Significant Atherosclerotic Disease Research Articles

Coronary Steal Phenomenon and Altered Myocardial Microcirculation Demonstrated by Contrast Enhanced Echocardiography in Apical Hypertrophic Cardiomyopathy Presenting as an Acute Coronary Syndrome

A 55 year-old female was admitted for central chest pain on a background of hypertension and morbid obesity. 12-lead electrocardiogram revealed sinus rhythm and T-wave inversion inferolaterally. Coronary angiography revealed no significant atherosclerotic epicardial coronary artery disease. Contrast blush was noted in the left ventricular (LV) cavity. Left ventriculography “spade-like” morphology was suggestive of apical hypertrophic cardiomyopathy (ApHCM) (Fig. 1). Cardiac MRI confirmed increased apical wall thickness (17 mm), mid-chamber obliteration during systole and contrast enhancement in thickened apical segments (Fig. 2). Transthoracic echocardiography (TTE) confirmed normal LV size and function (LVEF = 65%) with increased LV apical wall thickness (Fig. 3). Figure 2cMRI. View Large Image Figure Viewer Download Hi-res image Figure 3TTE. View Large Image Figure Viewer Download Hi-res image

The effect of revascularization in patients with anatomically significant atherosclerotic renovascular disease presenting with high-risk clinical features.

Patients with atherosclerotic renovascular disease (ARVD) and high-risk clinical presentations have largely been excluded from randomized controlled trials comparing renal revascularization and optimal medical therapy. Here, we explore the effect of revascularization on death, progression to end-stage kidney disease (ESKD) and cardiovascular events (CVE) in a highly selected cohort of patients with ARVD. All patients with a radiological diagnosis of ARVD referred to our tertiary centre have been recruited into a single-centre cohort study between 1986 and 2014. Patients with ≥70% unilateral or bilateral ARVD together with one or more of the following putative high-risk presentations were designated 'high-risk': flash pulmonary oedema (FPE), severe hypertension, rapidly deteriorating renal function. The effect of revascularization on clinical outcomes in high-risk patients, patients with bilateral severe ARVD and those with <1 g proteinuria at baseline was compared with 'control' patients who had the same degree of renal artery stenosis (RAS) but did not exhibit these features. Median follow-up was 58.4 months [interquartile range (IQR) 25.4-97.3]. Revascularization was associated with a reduced risk of progression to ESKD, CVE and all combined events in patients with rapidly deteriorating renal function [ESKD: hazard ratio (HR) 0.47 (95% confidence interval, CI, 0.25-0.85), P = 0.01; CVE: HR 0.51 (95% CI 0.29-0.91), P = 0.02; Any: HR 0.51 (95% CI 0.29-0.90), P = 0.02]. High-risk patients with bilateral ≥70% RAS and those with <1 g/day baseline proteinuria also had significantly better renal and cardiovascular outcomes post-revascularization when compared with controls. Our results indicate that revascularization may be of benefit in patients with anatomically significant RAS who present with rapidly deteriorating renal function, especially in the presence of severe bilateral ARVD or <1 g/day proteinuria.

Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study

Conventional coronary artery disease risk factors might potentially explain at least 90% of the attributable risk of coronary artery disease. To better understand the association between the pre-industrial lifestyle and low prevalence of coronary artery disease risk factors, we examined the Tsimane, a Bolivian population living a subsistence lifestyle of hunting, gathering, fishing, and farming with few cardiovascular risk factors, but high infectious inflammatory burden. We did a cross-sectional cohort study including all individuals who self-identified as Tsimane and who were aged 40 years or older. Coronary atherosclerosis was assessed by coronary artery calcium (CAC) scoring done with non-contrast CT in Tsimane adults. We assessed the difference between the Tsimane and 6814 participants from the Multi-Ethnic Study of Atherosclerosis (MESA). CAC scores higher than 100 were considered representative of significant atherosclerotic disease. Tsimane blood lipid and inflammatory biomarkers were obtained at the time of scanning, and in some patients, longitudinally. Between July 2, 2014, and Sept 10, 2015, 705 individuals, who had data available for analysis, were included in this study. 596 (85%) of 705 Tsimane had no CAC, 89 (13%) had CAC scores of 1-100, and 20 (3%) had CAC scores higher than 100. For individuals older than age 75 years, 31 (65%) Tsimane presented with a CAC score of 0, and only four (8%) had CAC scores of 100 or more, a five-fold lower prevalence than industrialised populations (p≤0·0001 for all age categories of MESA). Mean LDL and HDL cholesterol concentrations were 2·35 mmol/L (91 mg/dL) and 1·0 mmol/L (39·5 mg/dL), respectively; obesity, hypertension, high blood sugar, and regular cigarette smoking were rare. High-sensitivity C-reactive protein was elevated beyond the clinical cutoff of 3·0 mg/dL in 360 (51%) Tsimane participants. Despite a high infectious inflammatory burden, the Tsimane, a forager-horticulturalist population of the Bolivian Amazon with few coronary artery disease risk factors, have the lowest reported levels of coronary artery disease of any population recorded to date. These findings suggest that coronary atherosclerosis can be avoided in most people by achieving a lifetime with very low LDL, low blood pressure, low glucose, normal body-mass index, no smoking, and plenty of physical activity. The relative contributions of each are still to be determined. National Institute on Aging, National Institutes of Health; St Luke's Hospital of Kansas City; and Paleocardiology Foundation.

ACUTE CORONARY SYNDROME;

Microalbuminuria is a strong and independent indicator of increased cardiovascularrisk among individuals with and without diabetes and hypertension. The pathophysiologicmechanism underlying the association between albumin excretion and cardiovascular disease(CVD) is that microalbuminuria can be a predictor of CVD risk as it reflects the vascular damagein kidneys. It also shows endothelial damage predicting CV disease risk. Based on this theory,periodic screening for microalbuminuria could allow early identification of vascular diseaseand help stratify overall cardiovascular risk, especially in patients with risk factors such ashypertension or diabetes. Therefore microalbuminuria can be used for stratification of risk forcardiovascular disease. Once microalbuminuria is present, cardiovascular risk factor reductionshould be aggressive. Objectives: The objective of the study was to determine the role ofmicroalbuminuria as an atherosclerotic risk factor and its association with coronary arterydisease. Study Design: Cross-sectional study. Duration of Study: Duration of study was6 months with first patient enrolled on 16-03-2007 and last patient enrolled on 15-09-2007.Setting: Medical Unit-III and CCU Allied Hospital, Faisalabad. Subjects: 300 patients withacute coronary syndrome, admitted in Allied hospital Faisalabad were enrolled. Methods: 300patients diagnosed as having acute coronary syndrome admitted in Allied hospital Faisalabad,were included in the study. Early morning urine as well as 24 hour urine had been collectedin sterilized urine bags and microalbuminuria was tested. Results: In this study 300 patientshaving acute coronary syndrome were enrolled. Microalbuminuria was positive in 66 (22%)patients and 234 (78%) patients had no microalbuminuria. There was significant associationbetween microalbuminuria and atherosclerotic coronary artery disease. Conclusion: It isconcluded that microalbuminuria is an atherosclerotic risk factor and it is strongly associatedwith coronary artery disease.

Prevalence of Significant Carotid Artery Stenosis in Patients with Significant Atherosclerotic Peripheral Arterial Disease

Background: Peripheral arterial disease (PAD) and carotid occlusive disease (COD) are both known to be specific manifestations of atherosclerosis so can be correlated to each other. An important area of investigation is to identify those with significant carotid artery stenosis (CAS) to reduce the risk of cerebrovascular events. Duplex ultrasound scanning (DUS) is considered a valuable imaging modality to evaluate carotid arteries with high sensitivity and specificity and virtually non-existent hazards. Objectives: We investigated the prevalence of significant CAS among patients with severe peripheral vascular disease (PVD) using carotid duplex. Methods: A total of 50 patients with PVD diagnosed as having significant PAD by peripheral angiography (PA) underwent carotid duplex scanning. Data were collected concerning known risk factors. Significant CAS was defined as a stenosis of 70% or greater. Results: The mean age was 61.6 ± 8.5 years, male (88%). Out of the 50 patients with significant PAD, 7 patients (14%) had significant Carotid Stenosis of which 6 patients (12%) had severe stenosis and 1 patient (2%) had totally occluded carotid artery. CAS was correlated with diabetes, hypertension, dyslipidemia, smoking, coronary artery disease and severity of symptoms. On multivariate analysis, Diabetes and Dyslipidemia seemed to have independent influence. Conclusion: Significant CAS is prevalent among patients having significant PVD. Patients with PAD may be a suitable subgroup for screening for CAS using Carotid duplex, especially those with diabetes, dyslipidemia and positive CRP. Keywords: Carotid artery stenosis; Carotid duplex peripheral

Periprocedural myocardial infarction during percutaneous coronary intervention in an academic tertiary centre in Johannesburg

BackgroundPercutaneous coronary intervention (PCI) is effective therapy for significant atherosclerotic coronary artery disease. Despite medical and technological advances in PCI, periprocedural myocardial infarction (PMI) remains a common complication. The frequency and factors associated with PMI have been well investigated in the developed world, yet there is a paucity of data from the developing world, especially Sub-Saharan Africa. MethodsWe prospectively enrolled 153 adult patients undergoing PCI at the Charlotte Maxeke Johannesburg Academic Hospital from the 1st of February 2014 to 31st October 2014. Periprocedural Creatinine Kinase-MB and hs-Troponin I were routinely measured before PCI and at 16–24h post-procedure. The third universal definition of myocardial infarction was used to define a PMI event. Results152 participants met the inclusion criteria and were analysed for PMI. 70.4% participants were male. The mean age was 58.8 (SD 10.9) years old. Sixteen (10.5%) participants fulfilled the criteria for PMI. Side branch pinching with preserved TIMI III flow was noted in 62.5% of PMI cases. Duration of procedure (P=0.007), right coronary artery intervention (p=0.042) and total stent length (p=0.045) were independently associated with PMI. ConclusionPMI occurred in 10.5% of cases undergoing PCI. This is consistent with the prevalence of PMI internationally. Larger multicentre studies are required in our demographic region to further define relevant predictors and outcomes associated with PMI.

Congenital coronary artery anomalies in adults: review of 111 cases from a single-centre experience.

Coronary artery anomalies are a heterogeneous group of congenital disorders presenting with a wide spectrum of symptoms, ranging from vague chest pain to sudden cardiac death. Despite available data, there is no consensus about the classification, nomenclature, and outcomes of coronary anomalies in the normally connected heart. In this study, we aimed to investigate clinical and angiographic characteristics of coronary arterial anomalies, as well as the frequency of atherosclerotic involvement in anomalous coronaries, diagnosed at a tertiary referral centre. We retrospectively reviewed coronary angiograms performed between 2011 and 2015 for the presence of a coronary anomaly. A total of 111 patients with a final diagnosis of coronary anomaly were included in the study group. We also recruited 110 age- and sex-matched patients who underwent coronary angiography because of symptomatic coronary artery disease as controls. Among 36,893 coronary angiograms, 111 (0.30%) major coronary anomalies were found. Compared with controls, the prevalence of significant atherosclerotic coronary disease was lower in patients with coronary anomalies and stable symptoms (p=0.02); however, the prevalence of significant coronary atherosclerosis was similar among patients admitted with unstable angina or myocardial infarction (p>0.05). Compared with controls, patients with an anomalous left anterior descending coronary artery had significantly less atherosclerotic involvement than those in whom the left anterior descending artery was not anomalous (p=0.005). Although coronary artery anomalies are cited as a cause for myocardial ischaemia, atherosclerotic coronary artery disease is also frequent and may offer an alternative explanation to ischaemic symptoms. No predisposition to accelerated atherosclerosis was found, however, and atherosclerotic involvement was less frequent in some anomalous vessels.

Myocardial Infarction Caused by Coronary Artery Thromboembolism in a Atrial Fibrillation Patient on Rivaroxaban

SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Myocardial infarction (MI) is usually caused by a sudden occlusion of blood supply to cardiac muscle in the setting of atherosclerosis. Atrial fibrillation can cause a demand-supply mismatch leading to cardiac injury in the setting of rapid ventricular rate, however an embolic event to the coronary arteries secondary to atrial fibrillation is extremely rare, more so in the presence of anticoagulation. We present a unique case of coronary thromboembolic infarction in a patient with atrial fibrillation who failed anticoagulation with rivaroxaban. CASE PRESENTATION: A 58 y/o Caucasian male with a PMH significant for HTN, non-valvular atrial fibrillation and recent embolic stroke on rivaroxaban, biologic aortic valve replacement presented with sudden onset of sub-sternal chest pain. On exam, he was diaphoretic, tachycardic with irregular pulse, and faint crackles were heard over both of his lung bases. His EKG on admission showed atrial fibrillation with RVR and 1mm ST depressions in leads V5-V6 . Troponin I on admission was elevated at 0.08. His initial management included sublingual nitroglycerin, iv metoprolol and rivaroxaban was continued. His troponin levels however trended up to 9.56 at 12hrs. Repeat EKG remained unchanged. Heparin drip was started and subsequent cardiac cath showed a complete occlusion in the distal left circumflex artery with angiographic appearance of an embolus followed by successful embolectomy; he did not have any significant atherosclerotic disease in his other vessels. Given these findings, a post cardiac-cath TEE was done which revealed a new left atrial appendage clot which wasn’t present on a prior TEE done after his ischemic stroke few months ago. He was started on Coumadin and eventually discharged home on dual antiplatelet agents aspirin and clopidogrel. DISCUSSION: Systemic embolism is the most common major complication of atrial fibrillation. It is usually manifested as ischemic stroke, with peripheral embolization accounting for less then 10% of all embolic events1. Our case demonstrates the extremely rare scenario of cardio-cardiac embolization leading to MI. It is further made unique by the demonstration of failure of anticoagulant effect of rivaroxaban. Diagnosis is made by cardiac catheterization and demonstration of embolic clot within the vasculature, with further evidence of the origin of the clot as illustrated by the TEE. Treatment involves embolectomy followed by therapeutic anticoagulation. Our patient was switched to Coumadin and did well with INR maintained between 2 - 3. CONCLUSIONS: Our case elicits the importance of working up non-atherosclerotic causes of MI. Further studies may also be needed to support the use of novel anticoagulants in non-valvular atrial fibrillation. Reference #1: Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice? JAMA 2003; 290:2685. DISCLOSURE: The following authors have nothing to disclose: Steve Antoine, Dhruv Lowe, Kegan Jessamy, Obiajulu Anozie, Vincent Frechette No Product/Research Disclosure Information

OP.6C.05] THE POSSIBILITY OF IMPROVING THE COMPLIANCE TO THE TREATMENT BY USING OF ELECTRONIC VERSION OF SCORE IN HYPERTENSIVE PATIENTS

Objective: It is well-known that pts without signs of atherosclerotic disease are weakly motivated to drug treatment. We suggested that vivid demonstration to the pts their real risk and its favorable changes if achieving goals of therapy using electronic version of SCORE (EV SCORE) would lead to better motivation and compliance to drug treatment in hypertensive pts. Design and method: 140 hypertensive males aged 40–55 with high risk according to SCORE evaluation (all of them were smokers and had high level of total cholesterol - more than 5 mmol/l) and without signs of atherosclerotic disease were included in the trial. They were randomly divided in two groups by 70 pts in each. In one group total risk was calculated by using EV SCORE (main group). In the second group total risk was evaluated by chart version of SCORE (reference group). In both groups pts were shown not only initial risk but its change if achieving goals of therapy. All pts as high risk ones were prescribed antihypertensive and lipid-lowering drugs as well as healthy life-style recommendations during 9 months. Results: Compliance to both antihypertensive and lipid lowering therapy was significantly higher in the group where EV SCORE was used. In this group 46 pts out of 70 (65,7%) remained on antihypertensive drugs by the end of the study, while only 35 pts (50,0%) - in reference group, p < 0,05. The difference especially was pronounced concerning lipid- lowering treatment. The percentage of pts who remained on lipid- lowering drugs by the end of the study was significantly higher in the main group comparing with the reference group – respectively 42 pts (60,0%) and 12 pts (17,1%), p < 0,001. As a result more pts in the main group achieved blood pressure and lipid variables goals, then in the reference group. Conclusions: Results show, that using EV SCORE in clinical practice allows not only quick evaluation of total risk but also motivates hypertensive pts without signs of atherosclerotic disease to better compliance to antihypertensive and lipid-lowering therapy.

In-Stent Restenosis After Carotid Artery Stenting: From Diagnosis to Treatment

Although carotid artery stenting is a safe and effective treatment for preventing ischaemic stroke in significant carotid atherosclerotic disease, it can be complicated by in-stent restenosis (ISR). Factors involved in the ISR process are both mechanical and patient-related, but the most important is the neointimal thickening within stent struts, leading to lumen reduction. Overall incidence of carotid ISR is low and related embolic risk seems to be lower than native disease. Digital subtraction angiography is the gold standard for diagnosis. Nowadays, Doppler ultrasound should be considered the first-line investigation, due to its non-invasiveness and reproducibility. Computed tomography angiography remains useful when Doppler ultrasound is inconclusive. Indication and modality of treatment of ISR are still debated: both surgery (carotid endarterectomy with stent removal in most cases) or interventional procedures such as percutaneous transluminal angioplasty with simple balloon, cutting-balloon, drug-eluting balloon, and stenting, showed safety and efficacy in follow-up. Surgery is currently reserved for selected cases. Carotid ISR is an overall rare complication which can be easily identified at routine follow-up. This paper is a literature review and state-of-the-art assessment of ISR, clinical features, diagnosis, and treatment.

Anomalous Origin of the Right Coronary Artery with Inter-Aorto-Pulmonary Course Highlighted by ECG-gated Cardiac CT Angiography

Case presentation: A 46-year-old male was referred to the echo laboratory for further investigations of a 6-months history with typical chest pain that is predictably exertional. His past medical history was largely unremarkable and so was his cardiac physical examination. Electrocardiogram showed sinus rhythm, poor R wave progression in anterior precordial leads and small Q waves with isoelectric T waves in inferior leads (Figure 1). Transthoracic echocardiography revealed prominent basal inferior and mid inferior hypokinesis with reduced regional myocardial longitudinal strain (-9% and -11% respectively) (Figure 2A). Left ventricular ejection fraction was estimated to be 50%. Myocardial perfusion scintigraphy was positive for a significant reversible stress-induced ischemia of the inferior wall. Coronary angiography showed normal left coronary system and anomalous origin of the right coronary artery (RCA). For further assessment, ECG-gated cardiac CT angiography (CTCA) was done and revealed RCA arising from left aortic sinus separately of left coronary artery, with inter-aorto-pulmonary course and ostial-post-ostial part severe luminal narrowing at the takeoff portion (Figures 2B-2F), coronary artery calcifications of the mid-RCA without significant stenosis (Figures 2B and 2C) and no significant atherosclerotic disease of left coronary system. Surgical treatment was required. In fact, aggressive surgical management is often recommended to avoid sudden cardiac death, especially in documented coronary ischemia as a result of a coronary compression when coursing between the great arteries. The CTCA has an incontestable place as a first imaging modality tool for the assessment of the origin and course of coronary arteries and the detection of inter-aortopulmonary course that implies an appropriate surgical management.

Cognitive Deficits in Symptomatic and Asymptomatic Carotid Endarterectomy Surgical Candidates.

The role played by vessel disease in stroke-related cognition dysfunction is unclear. We assessed the impact of significant atherosclerotic disease on cognition-even in patients asymptomatic for stroke. We hypothesized that patients would perform poorly relative to controls, but that symptomatic/asymptomatic status (history of stroke/transient ischemic attack) would have no effect. Fifty-two carotid endarterectomy candidates with >60% carotid stenosis and 17 controls underwent a 60-min neuropsychological test protocol. Symptomatic and asymptomatic patients showed deficits in executive function, delayed verbal recall, and general knowledge. Patients symptomatic for stroke also performed worse on tests of language and motor/visuomotor ability. Symptomatic and asymptomatic patients differed in working memory and language task performance. Although all patients showed deficits in executive function and memory, only symptomatic patients showed additional deficits in language and motor function. Cognitive abnormalities in patients viewed as "asymptomatic" for stroke underscore the need for early identification and treatment.

How should I treat a significant and inoperable left main coronary atherosclerotic disease (LMCAD) in the setting of a severely depressed left ventricular systolic function and severe aorto-iliac atherosclerotic disease?

How should I treat a significant and inoperable left main coronary atherosclerotic disease (LMCAD) in the setting of a severely depressed left ventricular systolic function and severe aorto-iliac atherosclerotic disease?

Syphilitic aortic aneurysm in a young hepatitis B-infected man: Case presentation

Syphilitic aortit is a common manifestation of syphilis, involving the thoracic aorta, where destruction of elastic tissue in the media results in dilation and aneurysm formation. We report and identified a case of a 38-year old patient who presents a large ascending aorta aneurysm. He continues to carry the hepatitis B virus. The CT angiogram confirmed the presence of a giant fusiform ascending aortic aneurysm measuring 86mm of maximum diameter extending nearly to the origin of the brachiocephalic artery with normal diameter across the descending thoracic and abdominal aorta and no flow-limiting obstruction or significant atherosclerotic disease of the supra-aortic arteries. The definitive treatment of aortic aneurysm is surgical repair. Surgery and specific antibiotic treatment do not exclude future manifestations of the disease, even after erradication of the T. pallidum, which makes permanent follow-up needed.

Histopathological changes of radial artery wall in patients of chronic kidney disease stage 5 undergoing AV fistula formation and their correlation with serum iPTH levels.

Vascular complications arise in uremic patients in the absence of clinically significant atherosclerotic disease. Elevated serum parathyroid hormone (PTH) and abnormal calcium (Ca) and phosphorus (P) balance have been implicated in vascular damage in chronic kidney disease (CKD) patients, but there is lack of histo-pathological studies. Patients with CKD stage 5 and 5D who underwent arterio-venous fistula were included in this study. Baseline and laboratory parameters including assessment of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, uric acid, albumin, calcium, phosphorus, intact PTH (iPTH) and vitamin D level were documented. The specimens of the arterial wall were obtained during the procedure and were analyzed. Patients were divided into two groups iPTH <400 (Group A) and iPTH >400 (Group B). Mean intimal thickness (IT) was significantly high in patients of Group B (60.4 ± 24.1 μ m) as compared with patients of Group A (37.8 ± 14.9 μm) (P = 0.003). Vascular calcification was comparable in both groups. The iPTH level was found to be an independent risk factor for high intima thickness (correlation coefficient 0.653) (P-value <0.01). Patients with high (≥ 400 pg/mL) iPTH have 8.93 times the risk of developing intimal thickness of ≥ 60 μ m as compared with patients with low (<400 pg/mL) iPTH (P-value <0.05), with 95% confidence interval of 1.27, 62.61. The mean IT of the radial artery significantly correlated with the iPTH level, while vascular calcification was independent of the iPTH level. Hyperparathyroidism is an important cause of ongoing vascular damage and may contribute to higher vascular events in CKD patients.

B-Gamma-glutamyltransferase activity in human vulnerable carotid plaques

Objective: The atherosclerotic plaque that is vulnerable to rupture and to superimposed thrombosis is mainly represented by a thin-cap fibroatheroma with or without ulceration/thrombosis and inflammatory infiltrates. Total serum gamma-glutamyltransferase (GGT) activity is an independent predictor for cardiovascular events. Four GGT fractions have been identified in plasma and only one of them (b-GGT) in atherosclerotic plaques, but the possible role of GGT in plaque pathophysiology has not been assessed yet. We investigated the relationships between plaque b-GGT activity and the histological features of plaque vulnerability. Methods and results: Plaque GGT activity was investigated in 65 patients undergoing carotid endarterectomy; plaques were histologically characterized and immunostained for GGT. Intra-plaque total and fractional GGT activity was determined by a cost-effective test of molecular size exclusion chromatography, and compared with histological markers of plaque vulnerability. Plaque cholesterol content was also measured by chromatography. b-GGT was the only fraction detected within the atherosclerotic plaques and intra-plaque b-GGT activity correlated to plaque cholesterol content (r = 0.667, P < 0.0001), plasma b-GGT and f-GGT fractions (r = 0.249; r = 0.298, both P < 0.05). Higher b-GGT activity was found in thin-cap fibroatheromas and it was associated to histological markers of vulnerable plaques, i.e., larger necrotic areas, greater macrophage infiltration and higher cholesterol content (P < 0.05). Conclusions: intra-plaque b-GGT activity correlates with the histological markers of vulnerable plaque and with plasma b-GGT in human carotid atherosclerosis; these data support the possible role of b-GGT in clinically significant atherosclerotic disease.

Exercise stress testing enhances blood coagulation and impairs fibrinolysis in asymptomatic aortic valve stenosis

BackgroundIncreased thrombin formation and fibrin deposition on the valves were observed in patients with severe aortic valve stenosis (AS). Exercise enhances blood coagulation and fibrinolysis in healthy subjects, but its haemostatic effects in AS are unknown. We sought to investigate how stress echocardiography alters blood coagulation and fibrinolysis in AS patients free of significant atherosclerotic vascular disease. MethodsWe studied 32 consecutive asymptomatic moderate-to-severe AS patients and 32 age- and sex-matched controls. We measured peak thrombin generated using calibrated automated thrombogram, clot lysis time (CLT), and fibrinolytic markers at four time points, i.e. at rest, at peak exercise, and 1h and 24h after a symptom-limited exercise test. ResultsWe observed that peak thrombin generated rose at peak exercise to 25% higher value in the patients than in controls (p<0.001) and reached its highest level 24h from exercise in AS patients while it decreased post-exercise in controls. Baseline CLT was 13% longer in AS patients (p=0.006) and associated with thrombin activatable fibrinolysis inhibitor (TAFI) activity (r=0.69, p<0.001), antiplasmin (r=0.47, p=0.007), and plasminogen (r=−0.55, p=0.001). In AS, CLT remained unaltered at peak exercise, while it decreased in controls, yielding the intergroup difference of 28% (p<0.001). Twenty-four hours after exercise CLT became 15% longer in AS patients (p<0.001). This hypofibrinolytic effect followed a similar pattern observed for TAFI activity. ConclusionsAsymptomatic moderate-to-severe AS patients respond to exercise with more pronounced and prolonged increase in thrombin generation, together with impaired fibrinolysis as compared to controls. Repeated episodes of exercise-induced prothrombotic state in AS might contribute to the progression of this disease.

Presence of anomalous coronary seen on angiogram is not associated with increased risk of significant coronary artery disease.

It is unclear if anomalous coronary arteries are at higher risk for atherosclerosis. The link between anomalous coronary artery and early coronary artery disease has been suggested. The aim of this study is to determine whether the coronary artery anomaly predisposes to development of significant coronary disease. Using retrospective chart review, patients with documented anomalous coronary arteries recognized during coronary angiography between years 2000 to 2007 were analyzed. Prevalence of significant atherosclerotic coronary artery disease (defined as more than 50% luminal narrowing) was compared between normal and anomalous coronaries. A total of 147 patients with anomalous coronary arteries were found. Right coronary artery was the most common anomalous artery 128 of 148 (86.5%) in our dataset. There was no difference in the occurrence of atherosclerosis between anomalous and nonanomalous coronaries. Significant atherosclerosis was present in 59 of the 148 anomalous coronary arteries (37.8%), and 112 of the 293 nonanomalous coronary arteries (38.2%, p = 0.9). On the basis of our study, there is no evidence that anomalous coronary arteries predispose to significant coronary artery disease in comparison to normal coronary arteries.

Generalized aneurysmal disease in association with autosomal dominant polycystic disease.

A 78-year-old man with end-stage kidney disease secondary to autosomal dominant polycystic disease (ADPKD) on haemodialysis, presented to our institution following a myocardial infarction. He was known to have cystic involvement of his liver and spleen, significant mitral regurgitation secondary to mitral valve prolapse, and a distant history of abdominal aortic aneurysm repair. There was no family history of ADPKD or history of cerebral aneurysms. Coronary angiogram revealed widespread large coronary artery aneurysms affecting both branches of the left and right coronary artery, as well as significant atherosclerotic disease (Figure 1). During work up for coronary artery bypass surgery and mitral valve replacement, multiple other sites of aneurysmal disease were identified, including a 5 cm thoracic aortic aneurysm and bilateral femoral artery aneurysms (Figure 2). Fig. 1. Aneurysmal involvement of the mid to distal left anterior descending coronary artery (black arrow). Fig. 2. Bilateral femoral artery aneurysms (white arrows) together with large polycystic kidneys. Note incidental finding of calcified cyst in left polycystic kidney (black arrow). Whilst waiting for cardiac surgery the patient developed septic shock secondary to an infected renal cyst, requiring prolonged intensive care admission and extended rehabilitation. Given his age and frailty a decision was made to manage his widespread aneurysmal disease conservatively with regular radiographic surveillance. Previous case series have suggested a high incidence of coronary artery aneurysms in association with ADPKD. Hadimeri et al. [1] observed coronary aneurysms in 4 out of 30 (13%) ADPKD patients. This is markedly higher than the incidence observed in the general population, of ∼1.5% of patients studied by coronary angiography or autopsy [2]. There is less evidence regarding the link between ADPKD and aortic, thoracic and femoral aneurysms. While Bailey et al. [3] studied the association between aortic aneurysms and ADPKD, the study was unable to conclusively link the two conditions. Evidence linking thoracic or femoral aneurysms with ADPKD appears predominantly limited to case studies [4]. Given that the gene responsible for ADPKD has been linked with abnormalities of vascular smooth muscle, myofibroblasts, extracellular matrix and collagen defects [5], it seems reasonable for there to be widespread vascular abnormalities in this patient population, although it seems to be seldom described. In summary, we present a rare case of a patient with ADPKD and associated coronary artery aneurysms as well as aorto/iliac aneurysms.

Carotid Endarterectomy, Stenting in Elderly Debated

For elderly patients with carotid disease, carotid endarterectomy carries a lower risk of perioperative stroke or transient ischemic attack, the same risk of perioperative myocardial infarction (MI), and a slightly higher risk of death, compared with carotid stenting, according to a meta-analysis. However, the individual elderly patient's vascular anatomy plays a crucial role in determining perioperative risk, as does the person's overall health and clinical profile, said George A. Antoniou, MD, PhD, of the department of vascular surgery, Hellenic Red Cross Hospital, Athens, and his associates. Which treatment is the most appropriate for elderly patients is still much debated. Dr. Antoniou and his colleagues performed a comprehensive review of the medical literature since 1986 and a meta-analysis of 44 articles that directly compared outcomes in elderly patients with those of younger patients after carotid endarterectomy (39 studies) or carotid stenting (18 articles). “Elderly” was defined as older than 80 years in most of these studies. Overall, the meta-analysis included 269,596 endarterectomies in elderly patients against 243,089 in younger patients, and 38,751 carotid stenting procedures in elderly patients against 36,450 in younger patients. For endarterectomy, the rate of perioperative stroke was not significantly different between elderly (0.9%) and younger (1.2%) patients, nor was the rate of transient ischemic attack (1.9% vs. 1.8%, respectively). However, perioperative mortality was significantly higher in elderly (0.5%) than in younger (0.4%) patients. In contrast, for carotid stenting, the rate of perioperative stroke was significantly higher for elderly patients (2.4%) than for younger patients (1.7%), as was the rate of TIA (3.6% vs. 2.1%). But mortality was not significantly different between elderly patients (0.6%) and younger patients (0.7%), the researchers wrote (JAMA Surg. 2013;148[12]:1140–52). Both procedures were associated with an increased rate of perioperative MI in elderly patients, compared with younger patients. These rates were 2.2% in elderly patients, compared with 1.4% in younger patients undergoing endarterectomy; and 2.3% in elderly patients, compared with 1.5% in younger patients undergoing carotid stenting. “It seems that endarterectomy is associated with improved neurologic outcomes compared with carotid stenting in elderly patients, at the expense of increased perioperative mortality,” Dr. Antoniou and his associates said. However, the small increase in mortality seen with endarterectomy – 0.1% – may not be clinically significant. Moreover, neurologic risk is closely tied to vascular anatomy. Elderly patients tend to have more unfavorable anatomy than do younger patients. Unfavorable traits include heavily calcified and tortuous supra-aortic branches, as well as adverse morphology of the aortic arch such as elongation, distortion, and stenosis. Manipulating the stenting instruments through such features may in itself raise the risk of neurologic sequelae. It also makes the procedure more technically difficult, which increases the risk of endothelial trauma, thrombus dislodgement, and thromboembolic events. “In addition, elderly patients with significant extracranial atherosclerotic disease are likely to have a compromised cerebrovascular reserve, which makes them more susceptible to ischemic events from cerebral microembolization,” the researchers said. R. Clement Darling III, MD, said, in a published commentary, that variation in the definition of elderly among the trials is a concern: Some used 70 or even 65 years as the cutoff. “The bottom line is, carotid endarterectomy and carotid stenting seem to work equally well in younger patients, in expert hands. However, in the ‘elderly’ (at any age), endarterectomy has better outcomes with low morbidity, mortality, and stroke rate, and it remains the standard of care,” he said. Dr. Darling is a member of the Vascular Group, Albany, NY. Neither he nor any of the report's authors reported a financial conflict of interest.