Triple Vessel Disease Research Articles

Relationship between Myocardial Performance Index (Tei Index) and angiographic severity of coronary artery disease in patients with Acute ST Elevation Myocardial Infarction

Background: Tei index is a Doppler derived measure of combined systolic and diastolic myocardial function and a better predictor of global LV function and outcome in patients with acute STEMI. The objective of this study was to determine the relationship between the myocardial performance index of LV (Tei index) and angiographic severity of coronary artery disease as assessed by SYNTAX score in patients with acute STEMI. Methods: This was a prospective, observational single centered study conducted from March 2022 to November 2022 at Manmohan Cardiothoracic Vascular and Transplant Centre, Institute of Medicine. (MCVTC, IOM). 160 patients with acute STEMI were enrolled. LV Tei index was calculated with the help of 2D and Tissue Doppler imaging, and the lesion severity was categorized with the help of SYNTAX score after the patients underwent coronary angiography. Results: The mean age was 61.23±12.33 years with a male preponderance. 107 (67%) were male with male to female ratio of 2:1. Tei index was significantly higher among the hypertensive (0.74±0.17) and diabetic (0.78±0.18) patients. 64 (40%), 51(31.9%) and 45(28.1%) had Single vessel disease (SVD), Double vessel disease (DVD) and Triple vessel disease (TVD) respectively with the Mean Tei index values 0.57 ± 0.10, 0.76 ± 0.11, and 0.88±0.11 (p<0.05). The Tei index increased when patients were divided into low, mid, and high SYNTAX score groups as 0.58±0.11, 0.61±0.73, 0.88±0.13 respectively, p-value < 0.05). Moreover, the study showed a positive correlation between Tei index and SYNTAX score with increasing severity of coronary artery stenosis. (r=0.654, p-value<0.001). Proximal LAD, LCx and RCA lesions had greater Tei index than the distal lesions. Conclusion: More proximally located LAD, LCx, RCA lesions had higher value of Tei index, as assessed with the SYNTAX score.

Total arterial revascularization with RIMA-LIMA-Y configuration in patients with left subclavian artery stenosis.

Subclavian artery stenosis (SAS) occurs in 6% of patients undergoing coronary artery bypass grafting (CABG). Complications such as subclavian-coronary steal are common. Revascularization options in such cases remain debatable. In this case series, all patients with angina, had severe triple vessel disease on angiography. All tests including computed tomography (CT) angiography of neck vessels, were done as part of routine workup for CABG. The patients, all males, had a mean age of 66.5 years with three of them having hypertension and diabetes. All were ex-smokers with mean ejection fraction (EF) of 60.1%. CT angiography of neck vessels revealed that two patients had moderate to severe while one had severe left SAS and another had severe proximal left internal mammary artery (LIMA) stenosis. Total arterial revascularization was performed, with an average of 3.5 distal grafts. The LIMA graft was employed in a Y graft configuration, anastomosed to in-situ right internal mammary artery (RIMA). All patients had uneventful postoperative stay and were discharged with a mean hospital stay of 3.8 days. There were no postoperative strokes, myocardial infarction, neurological symptoms, or change in EF. At 6-month follow-up, they were asymptomatic and doing well. The RIMA-LIMA-Y configuration can be a safe, viable option in CABG for patients with left SAS. It is challenging, with re-entry and judicious utilization of the length of LIMA being of paramount importance. The importance of CT angiography of neck vessels to detect SAS cannot be under-emphasized.

Association of PCSK6 rs1531817(C/A) polymorphism with the prognosis and coronary stenosis in premature myocardial infarction patients: a prospective cohort study

Abstract Background An increasing proportion of younger patients are currently hospitalized for acute myocardial infarction. Exploring the factors affecting coronary artery lesions and prognosis in patients with premature myocardial infarction (PMI) from a genetic perspective is of great significance to clinical management. Proprotein convertase subtilisins/kexins 6(PCSK6), a member of the PCSK family, functions in protein hydrolytic cleavage. It has been shown that PCSK6 polymorphisms are associated with carotid atherosclerosis. Purpose This research intended to evaluate the relationship between the PCSK6 rs1531817 polymorphism and the prognosis of PMI patients and their coronary stenosis. Methods This study was a prospective cohort study, which consecutively included 605 patients with PMI who underwent emergency PCI from January 2017 to August 2022 at X Hospital. Using the Massarray technique, the single nucleotide polymorphisms(SNPs) of PCSK6 rs1531817 were identified, and the patients underwent follow-up for 12 to 72 months, with major adverse cardiovascular events (MACEs) as the outcome. Analyze the relationship between patients' SNPs, Gensini score(GS), Triple vessel diseases(TVD), and MACEs. Results In PMI patients with PCSK6 rs1531817 CA+AA genotypes, ApoA1/ApoB levels were higher than in patients with CC genotype, and TC/HDL levels were lower (p < 0.05). Logistic regression analysis showed that the PCSK6 rs1531817 polymorphism (Dominant model: CA+AA vs.CC) was significantly correlated with the GS (high vs. low GS, adjOR=0.297, 95%CI:0.139-0.632, p=0.002; high vs. medium GS, adjOR=0.449, 95%CI:0.211-0.956, p=0.038), and it was correlated with the number of coronary artery lesions (TVD vs. SVD, adjOR=0.420, 95%CI:0.226-0.782, p=0.006; TVD vs. DVD, adjOR=0.406, 95%CI:0.214-0.773, p=0.006). According to multivariate Cox regression analysis, the PCSK6 rs1531817 dominant model was associated with the MACEs in PMI patients (adjHR=0.454, 95%CI:0.269-0.766, p=0.003). The mediation effect results showed that ApoA1/ApoB played a partially mediating role in the association between PCSK6 rs1531817 polymorphism and the severity of coronary stenosis (the effect leading to high GS and TVD accounted for 14.6% and 8.3% respectively), TC/HDL and TVD partially parallel mediated the association between PCSK6 rs1531817 polymorphism and MACEs (effect proportions were 8.1% and 17.1%, respectively). Conclusion Carrying the PCSK6 rs1531817 mutant A allele is an independent protective predictor of severe coronary stenosis and long-term prognosis in patients with PMI. Patients with the PCSK6 CA+AA genotypes have milder coronary stenosis partially because they have higher levels of ApoA1/ApoB; in addition, these patients have a better long-term prognosis partially because they have lower TC/HDL levels and fewer TVD patients.Figure 1.ApoA1/ApoB and TC/HDL were compareFigure 2.Correlation of PCSK6 rs1531817 pol

The association between elevated systemic inflammation response index and long-term mortality in patients with triple-vessel coronary disease

Abstract Background Inflammation is a critical factor in the development of coronary artery disease. The systemic inflammatory response index (SIRI) is a novel biomarker of inflammation. Studies have shown that SIRI is associated with the severity of coronary artery disease. However, there is currently a lack of research on the relationship between SIRI and adverse outcomes in patients with multivessel coronary artery disease. Our study aimed to investigate the correlation between SIRI and long-term mortality risk in patients with triple-vessel coronary disease (TVD) and explore the interaction between SIRI and treatment strategies. Methods After excluding patients with missing data or loss to follow-up, a total of 8559 patients with TVD were included in our study. Based on their SIRI levels during hospitalization, patients were evenly divided into three groups (SIRI-L, SIRI-M, and SIRI-H). All patients received appropriate treatment, including medical therapy alone (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG). The primary endpoint was all-cause death. SIRI was calculated by the formula: neutrophil counts × monocyte counts / lymphocyte counts. Results During a median follow-up of 6.58 years, a total of 1264 all-cause deaths (14.8%) were recorded. Elevated SIRI was significantly associated with increased mortality rates (11.1%, 14.6%, and 18.6% in the SIRI-L, SIRI-M, and SIRI-H groups, respectively). The risk of all-cause mortality was significantly higher in the SIRI-M and SIRI-H groups compared to the SIRI-L group (adjusted HR: 1.203, 95% CI: 1.037-1.395, p=0.015; adjusted HR: 1.400, 95% CI: 1.212-1.617, p<0.001; respectively). In elderly patients, the relationship between elevated SIRI and the risk of all-cause mortality was more pronounced, while it attenuated in younger patients. Additionally, it is noteworthy that there was an interaction between SIRI and treatment strategy (p=0.037). In patients of the SIRI-L group, there was no significant difference between PCI and CABG treatment. However, in patients of the SIRI-M and SIRI-H groups, CABG shows a significant survival advantage over PCI. Conclusion Evaluating SIRI may help identify high-risk groups among patients with triple-vessel coronary disease and guide the selection of treatment strategies.Kaplan-Meier curves

The risk factors for in-stent restenosis following drug-eluting stent implantation in end-stage renal disease patients receiving renal replacement therapy

Abstract Background Chronic renal disease is a recognized risk factor for in-stent restenosis (ISR) following percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). However, the specific risk of ISR among individuals with end-stage renal disease (ESRD) remains unclear or insufficiently studied. Purpose It is imperative to identify the risk factors associated with ISR among patients with ESRD and coronary artery disease following the implantation of DES. This identification is crucial for generating evidence-based strategies aimed at preventing ISR. Methods ESRD patients undergoing renal replacement therapy with concomitant coronary artery disease who underwent PCI with their initial DES implantation at our hospital between January 2013 and December 2022 were included in the study cohort. Clinical data, laboratory test results, and PCI specifics were compared between patients with and without ISR. Univariate and multivariate analyses utilizing Cox proportional hazard regression were employed to identify independent risk factors for DES-ISR. Results Among the 321 patients with ESRD who underwent PCI with DES implantation, totaling 874.5 patient-years of follow-up, 53 cases of ISR occurred during this period, yielding an incidence rate of 6.1 per 100 patient-years. Several baseline characteristics, angiographic findings, and procedural details were found to elevate the risk of ISR significantly. These included underlying diabetes mellitus, peripheral artery disease (PAD), high serum parathyroid hormone levels, LDL-C levels, acute coronary syndrome as the clinical presentation, the presence of triple vessel disease, duration of dual antiplatelet therapy less than 1 year, target lesion involving the left main (LM) or left anterior descending (LAD) artery, target vessel size less than 3 mm, ostial lesion, bifurcation lesion, number of stents implanted equal to or more than 3, and stent size less than 3 mm. In the multivariate Cox proportional hazard model, bifurcation lesion (HR 14.70, 95% CI 4.66-46.38), PCI of LM or LAD (HR 5.29, 95% CI 1.14-24.60), target vessel size less than 3 mm (HR 4.10, 95% CI 1.77-9.50), PAD (HR 3.92, 95% CI 1.52-10.08), and ostial lesion (HR 2.92, 95% CI 1.16-7.38) were identified as independent risk factors for ISR (all p-values < 0.05). Conclusions Among ESRD patients with coronary artery disease, bifurcation lesion, PCI involving the LM or LAD, target vessel size less than 3 mm, PAD, and ostial lesion are identified as independent risk factors for ISR. These findings hold significance in enhancing risk stratification and decision-making concerning treatment planning for this population.Univariate analysis risk factors for ISR

Circulating ACE2 and the association of endothelial progenitor cell in CAD patients

Abstract Background/Introduction Angiotensin-converting enzyme (ACE) 2 is the homologue of ACE, and the local up-regulation of ACE2 expression associates to antiatherosclerosis. ACE2 hydrolyzes the angiogensin II, which related to impair of endothelial progenitor cell (EPC) function. EPCs maintain the integrity of vascular endothelium in case of damage. Decreased number of EPCs associate thrombosis. Purpose To investigate the circulating ACE2 and the link to EPC in CAD patients. Methods Data from 650 patients with stable angina pectoris requiring invasive coronary angiography were enrolled. They were divided into two groups according to the median value of ACE2. Two interventional cardiologists diagnosed obstructive CAD by angiography review. Demographic characteristics and clinical outcomes were compared between groups. Results In all subjects (median age 67 years, male=66.9%), a higher ACE2 level indicates elder, higher prevalence of hypertension, diabetes mellitus and chronic kidney disease. Significant EPC elevation when CAD numbers increased in higher ACE2 group (SVD vs. DVD vs. MVD = 0.005 vs. 0.006 vs. 0.007, p value=0.044). In multivariate analysis, higher ACE2 is positively correlated to triple vessel disease (TVD vs. no CAD, adjusted odds ratio=1.627, 95% CI 1.026-2.579). Conclusions Our data demonstrated higher circulation ACE2 links to EPCs in CAD patients.

Analysis of Angiographic Patterns in Acute Coronary Syndrome Patients With Diabetes Mellitus: Correlation With HbA1c Levels.

Background The relation of diabetes mellitus with cardiovascular diseases is well-known, even acute coronary syndrome (ACS). High levels of glycated haemoglobin (HbA1c) are used is a sign oflong-term glycemic control and may be associated with severity in coronary artery disease (CAD). In this particular setting, the aim of this investigation was to examine the relationship between the HbA1c values and the angiographic patterns of patients who were admitted with an ACS diagnosis. Methodology A cross-sectional study included 120 patients diagnosed with ACS. The criteria for eligibility included patients with ST-elevation myocardial infarction, unstable angina, and non-ST elevation myocardial infarction with history of documented diabetes mellitus. Every patient had a suitable clinical examination, had their HbA1c checked, and had coronary angiography to determine the severity of their CAD. Descriptive statistics and ANOVA were performed for statistical analyses to determine the connection between angiographic patterns and HbA1c. Results Patients with elevated HbA1c levels demonstrated a strong association with severe coronary artery disease. Notably, those with HbA1c exceeding 10.5% exhibited significant triple vessel disease and Type C lesions, indicative of advanced coronary artery disease. Statistical analyses revealed a marked difference in angiographic patterns across various HbA1c categories (p < 0.05). Conclusion The findings of this study suggest that maintaining optimal HbA1c levels is essential for mitigating the severity of coronary artery disease in patients with ACS. Moreover, effective glycemic control may be protective against advanced coronary atherosclerosis and subsequent cardiovascular complications in both diabetic and non-diabetic individuals.

Prognostic Significance of Right Ventricular Free Wall Longitudinal Strain and Angiographic Correlation in Acute Inferior Wall ST-elevation MI

Background: In this study, we assessed the prognostic significance of right ventricular free wall longitudinal strain (RVfwLS) in patients with acute inferior wall MI and investigated its association with angiographic characteristics and adverse outcomes. Methods: A prospective observational study was conducted with 200 patients admitted with acute inferior wall MI who underwent primary angioplasty. 2D speckle tracking echocardiography was used to measure the RVfwLS at the time of admission. Angiographic characteristics were collected, and patients were followed up for adverse outcomes until discharge. Categorical data were compared using the χ2 test or Fisher’s exact test. Logistic regression analysis was used to identify adverse cardiovascular outcomes independently associated with RVfwLS. A p-value of &lt;0.05 was considered statistically significant for all analyses. Results: Compared with patients with normal strain (n=88, 44%), patients with diminished strain (n=116, 56%) had significantly lower blood pressure (56.52% versus 43.58%; p=0.03), reduced tissue velocities (93.3% versus 6.7%; p&lt;0.01), elevated jugular venous pressure (58.93% versus 41.07%; p=0.04), and higher right ventricular systolic pressure (52.04% versus 47.96%; p=0.04). Additionally, patients with diminished strain had a higher incidence of triple vessel disease (80% versus 20%; p=0.026) and arrhythmias necessitating inotropic support (66.67% versus 37.33%; p=0.02), as well as a longer hospital stay (78.7% versus 21.3%; p&lt;0.01) compared with patients with normal strain. In multivariate analysis, arrhythmias (p=0.046; OR 2.05; 95% CI [0.93–8.10]) and right heart failure (p=0.035; OR 3.64; 95% CI [1.35–11.53]) were independently associated with RVfwLS. The optimal RVfwLS cut-off value for predicting adverse outcomes was −14.8% (AUC=0.915; 95% CI [0.876–0.954]; p&lt;0.001), with a sensitivity of 81.3% and specificity of 86.8%. Conclusion: RVfwLS can be used to categorise the severity of infarction and predict adverse outcomes.

Assessing renal function as a predictor of adverse outcomes in diabetic patients undergoing percutaneous coronary intervention

Background Cardiovascular diseases remain a leading cause of global mortality, particularly among diabetic patients undergoing percutaneous coronary intervention (PCI). Chronic kidney disease (CKD) poses an additional risk in this population. Yet, its specific impact on major adverse cardiovascular events (MACEs), mortality, and triple vessel disease (TVD) post-PCI remains a topic of debate, specifically in patients with type 2 diabetes mellitus (T2DM). Objective This study aimed to examine the impact of renal function on MACE, mortality, and TVD among diabetic patients undergoing PCI. Methods Diabetic patients undergoing PCI were analysed for renal function and outcomes. Participants were stratified by glomerular filtration rate (GFR). Logistic regression and receiver operating characteristic (ROC) analysis assessed associations and predictive capabilities. Results A total of 505 patients enrolled in the study. A significant difference was observed regarding age, creatinine levels, and number of culprit vessels between diabetics with and without CKD. Severe CKD was associated with higher odds of 1-month mortality (OR: 15.694, p value <.001), 1-month MACE (OR: 7.734, p value <.001), and TVD (OR: 3.740, p value <.001). Patients with severe CKD also had significantly higher odds of 6-months mortality (OR: 12.192, p value <.001) and 6-months MACE (OR: 3.848, p value: .001). Moreover, GFR showed significant predictive accuracy for mortality at one- and six-months follow-up (AUC: 0.77 and 0.71, respectively). Conclusions Renal dysfunction, particularly severe CKD, significantly elevates risks of MACE, mortality, and TVD. Strategies to optimise renal function and tailor cardiovascular management could mitigate adverse outcomes in this high-risk population.

Horner’s syndrome caused by the first rib fracture sustained during coronary artery bypass grafting: a case report and literature review

BackgroundHorner’s syndrome is a rare complication of cardiovascular surgery. A bone fragment and hematoma due to rib fracture after cardiac surgery may cause injury to the brachial nerve plexus and sympathetic nerve trunk, leading to neurologic disorders and Horner’s syndrome. However, few reports have revealed the etiology of Horner’s syndrome after cardiovascular surgery based on imaging. Herein we present a case in which a plain CT scan confirmed the etiology of Horner’s syndrome after coronary artery bypass grafting (CABG), reviewing 139 CABG cases retrospectively in our hospital and 6 case reports of Horner’s syndrome associated with cardiovascular surgery.Case presentationA 69-year-old woman with a history of percutaneous coronary intervention and total abdominal hysterectomy with bilateral salpingo-oophorectomy had chest pain on exertion. Coronary angiography showed severe triple vessel disease. She underwent off-pump coronary artery bypass grafting (CABG). A median sternotomy was performed, and the split sternums were widened using a sternal retractor. The bilateral internal thoracic arteries were harvested. A triple CABG was performed. She had left shoulder pain after surgery. She complained of anhidrosis involving the left face and hyperhidrosis involving the right face from postoperative day (POD) 6. Left ptosis and blurry vision appeared after discharge from the hospital, for which she saw a neurologist in our hospital on POD 48. Miosis could not be clearly confirmed. She was diagnosed with Horner’s syndrome. A plain CT scan revealed displaced fractures of the bilateral first ribs and left second rib. The bone fragment of the left first rib head was displaced 3 mm anteriorly compared to the left first rib head before surgery, which suggested that the fragment affected the stellate ganglion in the sympathetic trunk. The patient had regular follow-up evaluations. The anhidrosis persisted, but the ptosis improved, and the miosis was not confirmed at the 6-month follow-up evaluation.ConclusionsWe should recognize that Horner’s syndrome is one of the complications of cardiovascular surgery, especially CABG. Fracture of the first rib head with a displaced bone fracture was shown to be a contributor to ipsilateral Horner’s syndrome. When symptoms of Horner’s syndrome and other neurologic symptoms are noted after open heart surgery, a plain CT examination should be obtained.

Risk Factors, Clinical Profile, and Outcomes of Coronary Artery Disease in the Elderly

Objectives This study aimed to identify risk factors in patients diagnosed with angiographically significant coronary artery disease (CAD) after 65 years of age (elderly) with a subset analysis of more than 75 years, analyze their clinical, angiographic profile and assess their major acute cardiovascular and cerebrovascular events (MACCE). Methods This was an observational retrospective and prospective study conducted from January 2022 to June 2023 among consecutive elderly who underwent CAG for suspected or diagnosed CAD between 2010 and 2018 at a tertiary center in South India. Results A total of 1,511 patients satisfied eligibility criteria with mean age of 69.38 years and male preponderance (69%). Male gender, dyslipidemia and current tobacco use contributed to angiographically significant CAD by multiple logistic regression analysis but none of the risk factors contributed in the more than 75-year age group. Female patients had higher incidence of atypical presentation, less revascularizations and higher MACCE. Fourteen percent of patients with significant CAD developed MACCE over a median 3.5-year hospital follow-up. Survival analysis of 1,027 patients with significant CAD showed one, three, 5-year mortality rate of 4.3%, 6.9% and 10.8%, respectively, with left ventricular dysfunction and triple vessel disease being associated with worse survival. MACCE and 5-year survival was significantly better among those who underwent revascularization including those with significant left main or triple vessel disease. Conclusion This study showed a high prevalence of traditional risk factors in elderly patients among which male gender, dyslipidemia, current tobacco use were found to predict angiographically significant CAD. Triple vessel disease and left ventricular dysfunction were associated with worse survival. Mortality was significantly lower among elderly who underwent revascularization compared to medical management.

Assessment of Demographic Characteristics Among CAD Patients by Ethnicity

Background: This study was carried out to assess the demographic characteristics among CAD by ethnicity. Methods: Retrospective study was performed in (SGNHC) Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Hospital Database of 837 patients were used to gather the information about the disease during one year period. SPSS version 20 was used for statistical analysis. Results: As the hospital lies in the Capital city and Central Region of the country, most of the population 604 (72.2%) had come from Central region, 126 (15.4%) from Western region, 62(7.6%) from Eastern region, 15(1.8%) from Far-western region and 11(1.3%) from Midwestern region. Conclusion: The study examined 837 CAD patients, primarily Brahmin/Chhetris (44.7%), with an average age of 58.6 years and 71.9% being male. Most patients were from Nepal's Central Region.Acute STEMI was the most common diagnosis, particularly among Newars, while NSTEMI and Angina Pectoris were more prevalent in Dalits. Single vessel disease was frequent in Muslims, with Dalits showing higher rates of triple vessel disease, highlighting demographic and regional variations in CAD severity.CAD has been identified as public health priority in Nepal given the current and predicted burden of all forms of heart disease within the country. This study found that there was a diverse distribution in its well-known traditional risk factors among major Nepalese ethnic groups and demographic characteristics.

Clinical and Angiographic Profile of Non-ST Elevation Myocardial Infarction Patients with Multivessel Disease: A Study in a Tertiary Care Hospital in Bangladesh

Background: Non-ST elevation myocardial infarction (NSTEMI) is a type of acute coronary syndrome without ST-segment elevation on electrocardiography. Many non-ST elevation myocardial infarction patients have multivessel disease, which leads to worse outcomes compared to single-vessel disease. Their clinical and angiographic profiles provide valuable insightf into the nature, severity, and treatment of this common cardiac condition. This study aimed to evaluate the clinical and angiographic profiles of non-ST elevation myocardial infarction patients with multivessel disease. Methods: This prospective study was conducted in the Department of Cardiology, National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh from September 2022 to August 2023. The study enrolled 270 consecutive patients with NSTEMI. Coronary angiography and electrocardiogram were used in assessing the disease condition. The data were analyzed using SPSS version 23.0. Results: The mean age of total participants was 54.31 ±10.54 years and most of them were male (77.8%). Majority of the patients had hypertension (68.1%), diabetes mellitus (59.3%), and dyslipidemia (58.5%). In the clinical assessment, 89.6% of patients had femoral access, 31.1% had a bifurcation lesion, 8.1% showed calcification, and 22.6% had a left main lesion. Stents were used in 41.9% of cases, with a mean total stent length of 55.8 ±26.9 mm. The mean left ventricular ejection fraction was 49.10 ±7.3%. Among the major culprit vessel involvements identified, 6% involved the left main (LM) artery, 56% involved the left anterior descending (LAD) artery, 34% involved the left circumflex (LCX) artery, and 39% involved the right coronary artery (RCA). Regarding the final angiographic findings among the total participants, double vessel disease (DVD) was observed in 40% of cases, while triple vessel disease was observed in 60% of cases. Conclusion: The increased prevalence of triple vessel disease among non-ST elevation myocardial infarction patients underscores the importance of heightened vigilance among healthcare providers and policymakers. Understanding the clinical and angiographic profiles of these patients is essential for effective management strategies.

Erdheim-chester disease with bilateral proptosis, coated aorta and hairy kidney

Erdheim-Chester disease (ECD) is a rare histiocytic disorder with a spectrum of clinical manifestations, ranging from asymptomatic single-organ involvement to multisystem disease. We present a classic case of ECD with detailed radiographic and histopathologic findings. A 63-year-old Thai female with a history of triple vessel disease post-PCI presented with bilateral proptosis and blurred vision for one year. On admission, she exhibited marked proptosis epiblepharon, lagophthalmos, conjunctival injection, chemosis, limited extraocular movement and cranial nerve II palsy. Imaging showed increased bilateral retro-orbital infiltrative lesions, osteosclerotic changes, and soft tissue thickening along the great vessels and retroperitoneum. A retro-orbital soft tissue biopsy showed foamy histiocytic proliferation with Touton giant cells. EDC was confirmed by next-generation sequencing revealing a BRAF V600E mutation. This patient received pegylated interferon-alpha. At 1-year follow-up visit, the disease remained stable. In this report, we present a classic case of EDC. The rarity of this disease makes it challenging to diagnose. The typical presentation characteristics raise awareness for the diagnosis of EDC, which is based on features such as osteosclerotic lesions in the long bones, soft tissue infiltration in medium to large vessels (coated aorta) and the bilateral pelvicalyceal systems (hairy kidney). These findings were confirmed through tissue pathology and molecular diagnostics.

Risk Factors And Angiographic Profile of Young Adult Less Than 40 Years of Age in Bangladeshi Population

Back ground: : Coronary artery disease (CAD) in young adults under the age of 40 is an increasing medical, social, psychological, and economic concern, owing to the rise of civilization-related diseases and an unhealthy lifestyle. The problem of CAD in young people has not been studied as thoroughly as it has in older people, as current data consists primarily of case reports and small series, which are frequently tied to genetic features and family occurrence of the illness. Aim: To evaluate the risk factors for ischemic heart disease and the angiographic pattern of young adults with CAD who presented with chest pain in the ER. Methods : We conducted this observational study at Ibrahim Cardiac Hospital &amp; Research Institute in Dhaka, Bangladesh, from February 1 to June 30, 2024. Patients with chest discomfort aged 21-40 years who underwent coronary angiography were included in the study. Results: This retrospective analytical investigation was carried out from February 1st to June 30th, 2024, with 110 patients enrolled in the department of cardiology at Ibrahim Cardiac Hospital &amp; Research Institute. Patients aged 21 to &lt;40 years were separated into two groups: 21-30 years and more than 30 to &lt;40 years, with a mean age of 34.28±4.25 years. All patients underwent a coronary angiogram, which revealed that 30% had non-flow limiting coronary arteries, 29.1% had single vessel disease, 22.7% had double vessel disease, 17.3% had triple vessel disease, and 0.9% had left main with or without coronary involvement. Patients aged 30 to under 40 had more coronary artery disease than those aged 21 to 30. Conclusion: Young patients have distinct coronary artery disease patterns, hence the therapeutic plan must be tailored to their demographic. In this vulnerable age group, there should be a stronger emphasis on risk factor identification and management.

The impact of stress testing to guide PCI in patients with chronic coronary disease

BackgroundGuidelines and international appropriate use criteria increasingly endorse non-invasive stress testing to evaluate patients with suspected chronic coronary disease (CCD). We sought to review the real-world utilisation of non-invasive stress testing and investigate whether their use prior to PCI associates with outcomes in patients with CCD. MethodsConsecutive patients from a multicentre registry who underwent PCI for CCD between 2006 and 2018 were included. Clinical characteristics and outcomes were stratified according to whether stress testing was performed prior to PCI (stress vs no-stress groups). The primary outcome was 3-year all-cause mortality. ResultsAmong the 8251 patients included, 4970 (60.2 %) underwent pre-PCI stress testing and this proportion increased over time (p-for-trend<0.001). The stress group had a lower prevalence of prior revascularization, myocardial infarction, or heart failure, and a lower incidence of triple vessel disease, in stent re-stenosis, and ACC/AHA class B2/C lesions (all p < 0.001). When comparing post-procedural outcomes, the stress group had lower rates of arrhythmia (1.5 % vs 2.6 %, p = 0.001), new heart failure (0.2 % vs 0.8 %, p = 0.001), renal impairment, and a shorter length of stay (1.6 vs 2.1 days, p < 0.001). Mortality at 3-years was lower in those undergoing PCI following stress testing (5.8 % vs 8.8 %, p < 0.001). After adjusting for key clinical variables, stress guided revascularization was associated with a significantly lower risk of 3-year mortality (adjusted Hazard Ratio 0.77, 95 % CI 0.64–0.92). ConclusionsIn patients with CCD, PCI guided by non-invasive stress testing is increasingly utilized and associated with improved survival. Further studies are necessary to investigate whether this results from differences in patient characteristics, optimized patient selection, or refined choice of target vessel.

Predictive model for left main coronary artery or triple vessel disease in patients with chronic coronary syndromes.

Data about prediction of left main coronary artery disease (LMCAD)/three-vessel disease (TVD) in patients with chronic coronary syndromes (CCS) are lacking. This study aimed to develop a model for predicting patients at risk of LMCAD/TVD. This study used retrospective data from patients with CCS scheduled for invasive coronary angiography (ICA) and who were retrospectively recruited between January 2018 and December 2020. Predictors were obtained and analyzed by using logistic regression analysis, and generated the prediction score. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The cut-off value and area under the curve (AUC) were analyzed by using the receiver operating characteristic (ROC) curve. We recruited 162 patients with CCS. There were 75 patients in the non-LMCAD/TVD and 87 patients in the LMCAD/TVD groups. After the multivariate analysis, new onset of heart failure (HF) or left ventricular systolic dysfunction (LVSD) and suspected CAD, ST elevation (STE) in aVR, STE in V1 and lateral ST depression (STD) were associated with increased risk of LMCAD/TVD. Based on these 4 predictors, the prediction score was created. The cut-off value of the prediction score by using ROC curve analysis was 3.0. The sensitivity, specificity, PPV, and NPV were 71.26%, 86.67%, 86.11%, and 72.22%, respectively, with an AUC of 0.855. The CCS patients with new onset of HF or LVSD and suspected CAD, STE in aVR, and STE in V1 and lateral STD were associated with increased risk of LMCAD/TVD. The novel prediction score could predict LMCAD/TVD in those patients with acceptable sensitivity, specificity, PPV, and NPV.

Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited. The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI. After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07). In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.

Association of the PCSK6 rs1531817(C/A) polymorphism with the prognosis and coronary stenosis in premature myocardial infarction patients: a prospective cohort study

BackgroundProprotein convertase subtilisins/kexin 6 (PCSK6) polymorphisms have been shown to be associated with atherosclerosis progression. This research aimed to evaluate the relationship of PCSK6 rs1531817 polymorphisms with coronary stenosis and the prognosis in premature myocardial infarction (PMI) patients.MethodsThis prospective cohort analysis consecutively included 605 PMI patients who performed emergency percutaneous coronary intervention (PCI) at Tianjin Chest Hospital sequentially between January 2017 and August 2022, with major adverse cardiovascular events (MACEs) as the outcome. Analyses assessed the relationships among PCSK6 rs1531817 polymorphism, Gensini score (GS), triple vessel disease (TVD), and MACEs.Results92 (16.8%) patients experienced MACEs with an average follow-up of 25.7 months. Logistic analysis revealed that the PCSK6 rs1531817 CA + AA genotype was an independent protective factor against high GS and TVD. Cox analysis revealed that the PCSK6 rs1531817 CA + AA genotype was an independent protective factor against MACEs. The mediation effect results showed that apolipoprotein A1/apolipoprotein B (ApoA1/ApoB) partially mediated the association between PCSK6 rs1531817 polymorphism and coronary stenosis and that total cholesterol/high-density lipoprotein (TC/HDL) and TVD partially and in parallel mediated the association between the PCSK6 rs1531817 polymorphism and MACEs.ConclusionPatients with the PCSK6 CA + AA genotype have milder coronary stenosis and a better long-term prognosis; according to the mediation model, ApoA1/ApoB and TC/HDL partially mediate. These results may provide a new perspective on clinical therapeutic strategy for anti-atherosclerosis and improved prognosis in PMI patients.

The Current State of Coronary Revascularization: Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Interventions.

The optimal revascularization strategy for coronary artery disease depends on various factors, such as disease complexity, patient characteristics, and preferences. Including a heart team in complex cases is crucial to ensure optimal outcomes. Decision-making between percutaneous coronary intervention and coronary artery bypass grafting must consider each patient's clinical profile and coronary anatomy. While current practice guidelines offer some insight into the optimal revascularization approach for the various phenotypes of coronary artery disease, the evidence to support either strategy continues to evolve and grow. Given the large amount of contemporary data on revascularization, this review aims to comprehensively summarize the literature on coronary artery bypass grafting and percutaneous coronary intervention in patients across the spectrum of coronary artery disease phenotypes. Contemporary evidence suggests that for patients with triple vessel disease, coronary artery bypass grafting is preferred over percutaneous coronary intervention due to better long-term outcomes, including lower rates of death, myocardial infarction, and target vessel revascularization. Similarly, for patients with left main coronary artery disease, both percutaneous coronary intervention and coronary artery bypass grafting can be considered, as they have shown similar efficacy in terms of major adverse cardiac events, but there may be a slightly higher risk of death with percutaneous coronary intervention. For proximal left anterior descending artery disease, both percutaneous coronary intervention and coronary artery bypass grafting are viable options, but coronary artery bypass grafting has shown lower rates of repeat revascularization and better relief from angina. The Synergy Between PCI with Taxus and Cardiac Surgery score can help in decision-making by predicting the risk of adverse events and guiding the choice between percutaneous coronary intervention and coronary artery bypass grafting. European and American guidelines both agree with including a heart team that can develop and lay out individualized, optimal treatment options with respect for patient preferences. The debate between coronary artery bypass grafting versus percutaneous coronary intervention in multiple different scenarios will continue to develop as technology and techniques improve for both procedures. Risk factors, pre, peri, and post-procedural complications involved in both revascularization strategies will continue to be mitigated to optimize outcomes for those patients for which coronary artery bypass grafting or percutaneous coronary intervention provide ultimate benefit. Methods to avoid unnecessary revascularization continue to develop as well as percutaneous technology that may allow patients to avoid surgical intervention when possible. With such changes, revascularization guidelines for specific patient populations may change in the coming years, which can serve as a limitation of this time-dated review.