Transient Myocardial Ischemia Research Articles

Occurrence of Transient Myocardial Ischemic Events among Non-ST Segment Elevation Acute Coronary Syndrome Patients Before or After Invasive Coronary Angiography.

The occurrence of transient myocardial ischemia (TMI) is an important pathology in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), yet studies are scarce regarding when TMI occurs during hospitalization, particularly in relation to invasive coronary angiography (ICA). This study examined: (1) TMI before or after ICA; (2) patient characteristics and ischemic burden by TMI group (before or after ICA); and (3) major in-hospital complications (transfer to critical care, death) and length of stay (LOS) by TMI group (before or after ICA). Secondary data analysis in hospitalized NSTE-ACS patients with TMI event(s) identified from 12-lead electrocardiographic (ECG) Holter. Patient records were reviewed to assess ischemic burden (TMI time [minutes] ÷ hours recording duration), outcomes and TMI timing, before or after ICA. In 38 patients, 3 (8%) had TMI before and after ICA. Of the remaining 35 patients (92%), TMI occurred before ICA (16; 46%), and after ICA (9; 26%), and 10 (28%) did not have ICA. Patient characteristics, untoward outcomes, and TMI duration (minutes) did not differ by group. Ischemic burden was higher in patients with TMI after ICA (7.29±8.82 min/hr) compared to before ICA (2.54±2.11 min/hr), p=0.039. Hospital LOS by TMI group was 113±113 (before), 226±244 (after), and 85±65 hr (no ICA); p=0.172. Almost half of the sample had TMI before ICA; one-third had TMI but did not have ICA. Patients with TMI after an ICA had higher ischemic burden. Future studies with larger sample sizes are needed to investigate further the short- and long-term clinical significance of TMI among NSTE-ACS patients.

Abstract 14630: Young Female Presenting With Chest Pain Due to Left Main Aneurysm

Background: Incidence of ACS is increasing in young patients. While atherosclerosis needs to be ruled out, there should be high suspicion for alternate causes. Case: A 36-year-old African American woman with obesity, prediabetes and tobacco use, presented to the ED with chest pain. Initial cardiac investigations unremarkable. CTA chest ruled out pulmonary embolism and aortic dissection. Her pain had resolved and she was discharged home. Within hours, the pain recurred and became progressively worse. She returned to the ED and was found to have an anterior STEMI with a troponin I 0.72 ng/ml. Cardiology was consulted, left heart cath revealed a large left main aneurysm (LMA) with large thrombus burden, with mildly aneurysmal LAD, RCA and LCx, moderate decrease in systolic function and no significant arch or main vessel aneurysms. Case was discussed with cardiothoracic surgery, who recommended medical management. Her symptoms resolved while on anticoagulation. Discussion: Coronary artery aneurysms (CAA) are a rare cause of ACS. The reported incidence of CAA ranges from 0.3% to 5%, most often affecting men. The RCA is the most commonly affected artery followed by the LAD, with the LM being the least common. Risk factors include hypertension, dyslipidemia, smoking, diabetes, and a family history of coronary artery disease. Known etiologies include atherosclerosis, Kawasaki disease, inflammatory, congenital, and degenerative conditions. Transient myocardial ischemia may result from aneurysm-related blood stasis that may predispose to thromboembolic events, coronary spasm, and microvascular dysfunction. Conclusion: Although considered extremely rare, the number of LMA reported has increased in the last decades and may continue to grow with the widespread use of invasive and noninvasive coronary imaging. Considering the rarity of CAA and absence of dedicated studies, both the interventional and the pharmacological management of patients with LMA are challenging.

Role of speckle-tracking echocardiography in diagnosis and further prognosis of coronary heart disease

Echocardiography is one of the first-line methods of detection and evaluation of coronary artery disease, which helps clinicians in the diagnostic and prognostic evaluation of this disease. However, visual assessment of abnormal left ventricular myocardial wall motion is not always appropriate in detecting less severe or transient myocardial ischemia and in making an accurate differential diagnosis. Speckle-tracking echocardiography is a widely available non-invasive tool that can easily and quickly provide clarifying information and significantly extend the standard echocardiographic study, as the method allows you to identify subtle myocardial damage and local areas of ischemia that correspond to the pattern of coronary disease, and obtain an objective report in the form of simple visual scheme, very easy to use for differential diagnosis and treatment. Therefore, this method, which is increasingly used in various manifestations of coronary insufficiency and is convenient to use both at rest and with stress echocardiography, has proved efficient results in terms of predicting coronary heart disease, quantitative interpretation of emerging or persistent ischemia, assessment of the clinical course and outcome, and left ventricular remodeling. In this review, we have attempted to reflect the currently available findings that demonstrate the significance of speckle-tracking echocardiography for the evaluation and follow-up of coronary heart disease, including some congenital anomalies of the coronary arteries, and to touch on the main achievements and discoveries in the use of two-dimensional and three-dimensional deformation parameters and their potential application for a wider introduction into clinical practice.

Are there more acute cardiac hospitalizations in winter in patients with systemic sclerosis? An analysis from the National Inpatient Sample

Objective: Cold-induced transient myocardial ischemia has been described in patients with systemic sclerosis. The clinical impact of cold exposure in systemic sclerosis patients with acute cardiac conditions is unknown. We compared the seasonal variation of acute cardiac hospitalizations in patients with and without systemic sclerosis. Methods: We performed a retrospective cross-sectional study using the National Inpatient Sample from 2016 to 2019. The primary outcome was acute cardiac hospitalization primarily due to heart failure, acute myocardial infarction, or cardiac arrhythmias. We compared the proportion of acute cardiac hospitalizations in each season in patients with and without systemic sclerosis. We also performed a subgroup analysis by US geographic region (Northeast, Midwest, South, West). Results: There were a total of 10,118,002 acute cardiac hospitalizations over the 4-year study period. Compared to those without systemic sclerosis, patients with systemic sclerosis who were hospitalized for acute cardiac care were younger (mean age 67 ± 13 vs 70 ± 14 years, p < 0.01), a greater proportion were female (82% vs 45%, p < 0.01), and a smaller proportion were Caucasian (68% vs 71%, p < 0.01). There was a lesser proportion of traditional cardiovascular risk factors in systemic sclerosis compared to non-systemic sclerosis patients. There was no significant difference in the proportion of winter admissions between systemic sclerosis and non-systemic sclerosis patients for total acute cardiac hospitalizations (26.4% vs 25.9%, p = 0.51), heart failure (27.0% vs 26.5%, p = 0.64), acute myocardial infarction (26.9% vs 25.5%, p = 0.50), or arrhythmias (24.3% vs 25.0%, p = 0.68). The results were consistent across all four US geographic regions. Conclusion: Our study did not support that patients with systemic sclerosis had a disproportionally higher risk of acute cardiac hospitalization in winter compared to the general population. We found that systemic sclerosis patients hospitalized for acute cardiac care had a lower burden of traditional cardiovascular risk factors than their non-systemic sclerosis counterparts.

Myocardial dysfunction in newborns with severe birth asphyxia

Background: Severe birth asphyxia is one of the leading causes of mortality and morbidity in developing countries like India. Severe birth asphyxia can result in transient myocardial ischemia, myocardial dysfunction, and cardiac failure. Aims and Objectives: The current study was undertaken for a better understanding of myocardial dysfunction with the help of serum levels of CPKMB and their correlation with mortality. Materials and Methods: It was a prospective observational study. We studied 150 newborns with severe birth asphyxia admitted to be SNCU of Maharaja Yashwantrao Hospital Indore from August 2021 to July 2022 after clearance from the Institutional Ethics Committee and informed parental consent. Results: A total of 150 newborns with severe birth asphyxia were enrolled. Nearly 75% were males, and 25% were females. Most of the mothers (80%) were multigravidas. Antenatal complications were present in 85.33% of cases. Amniotic fluid was meconium stained in 73.33%, and fetal distress was present in 72.70%. CPKMB was deranged in 93%, and the ejection fraction was reduced in 53%. Out of the total 150 cases, 72 died, with levels of CPKMB elevated in 70 cases and ejection fraction reduced in 62 cases. Conclusion: We conclude that serum CPKMB levels rise early before ejection fraction is reduced and can help us identify myocardial dysfunction early. There is a statistically significant association between CPKMB, ejection fraction, and mortality in babies with severe birth asphyxia. Cardiac-specific enzyme CPKMB helps in the early recognition of myocardial dysfunction, and there is significant correlation with neonatal mortality.

Changes in circulating ApoJ-Glyc levels in patients with suspected acute coronary syndrome: The EDICA trial

BackgroundMyocardial ischemia induces intracellular accumulation of non-glycosylated apolipoprotein J that results in a reduction of circulating glycosylated ApoJ (ApoJ-Glyc). The latter has been suggested to be a marker of transient myocardial ischemia. ObjectiveThis proof-of-concept clinical study aimed to assess whether changes in circulating ApoJ-Glyc could detect myocardial ischemia in patients attending the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS). MethodsIn suspected ACS patients, EDICA (Early Detection of Myocardial Ischemia in Suspected Acute Coronary Syndromes by ApoJ-Glyc a Novel Pathologically based Ischemia Biomarker), a multicentre, international, cohort study assessed changes in 2 glycosylated variants of ApoJ-Glyc, (ApoJ-GlycA2 and ApoJ-GlycA6), in serum samples obtained at ED admission (0 h), and 1 h and 3 h thereafter, blinded to the clinical diagnosis (i.e. STEMI, NSTEMI, unstable angina, non-ischemic). Results404 patients were recruited; 291 were given a clinical diagnosis of “non-ischemic” chest pain and 113 were considered to have had an ischemic event. ApoJ-GlycA6 was lower on admission in ischemic compared with “non-ischemic” patients (66 [46–90] vs. 73 [56–95] μg/ml; P = 0.04). 74% of unstable angina patients (all with undetectable hs-Tn), had ischemic changes in ApoJ-Glyc at 0 h and 89% at 1 h. Initially low ApoJ-Glyc levels in 62 patients requiring coronary revascularization increased significantly after successful percutaneous intervention. ConclusionsCirculating ApoJ-Glyc concentrations decrease early in ED patients with myocardial ischemia compared with “non-ischemic” patients, even in the absence of troponin elevations. ApoJ-Glyc may be a useful marker of myocardial ischemia in the ED setting.

Features of the course of stable exertional angina against the background of iron deficiency anemia in outpatient practice

Introduction. Iron-deficiency accompanies many diseases, including cardiovascular pathology, so timely diagnosis and correction of this condition is necessary. Aim. To study the features of the course of stable exertional angina against the background of iron deficiency anemia before and after correction with iron (III) polymaltose hydroxide in patients in primary health care using a computerized patient register. Materials and methods. 1210 patients with stable exertional angina aged 50–85 years (309 men, 901 women) were included. A special computer program was created for data analysis. In 500 out of 1210 patients, IDA was detected (385 women, 115 men). Mild anemia – 410 patients, moderate – 75, severe – 15. The main group – patients with stable exertional angina and Irondeficiency anemia (the first subgroup – patients treated with iron (III) polymaltose hydroxide and the second subgroup – patients who did not receive the drug iron (III) polymaltose hydroxide due to refusal of treatment or contraindications) and the control group – patients with stable exertional angina without Iron-deficiency anemia. All patients received standard therapy recommended for the treatment of stable exertional angina (the main group additionally received iron (III) polymaltose hydroxide). Results. In the first subgroup of the main group, after treatment with iron (III) hydroxide polymaltose, there was a statistically significant increase in hemoglobin levels by 11,7%, hematocrit by 5%, erythrocytes by 4%, serum iron by 112,8%, and an improvement in exercise tolerance by 48,7%, episodes of ST segment depression by 30,2%. In the second subgroup and the control group, there were no significant changes in the above parameters. Conclusion. Iron-deficiency anemia contributes to the severe course of stable exertional angina, which is confirmed by the high frequency of III-IV functional class exertional angina, a decrease in tolerance to exercise stress. Correction of Iron-deficiency anemia reduces the frequency of episodes of transient myocardial ischemia in the main group.

SILENT MYOCARDIAL ISCHEMIA IN PATIENTS WITH ACUTE CORONARY SYNDROME AND DIABETES MELLITUS

ST-segment elevation myocardial infarction, stenting of the infarct-related coronary artery, silent (painless) myocardial ischemia, diabetes mellitus, 24-hour electrocardiographic monitoring.
 Introduction. Currently, approximately 422 million people in the world have diabetes mellitus, and over 1.3 million individuals in Ukraine are diagnosed with diabetes mellitus. Diabetic neuropathy is known to contribute to the development of atypical and painless variants of ischemic heart disease in individuals with diabetes. This poses a challenge for timely diagnosis and obscures the course of ischemic heart disease, as the prevalence of silent myocardial ischemia is significantly high in these patients. Therefore, the aim of this study is to investigate the occurrence of myocardial ischemia episodes in patients with ST-elevation myocardial infarction within the first day following stenting of the infarct-related coronary artery. Furthermore, we aimed to demonstrate the painless nature of these episodes in the presence of type 2 diabetes mellitus through a clinical case presentation.
 Materials and methods. 30 patients with ST-segment elevation myocardial infarction were examined, and 24-hour electrocardiographic monitoring was performed during the first day after the infarct-related coronary artery stenting. Results. Episodes of transient myocardial ischemia were registered in 50% of people. We found that the majority of episodes (80%) were painless. In the presence of diabetes mellitus, only episodes of painless myocardial ischemia were noted that is supported by the example of a clinical case. The study highlighted the informativeness of 24-hour electrocardiographic monitoring in identifying episodes of myocardial ischemia, particularly in its painless variant. The results demonstrate that patients with ST-elevation myocardial infarction (STEMI) experience episodes of transient myocardial ischemia within the first day after coronary artery stenting, with a majority of these episodes being painless. Furthermore, in the presence of diabetes mellitus, ischemic episodes tend to be painless. Therefore, 24-hour electrocardiographic monitoring serves as a valuable method for the detection of myocardial ischemia.

P320 AN UNUSUAL CASE SYNCOPE DUE TO SILENT CORONARY VASOSPASM

Abstract Background Variant angina is a condition due to a transient vasospasm of the epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. A non–negligible subset of patients can also experience silent myocardial ischemia, defined as objective documentation of myocardial ischemia in the absence of angina or equivalents. This condition is associated with increased cardiac mortality and incidence of acute cardiac events. Description of the case. A 65–years–old man was admitted to our Emergency Department for syncope. He reported palpitations before the event without chest pain. ECG showed biphasic T waves in V2–V6 (Fig 1A), troponin values were normal. Immediately after admission in our coronary care unit for monitoring, he developed dynamic ST segment elevation with signs of inferior and posterior transmural ischemia (Fig 1B) and non–sustained polymorphic ventricular tachycardias (Fig 2), being symptomatic only for palpitations. ECG abnormalities and symptoms quickly resolved after intra–venous nitrates administration. Coronary angiography was performed showing a critical non–occlusive (85%) fixed stenosis at the proximal right coronary artery (Fig 3 A). The lesion was treated by angioplasty and stenting (Fig 3 B) and the patients was discharged on dual anti–platelet therapy, statins and oral high–dose calcium–channel antagonist. Discussion This case underlines first the importance of searching for high–risk features in patients with syncope of non–obvious origin: our patient reported palpitations and ECG changes consistent with myocardial ischemia (even with normal troponin values and echocardiographic findings). A peculiarity of our case is that the patient did not complaint any chest pain despite the presence of ST elevation, a condition known as silent ischemia. The transient nature of ECG modification and ventricular arrhythmias, their dramatic response to nitrates and coronary angiography findings were suggestive of silent vasospasm. Coronary vasospasm induces transient myocardial ischemia and may cause ventricular arrhythmias which in turn can cause syncope due to transient cerebral hypoperfusion or, when sustained, even cardiac arrest and sudden death. We did not perform provocative test with acetylcholine or ergonovine due to the likely vasospastic origin of myocardial ischemia and to their potential risks, especially in the presence of non–sustained plymorphic ventricular tachycardias.

NSTE-ACS patients with transient myocardial ischemia after cardiac catheterization are more likely to have major in-hospital complications

Las complicaciones respiratorias ocurren en 10-20% de pacientes en el postoperatorio inmediato y constituyen la complicación peroperatoria más frecuente. Tanto factores asociados al paciente, como la edad o la presencia de comorbilidades, y al procedimiento anestésico-quirúrgico, tales como la duración, tipo de cirugía y grado de urgencia, se encuentran asociadas a la aparición de dichas complicaciones. Desde un punto de vista fisiopatológico, la alteración de la mecánica ventilatoria en cirugía mayor, el efecto residual de las medicaciones usadas para la anestesia y otras alteraciones metabólicas, desencadenadas por el estado de enfermedad o la agresión quirúrgica, pueden jugar un papel en este proceso. La respiración tiene como objetivo oxigenar la sangre, a la vez que se elimina el CO2 producido durante el metabolismo aerobio. En el postoperatorio, la hipoxemia ocurre con frecuencia como consecuencia de alteraciones en la relación ventilación/perfusión, como las que se dan en presencia de atelectasias, que ocasionan un fenómeno de shunt; mientras que la hipercapnia refleja una reducción de la ventilación alveolar, comúnmente relacionada con hipoventilación global en el contexto de sedación o bloqueo neuromuscular residual. Asimismo, aquellas situaciones en las que exista un incremento de la relación ventilación/perfusión (espacio muerto) favorecerán la aparición de hipercapnia si no se produce un incremento del volumen/minuto suficiente como para compensar el espacio muerto generado. Además, cabe tener en cuenta que no solo las alteraciones respiratorias pueden traducirse en un incremento del espacio muerto, sino que la caída del gasto cardiaco puede favorecer la aparición de este efecto por la incapacidad de aportar un flujo sanguíneo adecuado a todas las porciones ventiladas del pulmón. Por ello, la monitorización continua ofrece la posibilidad de identificar alteraciones fisiopatológicas de manera temprana con el objetivo de reducir las complicaciones perioperatorias.Respiratory complications occur in 10-20% of patients in the immediate postoperative period and represent the most frequent perioperative complication. Patient-associated factors, such as age or comorbidities, and the anesthetic-surgical procedure, such as duration, type of surgery and degree of urgency, are associated with the appearance of these complications. From a pathophysiological point of view, the alteration of ventilatory mechanics in major surgery, the residual effect of medications used for anesthesia and other metabolic alterations, triggered by the state of disease or surgical aggression, may play a role in this process. Respiration aims to oxygenate the blood, while removing CO2 produced during aerobic metabolism. In the postoperative period, hypoxemia frequently occurs as a result of ventilation/perfusion changes, such as those that occur in the presence of atelectasis, which lead to shunt; while hypercapnia reflects a reduction in alveolar ventilation, commonly related to global hypoventilation in the context of sedation or residual neuromuscular blockade. Likewise, those situations in which there is an increase in the ventilation/perfusion ratio (dead space) will favor the appearance of hypercapnia if there is not enough compensatory increase in minute volume. In addition, it should be borne in mind that not only respiratory alterations can result in an increase in dead space, but the fall in cardiac output can favor the appearance of this effect due to the inability to provide adequate blood flow to all ventilated portions of the lung. Given the impact of complications on prognosis, early detection of these alterations through continuous monitoring can potentially improve clinical outcomes.

High Grade AV Block Associated with Dipyridamole Infusion

The use of dipyridamole for thallium imaging has proved very successful in demonstrating coronary arterial disease [1]. Dipyridamole causes coronary arteriolar vasodilation by increasing interstitial adenosine levels by inhibition of both adenosine deaminase and facilitated cellular adenosine uptake. Differential flow changes occur in coronary arteries if a significant luminal stenosis exists [2]. Intravenous infusion of dipyridamole is safe although transient noncardiac side effects are common. These side effects are mostly mild and not need to treat although can be treated with aminophylline [5]. High-grade AV block after dipyridamole has been described in few case reports and mostly was associated with transient myocardial ischemia [2-4]. We describe a case of long-lasting high grade AV block following dipyridamole infusion. In context of near normal baseline ECG. In our case the AV block occurred without evidence of ischemia in myocardial perfusion imaging and we think it can be an unexpected adverse effect of dipyridamole and clinicians should be aware of AV block as a possible adverse effect of dipyridamole.

Clinical Spectrum of Neonatal Encephalopathy and the Role of CK-MB Assay in Transient Myocardial Ischaemia in Neonates with Hypoxic Ischaemic Encephalopathy: A Prospective Cohort Study

Introduction: Significant advancements have been made in the field of perinatal medicine through the use of newer monitoring technologies. However, birth asphyxia continues to cause prolonged hospitalisation due to multiple organ dysfunction and unfortunately, sometimes results in death. An elevation of the serum Creatine Kinase Myocardial Bound (CK-MB) fraction in myocardial ischaemia could indicate exposure to asphyxia and shock in neonates. Aim: The aim of this study was to examine the clinical spectrum of Neonatal Encephalopathy (NE) and investigate Transient Myocardial Ischaemia (TMI) in neonates with Hypoxic Ischaemic Encephalopathy (HIE) using CK-MB assay at birth, 24 hours, and 72 hours. Materials and Methods: A prospective clinical study was conducted in the Neonatal Intensive Care Unit (NICU) at a Tertiary Care Hospital in Tamil Nadu, India. The study duration was eight months, from January 2014 to August 2014. A total of 70 term neonates admitted with NE symptoms were included. Among them, 65 babies with evidence of asphyxia, such as an Appearance, Pulse, Grimace,Activity and respiration (APGAR) score less than 3 at five minutes, heart rate less than 60 Beats Per Minute (bpm), meconium-stained amniotic fluid, or the need for positive pressure ventilation for more than one minute, were evaluated for TMI. Myocardial involvement was assessed through clinical evaluation, chest X-ray (CXR), Electrocardiogram (ECG), Echocardiography (ECHO), and CK-MB assay at birth, 24 hours, and 72 hours. Statistical analysis was performed using Epi Info software version 7.0. Results: The mean Gestational Age (GA) of the study participants was 38.97±1.31 weeks. During the study period, 70 babies were admitted with NE symptoms, and HIE was the cause of encephalopathy in 65 babies. Other causes included hypoglycaemia, intraventricular haemorrhage, and bilirubin encephalopathy. Meconium staining of amniotic fluid was the most common intrapartum event in HIE babies. The survival rate in encephalopathy cases was 28.57%. Shock and respiratory failure were common complications in HIE, representing 46.15% and 44.61% respectively. Cardiomegaly in CXR, ST depression in ECG, Tricuspid Regurgitation (TR) in ECHO, and elevated CK-MB were commonly detected in babies with TMI associated with HIE. Conclusion: NE caused by HIE has a high mortality and morbidity rate. 83.3% of asphyxiated babies with shock had elevated CK-MB levels at birth, but the CK-MB values at 24 hours and 72 hours were not significantly elevated.

230 ANOMALOUS ORIGIN OF LEFT CIRCUMFLEX ARTERY FROM RIGHT SINUS OF VALSALVA: A RARE CASE BUT WITH GREAT CLINICAL RELEVANCE

Abstract Introduction The anomalous connection of the left circumflex artery (LCx) to the right coronary artery (RCA) or sinus is the most frequent coronary artery (CA) anomaly. Among them, only those with an interarterial course are regarded as hidden conditions at risk of myocardial ischemia (MI) and sudden cardiac death (SCD). We report an uncommon of anomalous origin of LCx from the right sinus of Valsalva and a retroaortic path causing MI. Case presentation A 61-year-old man presented to the emergency department complaining palpitations and chest discomfort for an hour. He only had history of hypertension. Physical examination was unremarkable. The ECG demonstrated atrial flutter with a 2:1 conduction ratio and a ventricular rate of 157 bpm and ST segment depression in leads V4-6. Transthoracic echocardiography did not reveal segmental kinetic anomalies but a five-chamber apical view showed a “RAC sign”, typical of anomalous retroaortic course of the left coronary artery. The patient was treated with intravenous infusion of amiodarone. He restored sinus rhythm and symptoms regressed completely, but the ECG taken after conversion showed flattened T waves in leads V5-6 and negative T waves in I and aVL. Cardiac enzymes had transient increase. After the acute episode ended the patient underwent cardiac computed tomography angiography (CTA) with evidence of anomalous origin of LCx from the right sinus with a retroaortic course. A coronary angiography excluded obstructive atherosclerotic coronary lesions. Nuclear myocardial perfusion imaging revealed reversible small subsegmental perfusion defects in mid inferolateral wall and apical lateral wall. We established a medical treatment with beta-blocker. Discussion Our patient had anomalous connection of the LCx branch to the right sinus of Valsalva with a retroaortic course. Although this anomaly is usually considered benign, cases of association with SCD and MI have been reported. The factor responsible for this pathogenicity could be high orifice, ostial stenosis, slit-like/fish-mouth-shaped orifice and acute-angle take-off. As cardiac CTA did not reveal any of these characteristics, we hypothesized that the increased cardiac output and expansion of the great vessels during tachycardia could cause compression of the retroaortic segment or angling at its origin and generate ischemia. Repolarization abnormalities at ECG are well documented during supraventricular tachycardia as a response to pacing-induced stress. These changes are usually diffused and disappear after conversion to sinus rhythm. In this case they appeared hours later, accompanied by cardiac enzyme buildup. As the epicardial coronary arteries did not show any pathology, we suggest that the patient had transient ischemia due to LCx anomaly. We confirmed it by myocardial perfusion imaging. As for the management of this anomaly in adults, surgery is recommended as class IC in patients with typical angina symptoms who present with evidence of stress-induced myocardial ischemia in a matching territory or high-risk anatomy. Our patient has never had clear manifestations of angina. All these elements together with the age of our patient motivated us to use a conservative approach. Conclusions We report a case of anomalous origin of LCx from right sinus of Valsalva causing transient myocardial ischemia in a patient that has always been asymptomatic. This anomaly has been and continues to be considered benign, nevertheless we suggest to judge the clinical significance of this kind of CA anomaly on a case-by-case integrated approach.

Significance of Markers of Transient Myocardial Ischemia and Hemodynamic Overload in Critically Ill Neonates

Monitoring of cardiospecific markers is significant during intensive care.The objective: to compare the diagnostic and prognostic significance of cardiac markers in newborns with somatic and surgical pathology.Subjects and Methods. The study included 76 newborns aged 1 to 14 days with somatic or surgical disorders. The changes in the concentration of cardiomarkers in newborns and their relationship with echocardiography data and non-invasive hemodynamic parameters are presented, their prognostic ability is assessed.Results. Rigidity of non-invasive hemodynamic parameters, and echocardiography data was revealed. In the somatic group, regression of NT-proBNP from 8,307 ng/ml (3,600; 9,000) to 1,717 ng/ml (1,041; 5,011) was regarded as a marker of resolution of hypervolemia against the background of cardiovascular maladaptation. The increase in NT-proBNP from 4,710 ng/ml (3,400; 6,989) to 7,987 ng/ml (3,397; 9,000) in the postoperative period requires a revision of the infusion therapy program with the priority of volume restriction.Conclusions. Stabilization of the condition of patients in the groups is accompanied by a decrease in the concentration of markers of myocardial tension (MB-fraction of creatine phosphokinase, troponin T).Measurement of NT-proBNP concentration allows assessment of fluid overload in critically ill neonates.

Causes of shortness of breath in patients with stable coronary heart disease

Shortness of breath is a common debilitating and limiting the quality of life symptom, which leads to frequent requests for medical help. The review summarizes data on the causes of shortness of breath in stable patients with suspected coronary heart disease (CHD), with an established diagnosis of CHD, as well as in patients with other cardiovascular diseases. PubMed, Science Direct, Google Scholar, and eLibrary search platforms were used for the selection of publications, the review includes publications from 2009 to 2021. Patients with suspected coronary artery disease complaining of shortness of breath, in addition to myocardial ischemia, not always associated with stenosing atherosclerosis of the coronary arteries. The following causes of shortness of breath are described: bronchial obstruction, psychogenic hyperventilation, and depression. When studying patients with other cardiovascular diseases, the causes of shortness of breath turned out to be even more diverse: transient myocardial ischemia (including in cases where the cause of shortness of breath initially appears to be non-ischemic), chronic heart failure, cardiac arrhythmias, pathology of the heart valves, thyroid dysfunction, lung diseases, obesity, anemia, etc. Thus, despite the limited evidence, it is obvious that in the presence of paroxysmal dyspnea in patients with stable coronary heart disease, its causes are more diverse than transient myocardial ischemia.

Sympathetic nerve innervation and metabolism in ischemic myocardium in response to remote ischemic perconditioning

Sympathetic nerve denervation after myocardial infarction (MI) predicts risk of sudden cardiac death. Therefore, therapeutic approaches limit infarct size, improving adverse remodeling and restores sympathetic innervation have a great clinical potential. Remote ischemic perconditioning (RIPerc) could markedly attenuate MI-reperfusion (MIR) injury. In this study, we aimed to assess its effects on cardiac sympathetic innervation and metabolism. Transient myocardial ischemia is induced by ligature of the left anterior descending coronary artery (LAD) in male Sprague–Dawley rats, and in vivo cardiac 2-[18F]FDG and [11C]mHED PET scans were performed at 14–15 days after ischemia. RIPerc was induced by three cycles of 5-min-long unilateral hind limb ischemia and intermittent 5 min of reperfusion during LAD occlusion period. The PET quantitative parameters were quantified in parametric polar maps. This standardized format facilitates the regional radioactive quantification in deficit regions to remote areas. The ex vivo radionuclide distribution was additionally identified using autoradiography. Myocardial neuron density (tyrosine hydroxylase positive staining) and chondroitin sulfate proteoglycans (CSPG, inhibiting neuron regeneration) expression were assessed by immunohistochemistry. There was no significant difference in the mean hypometabolism 2-[18F]FDG uptake ratio (44.6 ± 4.8% vs. 45.4 ± 4.4%) between MIR rats and MIR + RIPerc rats (P > 0.05). However, the mean [11C]mHED nervous activity of denervated myocardium was significantly elevated in MIR + RIPerc rats compared to the MIR rats (35.9 ± 7.1% vs. 28.9 ± 2.3%, P < 0.05), coupled with reduced denervated myocardium area (19.5 ± 5.3% vs. 27.8 ± 6.6%, P < 0.05), which were associated with preserved left-ventricular systolic function, a less reduction in neuron density, and a significant reduction in CSPG and CD68 expression in the myocardium. RIPerc presented a positive effect on cardiac sympathetic-nerve innervation following ischemia, but showed no significant effect on myocardial metabolism.

Mental Stress and Cardiovascular Health-Part I.

Epidemiological studies have shown that a substantial proportion of acute coronary events occur in individuals who lack the traditional high-risk cardiovascular (CV) profile. Mental stress is an emerging risk and prognostic factor for coronary artery disease and stroke, independently of conventional risk factors. It is associated with an increased rate of CV events. Acute mental stress may develop as a result of anger, fear, or job strain, as well as consequence of earthquakes or hurricanes. Chronic stress may develop as a result of long-term or repetitive stress exposure, such as job-related stress, low socioeconomic status, financial problems, depression, and type A and type D personality. While the response to acute mental stress may result in acute coronary events, the relationship of chronic stress with increased risk of coronary artery disease (CAD) is mainly due to acceleration of atherosclerosis. Emotionally stressful stimuli are processed by a network of cortical and subcortical brain regions, including the prefrontal cortex, insula, amygdala, hypothalamus, and hippocampus. This system is involved in the interpretation of relevance of environmental stimuli, according to individual’s memory, past experience, and current context. The brain transduces the cognitive process of emotional stimuli into hemodynamic, neuroendocrine, and immune changes, called fight or flight response, through the autonomic nervous system and the hypothalamic–pituitary–adrenal axis. These changes may induce transient myocardial ischemia, defined as mental stress-induced myocardial ischemia (MSIMI) in patients with and without significant coronary obstruction. The clinical consequences may be angina, myocardial infarction, arrhythmias, and left ventricular dysfunction. Although MSIMI is associated with a substantial increase in CV mortality, it is usually underestimated because it arises without pain in most cases. MSIMI occurs at lower levels of cardiac work than exercise-induced ischemia, suggesting that the impairment of myocardial blood flow is mainly due to paradoxical coronary vasoconstriction and microvascular dysfunction.

Atrioventricular (AV) block and sinus arrest associated with dipyridamole infusion.

The use of dipyridamole for thallium-201 imaging has proved very successful in demonstrating coronary arterial disease, and a combination of dipyridamole and dynamic exercise is becoming widely used. Dipyridamole is safe when given intravenously, although transient noncardiac side effects are common; side effects such as chest pain, headache, and dizziness. These side effects are mostly mild, and can be treated with aminophylline. We describe a 45-year-old woman with normal baseline electrocardiography (ECG) and unremarkable physical examination, referred for myocardial thallium scan with dipyridamole. A few seconds after infusion of dipyridamole, her ECG developed first-degree atrioventricular (AV) block, then, 2:1 AV block, complete heart block (CHB), and sinus arrest. After aminophylline infusion, junctional escape rhythm was seen, and a few seconds later, rhythm changed to sinus rhythm. Thallium scan was negative for ischemia. High-grade AV block after dipyridamole has been described in few case reports, and mostly was associated with transient myocardial ischemia; it seems that the presence of conduction abnormalities at baseline is a risk factor. But in our case, the sinus arrest and AV block occurred without evidence of ischemia in myocardial perfusion imaging, and we think it can be an unwanted complication of dipyridamole; clinicians should be aware of bradyarrhythmia as a possible complication of dipyridamole. An alternative explanation is that this arrhythmia can be caused by vagal activity; and another possibility is that the imaging study was false negative.

Fragmented QRS complex as a marker of myocardial fibrosis in patients with coronary artery disease

Aim– to analyze the relationship between fQRS and myocardial fibrosis in CAD patients using SPECT.&#x0D; Material and methods.Retrospectively, we have analyzed the anamnesis and examinations of 116 patients with suspected coronary heart disease. The fQRS was assessed according to the criteria of Das M. et al., 2006, along with the presence of a pathological Q wave and a slow increase in the amplitude of the R wave. We analysed the transient myocardial ischemia and/or myocardial scarring using stress/rest SPECT with technetium-99m.&#x0D; Results.fQRS was significantly more frequently detected in patients with stable and partially reversible perfusion defects – 44.1% and 52.2%, respectively, versus 13.0% and 5.5% in patients without perfusion defects or with reversible perfusion defects, p 0.05. Among 28 patients with QRS fragmentation and myocardial fibrosis, 19 (67.8%) had classical signs of fibrosis on the ECG, 9 (32.1%) had no ECG-registered fibrosis but fQRS was detected. The sensitivity of fQRS marker in detecting myocardial fibrosis reached 84.4%, the specificity was 63.3%.&#x0D; Conclusion.fQRS complex is an informative marker for detecting myocardial scarring in patients with coronary artery disease. Analysis of fQRS in daily clinical practice may increase the diagnostic value of electrocardiography in the detection of fibrosis.

Ischemic Pre-Conditioning is Present in Patients with Non-ST Elevation Myocardial Infarction and ECG Derived Moderate Obstructive Sleep Apnea.

Obstructive Sleep Apnea (OSA) is associated with an increased risk of cardiovascular events, including Acute Coronary Syndrome (ACS). There is conflicting evidence that suggests OSA has a cardioprotective effect (i.e., lower troponin), via ischemic pre-conditioning, in patients with ACS. This study had two aims: (1) compare peak troponin between non-ST elevation (NSTE) ACS patients with and without moderate OSA identified using a Holter derived respiratory disturbance index (HDRDI); and (2) determine the frequency of transient myocardial ischemia (TMI) between NSTE-ACS patients with and without moderate HDRDI. This was a secondary analysis. OSA events were identified from 12-lead ECG Holter recordings using QRSs, R-R intervals, and the myogram. Moderate OSA was defined as an HDRDI ≥15 events per/hour. TMI was defined as ≥1 millimeter of ST-segment ↑ or ↓, in ≥ 1 ECG lead, ≥ 1 minute. In 110 NSTE-ACS patients, 39% (n=43) had moderate HDRDI. Peak troponin was higher in patients with moderate HDRDI (6.8 ng/ml yes vs. 10.2 ng/ml no; p=0.037). There was a trend for fewer TMI events, but there were no differences (16% yes vs. 30% no; p=0.081). NSTE-ACS patients with moderate HDRDI have less cardiac injury than those without moderate HDRDI measured using a novel ECG derived method. These findings corroborate prior studies suggesting a possible cardioprotective effect of OSA in ACS patients via ischemic pre-condition. There was a trend for fewer TMI events in moderate HDRDI patients, but there was no statistical difference. Future research should explore the underlying physiologic mechanisms of this finding.