered in patients with “normal” coronaries, than in those with obstructive lesions. Conclusion: Our study reported a significant number (56.66%) of “normal” coronaries at angiography. The majority (54.16%) of this figure pertained to the African-Caribbean sub-group, which in other studies also appeared to have a lesser coronary disease morbidity and mortality than their white counterparts despite having a greater risk factor burden. This is particularly true in the female African-Caribbean population. Several research papers have made reference to racial, ethnic and gender disparities in the manifestation of cardiovascular diseases. Paradoxically in some cases risk factor burden may be higher in the non-obstructive group rather than in the obstructive population. Convincing research has led us to believe that the vascular endothelium in its state of dysfunction plays a key role in explaining these disparities. Wherever cardiovascular risk factors exert their damage, endothelial injury and dysfunction ensues. Therefore, having an established risk factor burden portends microvascular dysfunction independently of any angiographic result.

Coronary Microvascular Dysfunction.

Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed “ischemia with non-obstructive coronary artery disease” (INOCA) and for a small proportion of “myocardial infarction with non-obstructive coronary artery disease” (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).

Role of global longitudinal strain diastolic index in assessment of patients with suspected obstructive coronary artery disease and normal or mildly reduced ejection fraction

Objective – To examine the utility of global longitudinal strain imaging diastolic index (SI-DI) in the assessment of patients with suspected obstructive coronary artery disease (CAD). Methods – We performed rest 2D standard echocardiography and strain imaging in 30 healthy subjects and in 148 patients with normal or mildly reduced ejection fraction and indication for coronarography for suspected obstructive CAD. Standard echocardiographic and strain parameters were analysed. Results – Global SI-DI was signifi cantly lower in the selected vs control group (p &lt;0.001). After coronarography patients were divided in three subgroups: 74 patients with more than 50% obstruction in any major artery, 26 patients with previous revascularisation but no significant obstructive lesions at present and 48 patients without obstructive artery disease. Average global SI-DI was significantly lower in the subgroup with obstructive CAD vs the other two subgroups (p&lt;0.05). Global SI-DI lower than 0.5 had a good sensitivity (84%) and a reasonable positive predictive value (52%) for detection of obstructive CAD. Conclusions – Global SI-DI is significantly lower in patients with obstructive CAD and normal or mildly reduced ejection fraction compared with normal subjects. A cut off value lower than 0.5 selects patients with a higher probability of obstructive CAD.

P1539 Role of global longitudinal strain diastolic index in assessment of coronary artery disease in patients with stable angina and normal or borderline ejection fraction

Abstract Background Previous studies demonstrated that 2 D strain imaging segmental transverse diastolic index is a marker of regional ischemia and that global longitudinal strain diastolic index (GLSDI) correlates with left ventricular (LV) filling pressures and NTproBNP. However, usefulness of GLSDI in clinical practice has to be established. Purpose The aim of the study is to examine the utility of global longitudinal strain diastolic index in the assessment of patients with suspected ischemic heart disease (IHD). Methods We performed 2 D standard echocardiography and strain imaging in 30 healthy subjects and in 148 patients with stable angina with indication for coronarography. Patients with severe symptoms, severe valvulopathy, arrythmia and/or ejection fraction (EF) less than 45% were excluded. Standard echocardiographic parameters, left ventricular global longitudinal strain (LVGLS) and global longitudinal strain diastolic index were analysed. The patients subsequently underwent coronary angiographic examination. Results GLSDI was significantly lower in angina pectoris vs control group (0.41 vs 0,69, p &amp;lt;0.001). After coronarography patients were divided in three subgroups: 74 patients (50%) with more than 50% obstruction in any major artery, 26 patients (17.5%) with previous revascularisation but no significant obstructive lesions at present and 48 patients (32.5%) without obstructive artery disease. Average GLSDI was significantly lower in the subgroup with obstructive coronary disease vs the other two subgroups (0.32 vs 0.41 and 0.46 respectively, p &amp;lt; 0.05). Mean LVEF was different in subgroups but with no statistical significance (50 % vs 48 % vs 54 %, p= 0.08). Mean LVGLS was lower in the obstructive artery disease subgroup (-16.4% vs -18.2% vs -21% respectively, p&amp;lt; 0.05). In univariate analysis lower GLSDI was associated with a higher risk of coronary artery disease (Hazard Ratio 1.39, 95% Confidence Interval 1.09-1.49; p &amp;lt; 0.05 per 0.1% decrease). There was significant correlation between reduced GLSDI and the presence of coronary artery disease (r= -0,54, P &amp;lt; 0.05), hypertension (r=- 0.61, p &amp;lt; 0.05), left ventricular hypertrophy (-0.68, p &amp;lt; 0.05) and diastolic disfunction (-0.69, p &amp;lt; 0.05). GLSDI lower than 0.5 had a good sensitivity (84%) and negative predictive value (71%) and a lower specificity (40%) and positive predictive value (52%) for detection of ischemic heart disease. Conclusions Global longitudinal strain diastolic index is significantly lower in patients with stable angina and normal or borderline reduced ejection fraction compared with normal subjects. A cut off value lower than 0.5 selects patients with a higher probability of obstructive coronary heart disease.

P1496 Congenital anomalous origin of the left coronary system

Abstract A 62 year old gentleman presented with a history of recurrent central chest pains radiating to the left arm and jaw lasting up to 15-20 minutes and relieved with GTN. He had numerous admissions to hospital over a period of three years with negative Troponins and normal ECGs. There were several cardiovascular risk factors including obesity, diabetes, hypertension and dyslipidaemia. He also had a family history of ischaemic heart disease, with his mother and brother having heart attacks in their 60s. He was referred for outpatient investigations on multiple occasions but did not attend. This lead to a delay in a formal diagnosis until we eventually convinced him to undergo invasive diagnostic coronary angiography in June 2018. Prior to this, an Echocardiogram was done and showed reasonably preserved cardiac systolic function. Coronary angiography demonstrated unique anatomical distribution of the three main coronary vessels, with an anomalous origin of the left main system (LMS) and left sided arteries arising from the right coronary cusp. The right coronary artery stemmed from its natural position and was the dominant vessel. Hence, all the coronary arteries arose from the same cusp. The LMS was anomalous and hypoplastic; an exceedingly rare occurrence of less than 0.03%. These unusual findings were then confirmed on CT Coronary Angiogram. Although a surgical opinion was sought, the decision was a non-operative approach in view of no significant obstructive lesions and given the technical difficulties of undertaking coronary bypass. Viability imaging and ischaemia testing were then pursued with nuclear modalities. Ultimately, it was proven that the lesions did not show any significant reversible ischaemia and so a continued aggressive secondary prevention strategy was adopted. The patient is stable and doing well on optimal medical therapy. Abstract P1496 Figure. LMS Arising From Right Coronary Cusp

QUANTITATIVE CORONARY PLAQUE CHARACTERIZATION WITH MULTIDETECTOR CT ANGIOGRAPHY

Background: Coronary artery disease (CAD) is a major cause of morbidity and mortality. Coronary atherosclerosis is a progressive disease with sudden destabilizing changes leading to plaque thrombosis and reorganization. Aim of work: Quantitatively characterize coronary atherosclerotic plaque composition in patients with CAD referred to Ain shams radiology department (El Demerdash Hospital) by using CT coronary angiography and compare prevalence of different plaque types. Patients and Methods: Seventy-eight patients of CAD symptoms (49 male, 29 female; mean age, 54.8 years) underwent CT coronary angiography (CTCA). Each patient underwent a non-contrast scan to determine the calcium score, then a contrast enhanced ECG gated scan. Coronary plaques were analysed as regard number, type, severity and plaque volumes by using semiautomated software. Results: 14 patients had normal CTCA, 37 patient had significantobstructive lesions, and 4 of them had a totally occluded coronary vessel. A total of 232 coronary vessel plaques were found. The number of patients with multi-vessel disease was significantly higher in diabetic patients verses non diabetics. Noncalcified plaques were more prevalent (than calcified plaques), in patients 55 years only 39.3% of their plaques were noncalcified. Conclusion: Multi-slice CTCA is the non-invasive alternative to intravascular ultrasonography (IVUS) for plaque quantification, it is a reliable technique to detect CAD and estimate the degree of obstruction, number of affected vessels and the pattern of theiraffection. Using automated software provide the major advantage of higher reproducibility.

Recurrent acute coronary syndrome in a patient with right coronary artery ectasia: a case report

BackgroundCoronary artery ectasia is characterized by an abnormal dilatation of the coronary arteries. Coronary artery ectasia is observed in 3–8% of patients undergoing coronary angiography and sometimes leads to acute coronary syndrome regardless of the presence or absence of coronary stenosis or atrial fibrillation.Case presentationA 61-year-old Indonesian man presented with typical angina that began 1 week before admission and had worsened 3 hours prior to admission. Accompanying symptoms included dyspnea, nausea, and sweating. He was hemodynamically stable and had a history of tobacco smoking and dyslipidemia. An electrocardiogram showed ST-segment depression and T inversion. Laboratory results showed an international normalized ratio of 1.28. Dual antiplatelet therapy was administered along with fondaparinux, and symptoms were alleviated. Coronary angiography showed an ectatic and turbulent mid-distal right coronary artery and slow flow at the first presentation. There was a patent stent in the proximal-mid left anterior descending coronary artery. This patient had previously presented with recurrent acute coronary syndrome and received two coronary stents for the stenotic vessels.DiscussionHe had right coronary artery ectasia and experienced recurrent acute coronary syndrome. He received dual antiplatelet therapy along with warfarin after stenting of his left anterior descending coronary artery. However, he presented with unstable angina pectoris 7 months before the latest admission and at the latest admission despite a patent stent and no other significant obstructive lesion. The unstable angina pectoris might have been caused by slow flow, microvascular angina caused by small thrombi and/or vasospasm, or epicardial thrombosis at the ectatic coronary artery that dissolved after anticoagulation therapy prior to coronary angiography. Anticoagulant therapy may have a greater benefit than antiplatelet therapy in this patient due to the turbulence and stasis of blood in the ectatic vessel, although coexisting coronary conditions mandated antiplatelet therapy. His international normalized ratio was suboptimal and needed to be improved.ConclusionCoronary ectasia may play a role in recurrent acute coronary syndrome, and administration of an anticoagulant to prevent acute coronary syndrome in this patient was in accordance with the varying hemodynamic property of coronary artery ectasia.

Sensitive Troponin I and Stress Testing in the Emergency Department for the Early Management of Chest Pain Using 2-Hour Protocol.

Despite improvements in identifying high-risk patients with non-ST segment ACS (acute coronary syndrome), low risk patients presenting with atypical chest pain and non-diagnostic Electrocardiogram (ECG) continued to undergo unnecessary admissions and testing. Since 1992, our chest pain protocol included using 4-hour serial biomarkers from ED admission in combination with stress testing to evaluate these patients. Our study aimed at determining whether a new accelerated diagnostic protocol using sensitive cardiac troponin I (cTnI) 2 hours after admission to the ED followed by stress testing is safe and effective in emergency settings, allowing for appropriate triage, earlier discharge and reducing costs. We conducted a single center randomized trial at Presence St. Francis Hospital Chest pain center in Evanston, Illinois enrolling sixty-four consecutive patients with atypical chest pain and non-diagnostic ECG, participants were randomized to accelerated 2 hrs protocol or our pre-existing 4-hrs protocol. Sixty patients completed the protocol and were randomized to either a 2-hour (29 patients) or 4-hour protocol using both I-STAT and PATHFAST cTnI (31 Patients). Troponin I was evaluated at 0 and at 2 hours from ED presentation with and additional draw for patients in the 4-hour rule out-group. Patients with normal serial biomarkers were then evaluated with stress testing and qualified for earlier discharge if the stress test was negative, while those with a positive biomarker at any time were admitted. Thirty-six patients had exercise treadmill stress test and 24 patients had either nuclear or Echo stress test. Fifty-three patients had a normal stress test and were discharged home. One patient in the 4-hour group with normal serial troponins developed ventricular tachycardia/fibrillation during the recovery period of a regular stress test. Six patients had a positive PATHFAST cTnI and a normal I-STAT cTnI at 2-hours. Two out of these six patients evaluated by coronary angiography. One patient had severe tortuous coronaries but no significant obstructive lesion and one had a severe CAD who needed Coronary artery bypass grafting (CABG). Three of the six patients had a normal stress test and one patient decided to leave without further testing. None of the patients with a normal stress test had a major cardiac event or adverse cardiac outcome at six-month follow up. This study demonstrates that the 2 hours accelerated protocol using high sensitivity Troponin assay at 0 and 2 hours with comprehensive clinical evaluation and ECG followed by stress testing might be successful in identifying low-risk patient population who may benefit from early discharge from ED reducing associated costs and length of stay.

A Case of OCT Elucidating Coronary Plaque Rupture in Patient With Coronary Angiography With No Culprit Lesion Post STEMI

A 48-year-old gentleman with no significant past medical history presented with STEMI with significant anterior lead ST segment elevation and significant troponin rise thrombolysis was carried out in a referring hospital. Diagnostic coronary angiography carried out in our institution (Wellington Hospital) 1 day post thrombolysis revealed no significant obstructive lesions. There was a small stump in the area of the proximal LAD not consistent with site of origin of coronary vessels. OCT was utilised to establish nature of disease in the proximal LAD. Pullback of OCT revealed ruptured plaque in the proximal LAD consistent with clinical presentation of patient. There was a large lipid core distal to ruptured plaque. ‘Stump’ identified on coronary angiogram represented filling defects as a result of rupture plaque. Decision made for conservative management in view of no flow limiting lesion. Dual antiplatelet therapy for 1 year prescribed in view of OCT findings. Conclusion: This case highlights the important role of intravascular imaging (OCT) in elucidating underlying aetiology of patients presenting with acute coronary syndrome with no obstructive lesion identified by coronary angiography alone.

THE ASSESSMENT OF PRETEST PROBABILITY IN OBSTRUCTIVE CORONARY LESION DIAGNOSTICS: UNRESOLVED ISSUES

Invasive coronary arteriography is a gold standard in CHD diagnostics, however in many cases it ends with none significant obstructive lesions revealed. Recently, an algorithm was implemented, based on the assessment of pretest probability (PTP) of coronary heart disease. It is noteworthy that current international guidelines do differently recommend the PTP calculation, there are differences in further tactics of non-invasive and invasive investigation. Also, real clinical practice witness on significant overestimation of PTP when the recommended scores are in use. The review is focused on different PTP scores, the reasons discussed for differences in results of application. This helps to make clinical usage more conscious.

The relation between coronary tortuosity and calcium score in patients with chronic stable angina and normal coronaries by CT angiography

PurposeCoronary tortuosity (CorT) is a phenomenon often noticed by cardiologists and may be associated with stable angina even without significant lesion. We aim to determine the relationship between CorT and coronary artery calcium (CAC) scoring in patients with chronic stable angina and normal or near normal coronaries detected by computed tomography (CT) angiography. MethodsThis is a cross sectional retrospective study included all patients with stable angina underwent CT coronary angiography and calcium scoring that reveals normal or non-significant coronary artery lesion. The presence of CorT was revised. CorT is defined as a fixed ≥3 bends during both systole and diastole, with each bend ≥45°. ResultsThe study involved 83 patients. CT angiography revealed 31 patients (37.3%) with tortuous one or more coronary arteries and 52 patients (62.7%) without any CorT. The patients were divided into 2 groups; those patients with tortuous coronary arteries (CorT group) and those without coronary tortuosity (N CorT group). There was no significant difference between both groups regarding age, presence of DM, and dyslipidemia. However, there was a highly significant difference between both groups regarding hypertension with more hypertension among the CorT group (p value < 0.001). There was a significant difference between both groups in CAC score with high CAC score in the CorT group (p value < 0.05). There was significant correlation between CorT and CAC score (unadjusted p = 0.06); if adjusted for co-variated affecting CorT (p = 0.022). ConclusionCorT is associated with subclinical atherosclerosis and increased CAC score even in the absence of significant obstructive lesion.

Role of multi-slice CT coronary angiography in evaluating the different patterns of coronary artery disease in patients with unstable angina

ObjectiveTo evaluate the different patterns of coronary artery disease among patients with unstable angina by the role of multislice CT coronary angiography. Patients and methodsFrom September 2013 to May 2014, 40 patients complaining from unstable angina showing initial negative ECG and troponin enzyme underwent a multi-slice CT coronary angiography. Each patient underwent a non-contrast scan to determine the calcium score, then a contrast enhanced ECG gated scan, then the obtained axial images were reconstructed on an advanced workstation. Finally, a systematic analysis of the coronary artery lesions was performed. Results9 patients had normal CTCA, 5 had dense coronary calcification, 16 had no significant obstructive lesion and 10 patients had significant CAD. A total of 60 coronary vessels were found to have plaques. The number of patients with multi-vessel disease was significantly higher than those with single-vessel disease at the time of diagnosis. ConclusionNon-invasive multi-slice CT coronary angiography is a reliable technique of high ability to detect coronary artery disease and estimate the degree of obstruction, number of affected arteries and the pattern of their affection and can be used in workup in patients with unstable angina.

Non-stenotic coronary lesion — is it really non-ischemic?

E-mail: alexander.kisko@unipo.sk Coronary angiography has a diagnostic limitation in identifying non-stenotic coronary lesion (NSCL) responsible for ischemia. Although an abnormal fractional flow reserve (FFR) increases the probability of significant obstructive lesions, it cannot reliably distinguish intermediate epicardial stenosis from ischemic, diffuse atherosclerosis or microvascular disease. Myocardial perfusion defects in patients (pts) with NSCL have often been unreasonably considered by invasive cardiologists to be falsely positive. We evaluated a prognostic value of gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in unselected group of the pts with NSCL over a 24 month period of follow-up. 170 pts (115 males, 67.6%; aged 42-68; mean age 56.4±9.2 years) with NSCL (stenosis of 50% or less of left anterior descending artery and 70% or less of any other coronary artery or its major branches, FFR cut-off 0.80) were enrolled into the study. Retrospective analysis of 86 pts with NSCL and subsequent positive MPS performed within 6 months from the time of coronary angiography (study group) and 84 pts with normal scan results (control group) was performed. The follow-up period lasted for 24 months from the time of MPI or up to the time of major coronary event (MCE) — first occurrence of cardiac death or myocardial infarction. Over a two-year follow-up, approximately 11% of the pts in the study group had MCE as compared to 3.2% in the control group (P <0.01). Abnormal MPI, EF <35% and high levels of hs-CRP were independent predictors for MCE in the study group. In multivariate analysis only an abnormal MPI remained to be an independent predictor regardless of the size or severity of perfusion abnormalities (P <0.005). Pts with NSCL on coronary angiography and myocardial perfusion defects have relatively high event rate (11%) of MCE over a period of 24 months from the time of MPI. So, we highly recommend gated SPECT MPI to be performed in cases of NSCL to look for possible ischemia and to avoid life-threatening coronary complications in the forthcoming future. It can also prevent unnecessary repeatedly performed coronary interventions for identifying lesion responsible for angina in NSCL.

Relationship between type 2 diabetes mellitus and coronary artery lesion characteristics: a single center study

Background: Coronary atherosclerotic burden is excessive in diabetic patients. The aim of present study was to assess the relationship between diabetes mellitus and plaque characteristics in patients with coronary artery disease.Methods: The coronary angiograms of 223 patients with significant obstructive lesions during April 2011 to May 2013 in College of Medical Sciences and Teaching Hospital were analyzed. The coronary lesions of patients with and without type 2 diabetes were compared. Results: 81 diabetic and 142 non-diabetic patients had significant coronary artery disease. Diabetic patients had more multivessel (64.2% versus 55.6%, p&lt;0.05), and small vessel disease (74.1% versus 54.9%, p&lt;0.05) than nondiabetic patients. Moreover, complex Type C lesion was significantly higher in the diabetic patients as compared to the nondiabetic patients (55.5% versus 29.6%, p&lt;0.01). Conclusions: Complex coronary lesions were significantly more common in diabetic patients than in nondiabetic patients. Nepalese Heart Journal | Volume 10 | No.1 | November 2013| Pages 20-22 DOI: http://dx.doi.org/10.3126/njh.v10i1.9742

Cardio-embolic stroke following remote blunt chest trauma

A cardio-embolic stroke as a sequela of remote blunt chest trauma is a rare clinical presentation. Blunt chest trauma can cause various acute cardiac complications like arrhythmias, cardiac contusion etc. However, delayed consequences such as left ventricular thrombus resulting in thromboembolic phenomena are reported infrequently.A 30-year-old healthy man presented to an outside facility with transient neurological deficits. An MRI brain showed lesions suggestive of embolic etiology. A trans-thoracic echocardiogram (TTE) showed a 1.5 × 1.5 cm mass present in the left ventricular (LV) apex. Patient was transferred to our institution for cardiac surgery evaluation. On detailed questioning, he reported an incident of blunt chest trauma during a martial arts exhibition fight that took place 2 years back. Given this history, a cardiac catheterization was done, which showed 30% stenosis in mid-left anterior descending artery (LAD) without any other significant obstructive lesion. A trans-esophageal echocardiogram (TEE) showed akinesis of the LV apex and confirmed TTE finding of a mass, consistent with an apical thrombus. Surgery was deferred and patient was started on anticoagulation. A cardiac MRI done 2 weeks later showed evidence of apical infarction in the LAD territory.LAD is the most commonly affected coronary vessel by blunt traumatic injuries, likely due to its vulnerable anatomical position on the anterior aspect of the heart. A variety of mechanisms including intimal tear, rupture and spasm have been implicated in the pathogenesis of myocardial infarction after blunt chest trauma.