Ischemic Symptoms Research Articles

Myocardial Bridging: In-Depth Review of Coronary Anomalies

Myocardial bridging (MB) is a congenital coronary anomaly where segment of the epicardial coronary artery traverses through the myocardium for a portion of its length. While traditionally regarded as a benign condition, there is a growing focus on specific subsets of MB associated with ischemic symptoms and requires treatment. Increasing attention is being given to specific subsets of MB associated with ischemic symptomatology. The emergence of modern functional and anatomical imaging techniques; coronary angiography, coronary computed tomography angiography (CCTA), instantaneous wave-free ratio (iFR), dan diastolic fractional flow reserve (dFFR), has improved our capacity to characterize symptoms associated with MB. In cases involving symptomatic patients, medical therapy often represents an effective treatment option. For individuals who do not respond satisfactorily to medical interventions, comprehensive multimodal assessment; percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and myotomy should be considered.

Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia

ObjectiveHemodialysis access-induced distal ischemia (HAIDI) is a known complication of hemodialysis (HD) access. Distal revascularization and interval ligation (DRIL) is the preferred treatment for HAIDI by many surgeons. Proximalization of arterial inflow (PAI) is a promising alternative technique that, unlike DRIL, preserves the native arterial inflow. The purpose of this study is to report our experience with PAI on a series of 64 patients. MethodsThis is a single-center, retrospective cohort study of patients with both arteriovenous (AV) fistulas and grafts who underwent PAI for HAIDI from 2017 to 2023. A 4 × 7 tapered polytetrafluoroethylene (PTFE) graft was used to connect HD access inflow to the axillary artery in the majority of cases. The primary outcome of the study is resolution of HAIDI (complete, partial, or no resolution). Secondary outcomes include functional patency (primary and secondary) and 30-day complications following PAI. ResultsOf the 71 patients identified to have had PAI between May 2017 to August 2023, seven were lost to follow-up. In total, 64 patients were included, with an average age of 65 years (standard deviation, 15 years), 59.4% (38/64) female, and 37.5% (24/64) African American. The study population was notable for numerous comorbid conditions including 95.3% (61/64) hypertension; 50% (32/64) coronary artery disease; 79.7% (51/64) diabetes; and 43.8% (28/64) smoking history. Following PAI intervention for HAIDI, 55 of 64 patients (85.9%) experienced complete resolution of ischemic symptoms; five of 64 patients (7.8%) had partial resolution; two of 64 patients (3.1%) had no resolution, and two of 64 patients (3.1%) had unknown resolution. Primary patency at 1, 12, and 24 months was 94%, 81%, and 71%, respectively. Secondary patency at 1, 12, and 24 months was 97%, 87%, and 84%, respectively. The 30-day complication rate was 10.9% (7/64), with five of 64 (7.8%) thromboses, one of 64 (1.6%) thrombosis and infection, and one of 64 (1.6%) upper extremity swelling secondary to central venous stenosis (resolved with angioplasty of central venous system). Failure rate due to thrombosis at 12 and 24 months was 14% (9/64) and 15.6% (10/64), respectively. ConclusionsOur study, the largest case series of PAI to date, demonstrates that PAI is a reliable option for HAIDI intervention and has comparable safety and efficacy results to DRIL, despite the use of a synthetic graft. Furthermore, PAI has the added benefit of maintaining the native arterial pathway. Further investigation of PAI is warranted as a promising alternative to DRIL for HAIDI management.

Code Stroke Alert: Focus on Emergency Department Time Targets and Impact on Door-to-Needle Time across Day and Night Shifts.

To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the "code stroke" emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). This research will outline our experience in implementing the stroke code protocol for acute ischemic stroke patients and its impact on door-to-needle time (DTN) in the ED. Our study included patients with a "code stroke alert" upon arrival at the emergency department. The final sample of this study consisted of 258 patients eligible for intravenous (IV) thrombolysis with an onset-to-door time < 4.5 h. ED admissions were categorized into two distinct groups: "day shift" (from 8 a.m. to 8 p.m.) (n = 178) and "night shift" (from 8 p.m. to 8 a.m.) (n = 80) groups. An analysis of ED time targets showed an increased median during the day shift for onset-to-ED door time of 310 min (IQR, 190-340 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), and for door-to-physician (neurologist) time of 7 min (IQR, 5-10 min), also during the day shift. During the night shift, an increased median was found for door-to-CT time of 21 min (IQR, 16.75-23 min), for door-to-CT results of 40 min (IQR, 38-43 min), and for door-to-needle time of 57.5 min (IQR, 46.25-60 min). Astonishingly, only 17.83% (n = 46) of these patients received intravenous thrombolysis, and the proportion of patients with thrombolysis was significantly higher during the night shift (p = 0.044). A logistic regression analysis considering the door-to-needle time (minutes) as the dependent variable demonstrated that onset-to-ED time (p < 0.001) and door-to-physician (emergency medicine physicians) time (p = 0.021) are predictors for performing thrombolysis in our study. This study identified higher door-to-CT and door-to-emergency medicine physician times associated with an increased DTN, highlighting further opportunities to improve acute stroke care in the emergency department. Further, door-to-CT and door-to-CT results showed statistically significant increases during the night shift.

Application of individual brain connectome in chronic ischemia: mapping symptoms before and after reperfusion.

How brain functions in the distorted ischemic state before and after reperfusion is unclear. It is also uncertain whether there are any indicators within ischemic brain that could predict surgical outcomes. To alleviate these issues, we applied individual brain connectome in chronic steno-occlusive vasculopathy (CSOV) to map both ischemic symptoms and their postbypass changes. A total of 499 bypasses in 455 CSOV patients were collected and followed up for 47.8±20.5 months. Using multimodal parcellation with connectivity-based and pathological distortion-independent approach, areal MR features of brain connectome were generated with three measurements of functional connectivity (FC), structural connectivity, and PageRank centrality at the single-subject level. Thirty-three machine-learning models were then trained with clinical and areal MR features to obtain acceptable classifiers for both ischemic symptoms and their postbypass changes, among which, 11 were deemed acceptable (AUC>0.7). Notably, the FC feature-based model for long-term neurological outcomes performed very well (AUC>0.8). Finally, a Shapley additive explanations plot was adopted to extract important individual features in acceptable models to generate "fingerprints" of brain connectome. This study not only establishes brain connectomic fingerprint databases for brain ischemia with distortion, but also provides informative insights for how brain functions before and after reperfusion.

Treatment of Symptomatic Carotid Webs: A Single-Center Review

IntroductionCarotid webs are abnormal thin shelf-like or flap-like tissue in the carotid bulb (proximal internal carotid artery). Rarely are carotid webs detected prior to symptoms since routine carotid artery surveillance is not performed in younger individuals without traditional risk factors for carotid disease. The cause and natural history remain unknown. In general, they are not common, but should be considered in the differential diagnosis of a patient who presents with ischemic neurologic symptoms. The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Current treatment is to reduce thrombus formation (antithrombotics and/or anticoagulation) or to alter the flow disturbance caused by the web (surgical removal or stent). MethodsWe retrospectively identified all patients presenting with acute ischemic stroke to our Comprehensive Stroke Center that were diagnosed with carotid web from January 2020 to December 2023. Patient demographics, presentation, hospital course including treatment and complications were collected and reported. ResultsFifteen patients presented with carotid web and stroke from 2020-2023 and 13 underwent carotid artery stenting or endarterectomy with no periprocedural complications. Most (40%) carotid webs were not primarily identified by the initial radiology interpretation. DiscussionWe discuss our experience of carotid web and its management as well as review of the current literature.

Endovascular Rescue of Previously Treated Carotid Aneurysm: Higher Radial Force 48-Wire Flow Diverter for Salvage of Collapsed 64-Wire Device With Braid Deformation: 2-Dimensional Operative Video.

Aneurysm treatment presents various therapeutic options. Flow diverters (FD) stents are a revolutionizing endovascular technique for previously untreatable aneurysms.1 FD stents have documented success rates up to 95% and complication rates as low as 2.3%.2 This modality has proven its effectiveness and safety, but it is critical to consider potential complications. Complications include vascular-related problems such as perforation, occlusion, cerebral hyperperfusion, stent thrombosis, restenosis, and embolic events.3 To date, there is no standardized definition for braid collapse and fish-mouthing; however, braid collapse has been reported to occur at a rate of 1% and the latter at a rate of 3%.4 This technical video presents a case of a 51-year-old woman initially treated with a Surpass Evolve flow diverter (Stryker) for a right ophthalmic aneurysm. Secondary to device malapposition and collapse, she developed recurrent ischemic progressive neurologic impairment symptoms. The braid collapse was treated using a Pipeline Embolization device 3.25 × 20 mm (Medtronic) because this device exhibited a larger partial compressive force when compared with the 64-wire device.5 The procedure was uneventful and significantly improved the patient's neurologic symptoms. This technical video illustrates rescue stenting as a salvage intervention for FD collapse cases. The patient gave informed consent for surgery. Institutional review board approval was deemed unnecessary.

Classification and management strategy of spontaneous carotid artery dissection

ObjectiveSpontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance. MethodsThis is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs. ResultsA total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P > .05). Favorable outcome was achieved in 168 patients (93.9%). ConclusionsThis study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research.

Evaluation of the efficacy of Wall Shear Stress in Carotid Artery Stenting

To characterize the value of carotid wall shear stress (WSS) following carotid artery stenting (CAS) in patients with carotid stenosis. Twenty-eight patients with carotid stenosis treated with CAS between March 2021 to May 2022 in the eighth medical center of the PLA General Hospital were selected for our study. Carotid ultrasound was performed before the operation, one week post-operation, and six months post-operation. Carotid artery WSS was detected by blood flow vector imaging, and the changes in WSS before and after the operation were collected. Genetic testing of drugs was detected for patients with restenosis. Pre-operative WSS of the proximal, narrowest region, and distal carotid arteries in patients with ischemic carotid artery stenosis was 7.88±3.18Pa, 14.36±6.66Pa, and 1.55±1.15Pa, respectively. Comparatively, pre-operative WSS of the proximal, narrowest region and distal carotid arteries in patients without ischemic symptoms was 5.02±1.99Pa, 9.68±4.23Pa, and 1.10±0.68Pa, respectively, with a significant difference between the two groups (p<0.001). Overall WSS of the proximal, narrowest region, and distal carotid arteries in patients before CAS was 6.68±3.0Pa, 12.47±5.98Pa, and 1.39±0. 96Pa. WSS of the proximal, narrowest region, and distal carotid was 4.15±1.42Pa, 6.71±2.64Pa, and1.86±1.13Pa one week after CAS, compared to 4.44±1.91Pa, 7.90±4.38Pa, and 2. 36±1.09Pa six months after CAS. WSS of the proximal and narrowest region of the carotid artery was reduced after carotid stenting, and the difference was statistically significant (p<0.001). There was no statistically significant difference in WSS between one week and six months after stenting (P>0.05). We employed early carotid WSS as a means of evaluating the efficacy of carotid artery stenting. Changes in carotid WSS are closely associated with carotid artery stenosis, providing valuable hemodynamic information for CAS treatment. This technique holds great application value in pre-operative evaluation and long-term follow-up.

Safety and Effectiveness of a Novel Microcatheter in Coronary Chronic Total Occlusions—The BIOMICS Study

BackgroundChronic total occlusion (CTO) remains the most complex anatomical subset of lesions in percutaneous coronary intervention (PCI), often requiring advanced techniques and technologies, including the use of microcatheters. MethodsThe BIOMICS study is a premarket first-in-human prospective, multicenter, open-label, single-arm trial investigating the safety and efficacy of a novel coronary microcatheter (BioMC, Biosensors International) in 100 patients with symptoms of ischemia undergoing elective CTO-PCI. The primary efficacy end point of the study was device success defined according to the CTO-ARC (Chronic Total Occlusion Academic Research Consortium) criteria namely the ability of the microcatheter to successfully facilitate placement of a guide wire beyond the occluded coronary segment. The primary safety end point was the incidence of in-hospital cardiac death or myocardial infarction at hospital discharge. ResultsHundred patients were recruited between March 2022 and January 2023. The primary efficacy end point was achieved in 75% of patients (95% CI, 65.3%-83.1%; P < .0001 for superiority compared to the prespecified performance goal of 54%). The primary safety end point of in-hospital cardiac death or myocardial infarction was observed in 2% of the patients. There were no study device-related coronary perforations or device failures. ConclusionsThe use of a novel coronary microcatheter during CTO-PCI was associated with a high device success and an excellent safety profile.

CLINICAL CASE OF A VERY YOUNG PATIENT AFFECTED BY CAD

Abstract Young patient of 24 years old, smoker, dyslipidemic and family history of coronary artery disease (CAD). He was admitted to emergency room for chest pain after moderate effort in December. EKG was normal, troponin was negative and echocardiography showed left ventricle with normal contractility. Blood chemistry test showed LDL 130 mg/dL, Triglycerides 200 mg/dL e Lipoprotein (a) 16 nmol/L. Elective cardiovascular exercise test resulted positive for signs and symptoms of cardiovascular ischemia (Figure 1). Coronary angio–TC showed 60% stenosis of proximal LAD and intramyocardial bridging of mid LAD. Subsequently elective coronary angiography confirmed the description of coronary angio–TC; contextually optical coherence tomography (OCT) was performed and showed fibrous cap rupture of proximal LAD (Figure 2 – 3). The patient was discharged with indication of medical therapy (Cardioaspirina 100 mg, Atorvastatina 40 mg, Bisoprololo 1,25 mg). CAD is a chronic condition usually occurring after the sixth decade of life. However, some populations experience this disease prematurely. In the last few decades, different studies have shown an increased incidence of CAD in very young people. The prevalence of CAD reported in very young people is 1–16%. Clinical and interventional management of CAD in very young people is still subject of discussion today. The literature showed how risk factors such us current smokers, dyslipidemia, and family history of CAD are significantly associated with the existence of severe CAD in patients of ≤40 years. The above risk factors are present in this patient, therefore we opted for correct them by medical therapy and follow–up by OCT at 6 months. The patient was stable and asyntomatic for chest pain at 1 month telephone follow–up.Figure 1.Figure 2.Figure 3.

THE APEX TALKS…CARDIAC METASTASIS MIMICKING ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Abstract A 78–year–old man with a recent diagnosis of lung squamous cell carcinoma was referred to our cardiology department for marked ECG abnormalities (ST segment elevation in V2–V4 and T waves inversion in the antero–lateral leads, Fig.1) in the absence of ischemic symptoms and for the detection of an intramyocardial mass at the apical segments on the CT scan. He had no significant previous cardiovascular history. A transthoracic echocardiogram (TTE) was performed and showed an isoechoic mass at the LV apical segments measuring 3 x 4 cm apparently incorporating the myocardial wall without a clear cleavage plane (Fig.2a). The EF was normal. No pericardial effusion present. The contrast echocardiography with Sonovue revealed a late uptake of the contrast (Fig.2b). Cardiac magnetic resonance (CMR) showed an ovular image in the para–apical area of 40 x 23 cm consistent with a secondary lesion (Fig.3). Unfortunately, the exam was interrupted early due to a patient’s claustrophobic crisis, without having acquired the post–contrast images. Due to infiltrative appearance of the mass and the oncology history, this formation was highly suspicious for metastasis. No complicated ventricular arrhythmias were detected on ECG monitoring. No symptoms of heart failure were reported. Due to the marked EKG repolarization abnormalities the patient underwent coronary angiography which excluded significant stenosis. FDG PET/CT showed areas of increased metabolism also at liver and adrenal left gland. Finally, the patient was transferred to the oncology department for specific management. Cardiac metastases are more common than primary cardiac malignancy and are more frequently related to primary lung cancer, followed by breast cancer and hematologic malignancies. Typical presentation includes arrhythmias or conduction disturbances. The imaging findings of cardiac metastases are non–specific but mostly infiltrative, heterogeneous, and multiple masses may be present. Echocardiography is the initial imaging test for the detection of cardiac metastasis, although CMR, CT and PET/CT may be helpful. Herein we described a case of cardiac metastasis with EKG mimicking acute coronary syndrome. This finding is not uncommon among these patients. EKG findings of myocardial ischemia or injury, particularly localized and prolonged ST elevation, in the absence of ischemic symptoms have been reported in previous studies as high specificity for cardiac metastasis in patients with malignancy.

Enhanced external counterpulsation treatment improves multi-organ hemodynamics for postoperative liver transplantation patient. A case report

IntroductionPost liver transplantation (LT) patients endure high morbidity rate of multi-organ ischemic symptoms following reperfusion. We hypothesize that enhanced external counterpulsation (EECP) as a typical non-invasive assisted circulation procedure, which can efficiently inhibit the relative ischemic symptoms via the systemic improvement of hemodynamics.Case presentationA 51-year-old male patient, 76 kg, 172 cm, received orthotopic LT surgery for viral hepatitis B induced acute-on-chronic liver failure hepatic failure. His medical records revealed ischemic symptoms in multi-organ at the time of hospital discharge, including headache, refractory insomnia, abdominal paralysis, and lower limb pain. The EECP treatment was introduced for assisted rehabilitation and to improve the postoperative quality of life. Doppler Ultrasound examination showed significant augmentation of blood flow volume in the carotid arteries, the hepatic artery, the portal vein and the femoral artery during EECP intervention. A standard 35-hour EECP treatment led to significant improvement in quality of life, e.g. sleep quality and walking ability.ConclusionWe report a case of multi-organ ischemic symptoms in a post LT patient. EECP treatment can significantly improve the quality of life via the systematic promotion of hemodynamics.

Women Acute Myocardial Infarction-Identifying and Understanding the Gender Gap (WAMy-GAP): A Study Protocol.

Barriers to accessing care and misinterpretations of ischemic heart disease symptoms due to lack of awareness contribute to women's delay in seeking care. Women may delay seeking treatment for up to 3 h or even up to 5 days. They often perceive themselves to be at low risk of cardiovascular disease (CVD) and prioritize family responsibilities or household chores. The causes of this delay are multifactorial and influence the decision-making process, particularly in the pre-hospital phase. The objective of this study protocol is to evaluate prodromal symptoms and identify risk behaviors in women with acute myocardial infarction (AMI). This is a protocol for a multicenter study that will be conducted using the mixed-method methodology using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) to evaluate symptoms and semi-structured interviews to investigate behaviors. This study protocol is intended to fill an important knowledge gap on premonitory and acute symptoms of AMI in women in Italy, as well as to understand the causes and mechanisms underlying delays in accessing healthcare services during an acute event such as AMI. The investigation of this issue will facilitate the removal of gender-related inequalities in the diagnosis and treatment of acute myocardial infarction while also fostering dialogue on the barriers to behavior change.

Electrocardiography in myocardial infarction diagnosis: a view through the prism of guidelines (Lecture)

Electrocardiography (ECG) is considered as an essential step in acute coronary syndrome (ACS) diagnostic algorithm. Сurrent classification is based on the ECG changes of ST-segment and includes ACS with persistent ST elevation and without persistent ST elevation. ACS with persistent ST elevation is characterized by prolonged (more than 20 min) ST-segment elevation exceeding 0.1 mV in two or more contiguous ECG leads (except V2–3 as well as aVR). When the symptoms of acute myocardial ischemia are present, ECG should be recorded within 10 minutes from the first contact with a medical professional. Some changes on the initial ECG of a patient with ACS may be nonspecific or absent, so the key role in diagnosis is given to the clinical presentation and the ECG in dynamics.

Tenecteplase Versus Alteplase in Acute Ischemic Stroke in Chinese Patients: Protocol for the ORIGINAL Study

Background Tenecteplase, a bioengineered variant of alteplase, is a new alternative thrombolytic agent. The ORIGINAL study aims to evaluate the efficacy and safety of tenecteplase versus standard care in Chinese patients with acute ischemic stroke within 4.5 hours of symptom onset. Methods This is a multicenter phase III study that employs a randomized (1:1), active‐controlled, parallel‐group, prospective, open‐label, blinded–end point design. Adult participants (aged ≥18 years) with acute ischemic stroke who are eligible for intravenous thrombolysis within 4.5 hours of symptom onset according to current guideline recommendations are recruited from ≈55 neurology clinics/stroke centers throughout China. Results The primary objective of the ORIGINAL study is to demonstrate the noninferiority of tenecteplase (0.25 mg/kg) to alteplase (0.9 mg/kg) on the basis of the proportion of patients who achieve a modified Rankin Scale score of 0 or 1 on day 90, that is, a favorable functional outcome. The prespecified noninferiority risk ratio margin is 0.937. Secondary end points include other functional outcomes and the following safety end points: adjudicated symptomatic intracerebral hemorrhage (up to 36 hours after the end of study drug administration) based on the European Cooperative Acute Stroke Study III definition; all‐cause death within 90 days; and the proportion of patients with a modified Rankin Scale score of 5 or 6 on day 90. Conclusions It is anticipated that the results of this study will contribute to the growing body of evidence for the noninferiority of tenecteplase to alteplase given within 4.5 hours of acute ischemic stroke symptom onset and support a new indication for tenecteplase in China. Clinical Trial Registration Information NCT04915729 ( https://clinicaltrials.gov/study/NCT04915729 )

Arterial transit artifacts and carotid Plaque-RADS may predict symptoms in patients with carotid stenosis

AimTo analyze the correlation of carotid stenosis severity, the Plaque Reporting and Data System (RADS) score, arterial transit artifacts (ATAs), and cerebral blood flow (CBF) with clinical cerebral ischemic symptoms in patients with carotid artery stenosis (CAS). Materials and methodsSixty-one patients with unilateral internal carotid artery stenosis or occlusion (≥50% stenosis) diagnosed by ultrasound, Computed Tomography(CT) angiography, or Magnetic Resonance(MR) angiography in Yichang City Central People's Hospital from January 2022 to February 2024 were retrospectively enrolled and divided into two groups according to the presence or absence of symptoms. Both groups underwent MR plaque imaging and arterial spin labeling (ASL)-based 3.0 T MRI to compare the differences in stenosis degree, Plaque-RADS score, ATA grade, and CBF between the two groups. Binary regression analysis was used to identify the parameters with statistically significant differences between the two groups and to evaluate their diagnostic efficacy using the area under the workup curve of the subjects. ResultsThe Plaque-RADS score, ATA grade, and CBF differences in the anterior cerebral artery(ACA)blood supply region were correlated with symptoms, and the areas under the ROC curves for the CBF differences in the ACA blood supply region, Plaque-RADS score, ATA grade and a joint model that combines all three to predict symptoms in CAS patients were 0.672, 0.796, 0.788 and 0.919, respectively. ConclusionsCBF, Plaque-RADS and ATAs were identified as independent risk factors for symptoms in patients with CAS and have a certain predictive value for symptoms, and the combined predictive value is greater, potentially providing a more effective imaging modality for clinical treatment and evaluation.

Long-Term Drug Therapy Following Carotid Endarterectomy Aimed at Reducing Major Adverse Cardiovascular Events

IntroductionTimely carotid endarterectomy (CEA) reduces the risk of future stroke. This benefit is maximised with lifelong drug therapy aimed at reducing further major adverse cardiovascular events (MACE), including stroke. Studies suggest that around half discontinue these drugs within 12 months. To assess if this is the case following CEA, we considered the MACE-reducing drugs prescribed several years later and compared this with the drugs they were prescribed at CEA. MethodsThe electronic primary care records of 347 post-CEA patients a mean of 108 (range 43-185) months after surgery were interrogated. The prescriptions of generic MACE-reducing drugs (antithrombotic, lipid-lowering, antihypertension and diabetes) of the 187 alive were compared with their prescriptions at CEA and with the last prescription of the 160 who had died before the late review. The post-CEA incidence of further MACE in survivors was determined. ResultsAt late review, fewer of the post-cea patients alive were taking antiplatelet drugs (143, 76% v 170, 91% p<0.01), but more were fully anticoagulated (37v4 p<0.01) when compared with prescriptions at CEA. Overall, there was no change in antithrombotic drug prescription rates (167, 89% v 172, 92%). Lipid-regulating drugs were well prescribed both at late review and at CEA (173, 93% v 169, 90%). The number prescribed antihypertension drugs was significantly higher at late review than at CEA (166, 89% v 67, 35% p<0.01). The number treated for diabetes was similar (64, 34% v 42, 23%). There was no difference in the numbers of any of the MACE-reducing drugs prescribed between those who had survivors to late review and those who had not. At late review, of those alive, there were 22 (12%) new strokes, and 24 (14%) had developed new or worsening ischaemic cardiac symptoms. DiscussionWe found a higher than expected prescription rate of MACE-reducing drugs many years after CEA. This finding may be due, in part, to the nationalised health service in the United Kingdom.

Abstract 2099: Coronary Artery Thrombosis Due To Intramural Hematoma

BJMC ,male 61 years old, presented with acute chest pain and non ST acute myocardial infarction. ECG showed ST segment depression on anterior and lateral precordial leads and ST elevation on aVR. Ultra-sensitive Troponin T rised . Coronary angiography showed calcified Left main(LM) with critical lesion extending to anterior descending artery. Percutaneous Coronary Intervention (PCI) was performed succesfully with stent implantation. Two hours later he started with epigastric discomfort , anxiety ,chest pain , diaphoresis , tachycardia and acute ECG changes , irresponsive to intravenous nitroglycerin . He evolved to ventricular tachycardia and cardiac arrest , with CPR. New PCI was followed with immediate clinical improvement . Clinical symptoms of ischemia and hemodynamic instability were due to significant (LM) caliber reduction .IMH is a pathological process were blood accumulate within the media space, suggesting new stenosis or spasm. IMH is unfrequent - may occur in initial hours and even at several days after apparently succesfull intervention. IMH causes acute lumen obstruction and thrombosis. The diagnosis is frequently missed and the clinical course can be dramatic and life threatening. Intravascular ultrasound (IVUS) is a very importante tool to identify IMH and should be available in complex cases interventions.

Sex differences in delay times in ST-segment elevation myocardial infarction: A cohort study

BackgroundThe present study analyzes a cohort of consecutive patients with ST-segment elevation acute myocardial infarction (STEMI), evaluating the ischemia–reperfusion times from the perspective of gender differences (females versus males), with a long-term follow-up. MethodsSingle-center analytical cohort study of patients with STEMI in a tertiary hospital, between January 2015 and December 2020. ResultsA total of 2668 patients were included, 2002 (75%) men and 666 (25%) women. The time elapsed from the onset of symptoms to the opening of the artery was 197min (IQR 140–300) vs 220min (IQR 152–340), p=0.004 in men and women respectively. A delay in health care significantly impacts the occurrence of cardiovascular adverse events at follow-up, HR 1.34 [95%CI 1.06–1.70]; p=0.015. ConclusionsWomen took longer to go to health care services and had a longer delay both in the diagnosis of STEMI and in coronary reperfusion. It is imperative to emphasize the necessity of educating women about the recognition of ischemic heart disease symptoms, empowering them to raise early alarms and seek timely medical attention.

Potential Targets of Natural Products for Improving Cardiac Ischemic Injury: The Role of Nrf2 Signaling Transduction.

Myocardial ischemia is the leading cause of health loss from cardiovascular disease worldwide. Myocardial ischemia and hypoxia during exercise trigger the risk of sudden exercise death which, in severe cases, will further lead to myocardial infarction. The Nrf2 transcription factor is an important antioxidant regulator that is extensively engaged in biological processes such as oxidative stress, inflammatory response, apoptosis, and mitochondrial malfunction. It has a significant role in the prevention and treatment of several cardiovascular illnesses, since it can control not only the expression of several antioxidant genes, but also the target genes of associated pathological processes. Therefore, targeting Nrf2 will have great potential in the treatment of myocardial ischemic injury. Natural products are widely used to treat myocardial ischemic diseases because of their few side effects. A large number of studies have shown that the Nrf2 transcription factor can be used as an important way for natural products to alleviate myocardial ischemia. However, the specific role and related mechanism of Nrf2 in mediating natural products in the treatment of myocardial ischemia is still unclear. Therefore, this review combs the key role and possible mechanism of Nrf2 in myocardial ischemic injury, and emphatically summarizes the significant role of natural products in treating myocardial ischemic symptoms, thus providing a broad foundation for clinical transformation.