Diseño y justificación del estudio clínico aleatorizado BA-SCAD (bloqueadores beta y agentes antiplaquetarios en pacientes con disección arterial coronaria espontánea) / Rationale and design of the BA-SCAD (Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection) randomized clinical trial

Introducción y objetivos: La disección coronaria espontánea (DCE) es una causa rara de síndrome coronario agudo. La mayor parte de los pacientes con DCE son tratados empíricamente con bloqueadores beta (BB) y antiagregantes plaquetarios (AP). El estudio BA-SCAD (bloqueadores beta y agentes antiplaquetarios en pacientes con disección coronaria espontánea) es un ensayo clínico académico, pragmático, diseñado con metodología PROBE (prospective randomized open blinded endpoint), con el patrocinio de la Sociedad Española de Cardiología, para conocer la eficacia del tratamiento farmacológico en pacientes con DCE. Métodos: Mediante un diseño factorial 2 × 2, se aleatorizará a 600 pacientes (1:1/1:1) a: a) BB (sí/no) y b) tratamiento con AP «corto» (1 mes) frente a tratamiento antiagregante plaquetario doble y «prolongado» (12 meses). Se aleatorizará a BB (sí/no) solo a los pacientes con fracción de eyección del ventrículo izquierdo conservada, ya que a los pacientes con fracción de eyección reducida se los tratará con BB de acuerdo con las guías actuales. De modo similar, se aleatorizará al estrato de AP solo a los pacientes en tratamiento conservador (sin revascularización), ya que los que requieran intervención coronaria recibirán tratamiento antiagregante plaquetario doble durante 1 año. El objetivo primario de valoración incluye muerte, infarto de miocardio, accidente cerebrovascular, revascularización coronaria, DCE recurrente y hospitalización no planeada por síndrome coronario agudo o insuficiencia cardiaca al año de seguimiento. El objetivo de seguridad es la hemorragia. Todos los pacientes serán seguidos anualmente. Se desarrollará un programa exhaustivo de subestudios adicionales (clínicos, de imagen, de revascularización, de biomarcadores, inflamatorios, inmunológicos, farmacogenéticos y genéticos) para garantizar una visión completa de esta entidad tan especial y compleja (AU)

introduction y objectives: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Most patients are empirically treated with beta-blockers and antiplatelet drugs. The Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection (BA-SCAD) is an academic, pragmatic, prospective, randomized, open-label, blinded-endpoint clinical trial, performed under the auspices of the Spanish Society of Cardiology, to assess the efficacy of pharmacological therapy in patients with SCAD. Methods: Using a 2 x 2 factorial design, 600 patients will be randomized (1:1/1:1) to: a) beta-blockers (yes/no) and b) “short” (1 month) vs “prolonged” (12 months) antiplatelet therapy. Only patients with preserved left ventricular ejection fraction will be randomized to beta-blockers (yes/no) because patients with reduced left ventricular ejection fraction will receive beta-blockers according to current guidelines. Similarly, only conservatively managed patients (ie, no coronary intervention) will be randomized to the antiplatelet stratum, as patients requiring coronary interventions will receive 1-year dual antiplatelet therapy. The primary efficacy endpoint includes a composite of death, myocardial infarction, stroke, coronary revascularization, recurrent SCAD, and unplanned hospitalization for acute coronary syndrome or heart failure at 1 year. The primary safety endpoint will be bleeding. All patients will be clinically followed up yearly. A comprehensive set of additional substudies (clinical, imaging, revascularization, biomarkers, inflammatory, immunologic, pharmacogenetics, and genetic) will be conducted to ensure a holistic view of this unique and challenging clinical entity.Conclusions: The results of the BA-SCAD randomized clinical trial will advance our knowledge in the treatment of patients with SCAD (AU)

Disección coronaria espontánea / Spontaneous coronary artery dissection

La disección coronaria espontánea es una entidad infradiagnosticada, que ha resultado ser una causa importante de síndrome coronario agudo y muerte súbita, en particular, en mujeres jóvenes y personas con pocos factores de riesgo cardiovascular convencionales. Este documento ofrece una revisión actualizada sobre la fisiopatología y etiología de esta enfermedad; se describen las principales características clínicas de estos pacientes, así como las pruebas diagnósticas que se deben realizar y el tratamiento más adecuado (AU)

Spontaneous coronary artery dissection is an underdiagnosed entity. It has been recognized as an important cause of acute coronary syndrome and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. This document provides an exhaustive review of the pathophysiology and etiology of this disease. In addition, we describe the main clinical characteristics of these patients, the diagnostic tests that must be performed, and the most appropriate treatment (AU)

Risk factors for spontaneous coronary artery dissection / Factores de riesgo para la disección coronaria espontánea

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Reply: Risk factors for spontaneous coronary artery dissection / Respuesta: Factores de riesgo para la disección coronaria espontánea

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Presentación benigna de anomalia potencialmente maligna / Benign presentation of potentially malignant anomaly

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Direct emergence of the conus artery from an independent ostium. A cadaveric study on a Spanish sample

The main purpose of this study was to evaluate the frequency with which the conus artery originates from an independent ostium in the right aortic sinus. Twenty-five adult hearts (3 females, 5 males and 17 unknown sex), from the body donation program of the University of Girona, were analysed. After intravascular injection of natural coloured latex in the coronary ostia, the origin of the conus artery and its distribution pattern were analysed by microdissection. Three of the 25 hearts analysed (12.0%) displayed the direct emergence of the conus artery from a discrete ostium in the right aortic sinus: in two specimens (8%) showing a single ostium for the independent conus artery, and in one heart (4%) two ostia for two independent conus arteries. In all cases, the independent conus arteries were shorter than the coronary artery and extended up to the anterior wall of the right ventricle, coinciding with the observations of previous authors. The independent conus artery may be an important source of collateral blood flow to the infundibulum. It may be an important source of apex and interventricular septum collateral irrigation. To ascertain the origin of the conus artery and its distribution is clinically important, particularly in obstructions of the anterior interventricular artery. The independent conus artery's collateral perfusion can both obscure the detection of any ischaemic modification in the apex and septum regions, and serve as a therapeutic source. Consequently, interpretations of the coronary occlusion clinical test should take this vascular channel into account

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Coronary venous anatomy relevant to cardiac resynchronization therapyan angiographic study

Cardiac resynchronization therapy (CRT) in-volves placing a lead through the coronary sinus to pace the left ventricle. However, technical problems arise in the procedure either due to variant anatomy or due to the presence of valves. Information on coronary venous anatomy is scarce in the South Indian population. The aim of this study was to describe the coronary sinus anatomy in patients undergoing CRT implant. Coronary sinus angiograms were used to study the following parameters: (a) Dimensions of coronary sinus (b) Number and distribution of tributaries (excluding middle and great cardiac veins) (c) Diameter of major veins at the origin (d) Angulation of tributaries with CS. Measurements were made using calipers in the dicom viewer. Out of the 24 angiograms studied, only a single tributary of adequate size was noted in 70.8% (17/24) of the cases, which was most commonly a midlateral vein (76.5%). Two prominent tributaries were noted in 29.2% (7/24) of cases. The average diameter of the veins was 3.93 mm and 80.6% of the veins had an obtuse angle of drainage. Anatomical variations in the coronary venous systemin this population suggest that the majority of patients have a single suitable tributary and this is most often the midlateral vein, which is known to have the most favorable outcome. Data obtained in this study will guide clinicians in left ventricular lead placement in the South Indian population leading to greater procedural success

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Trasposición de grandes arterias congénitamente corregida, anomalía coronaria y trasplante / Congenitally corrected transposition of the great arteries, coronary anomaly and transplant

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A complete situs inversus viscerum with hepatic, intestinal and renalvascular anomalies: one case report and review of the literatur

Situs inversus viscerum (SIV) is a rare congenital anomaly, which is still an intriguing phenomenon to anatomists and physicians alike. A complete SIV is characterized by a left-right transposition and mirror image of all thoraco-abdominal organs and their vasculature. The present report is based on one case with complete SIV, which was observed during the routine educational dissections of cadavers in the authors' Anatomy Department. A transposition of all truncal organs and their vasculature, and several variations of arteries and veins were present. The right branch of the proper hepatic artery was replaced by an artery that emanated from the superior mesenteric artery. The latter also released the inferior mesenteric artery. Additionally, a left accessory renal artery ran anterior to the inferior caval vein and posterior to the ureter to enter the hilum of the left kidney. There was also a variation in the anterior-posterior arrangement of the hilar structures of the left kidney. Additionally, a globally enlarged heart with coronary artery by-passes, a replaced aortic valve and an aortic arch aneurysm was observed. This case report is unique, as it presents a previously unreported co-incidence of SIV and hepatic, intestinal and renal vascular anomalies. It is important for the surgeon to be aware of such variations while planning an abdominal surgery in patients with SIV

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Spontaneous coronary artery dissection: Not so infrequent to be ignored / Disección coronaria espontánea: no tan infrecuente para ser ignorada

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¿Doble arteria descendente anterior en Y o circulación colateral coronaria? / Y-shaped dual left anterior descending artery or coronary collateral circulation?

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Formación de vasos coronarios a partir del proepicardio / Proepicardial origin of developing coronary vessels

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Arteria coronaria derecha intraauricular: una entidad por conocer / Intra-atrial right coronary artery: an unknown disorder

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Hematoma intramural coronario visualizado en angio-TC multicorte / Coronary intramural hematoma visualized on multislice CT angiography

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Fístula coronaria congénita gigante / Large congenital coronary fistula

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Arteria coronaria descendente anterior superdominante / Super dominant left anterior descending coronary artery

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