Common sequence variants associated with coronary artery disease correlate with the extent of coronary atherosclerosis.

OBJECTIVE: Single-nucleotide polymorphisms predisposing to coronary artery disease (CAD) have been shown to predict cardiovascular risk in healthy individuals when combined into a genetic risk score (GRS). We examined whether the cumulative burden of known genetic risk variants associated with risk of CAD influences the development and progression of coronary atherosclerosis. APPROACH AND RESULTS: We investigated the combined effects of all known CAD variants in a cross-sectional study of 8622 Icelandic patients with angiographically significant CAD (≥ 50% diameter stenosis). We constructed a GRS based on 50 CAD variants and tested for association with the number of diseased coronary arteries on angiography. In models adjusted for traditional cardiovascular risk factors, the GRS associated significantly with CAD extent (difference per SD increase in GRS, 0.076; P=7.3 × 10(-17)). When compared with the bottom GRS quintile, patients in the top GRS quintile were roughly 1.67× more likely to have multivessel disease (odds ratio, 1.67; 95% confidence interval, 1.45-1.94). The GRS significantly improved prediction of multivessel disease over traditional cardiovascular risk factors (χ(2) likelihood ratio 48.1; P<0.0001) and modestly improved discrimination, as estimated by the C-statistic (without GRS versus with GRS, 64.0% versus 64.8%) and the integrated discrimination improvement (0.52%). Furthermore, the GRS associated with an earlier age at diagnosis of angiographic CAD. These findings were replicated in an independent sample from the Emory Biobank study (n=1853). CONCLUSIONS: When combined into a single GRS, known genetic risk variants for CAD contribute significantly to the extent of coronary atherosclerosis in patients with significant angiographic disease.

[Cardiac arrest in a teenager - a case report]. / Hjartastopp hja unglingsstulku - sjukratilfelli.

Cardiac arrest is rarely seen in children and teenagers. We present a 12-year old girl with cardiac arrest following myocardial infarction, that required prolonged cardiac massage and extracorporeal-membranous-oxygenation (ECMO). At coronary angiography the left main coronary artery (LMCA) was stented for a suspected coronary dissection. The contraction of the heart improved and the ECMO-treatment was discontinued a week later. The patient was discharged home, but six months later a coronary artery bypass surgery was performed for in-stent restenosis. Further work-up with computed tomography (CT) showed that the LMCA originated from the right aortic sinus instead of the the left one. This case demonstrates how life threatening myocardial infarction can be caused by coronary artery anomalies.

Diagnostic accuracy of 64-slice multidetector CT for detection of in-stent restenosis in an unselected, consecutive patient population.

OBJECTIVES: To investigate the diagnostic accuracy of 64-slice multidetector computed tomography (64-CT) for detection of in-stent restenosis (ISR) in an unselected, consecutive patient population. BACKGROUND: Detection of in-stent restenosis by cardiac CT would be a major advance for the evaluation of patients suspected of having ISR. However, the diagnostic accuracy of current generation 64-CT in this context is not fully established. METHODS: We conducted a prospective study on patients with stable angina or acute coronary syndrome with no prior history of coronary artery disease. Six months after percutaneous coronary intervention (PCI) with stent placement they underwent a 64-CT scan (Toshiba Multi-Slice Aquilion 64) and consequently a repeat coronary angiography for comparison. Cardiac CT data sets were analyzed for the presence of in-stent restenosis by two independent expert readers blinded to the coronary angiographic data. RESULTS: Ninety-three patients with a total of 140 stents were evaluated. Males comprised 82% of the study group and the mean age was 63±10 years. The mean time from PCI to the repeat coronary angiography was 208±37 days and the mean time from 64-CT to repeat coronary angiography was 3.7±4.9 days. The restenosis rate according to coronary angiography was 26%. Stent diameter, strut thickness, heart rate and body mass index (BMI) significantly affected image quality. The sensitivity, specificity, positive and negative predictive values of 64-CT for detection of in-stent restenosis were 27%, 95%, 67% and 78%, respectively. CONCLUSIONS: Current generation, 64-slice CT, remains limited in its ability to accurately detect in-stent restenosis.

[Primary percutaneous coronary interventions in Iceland]. / Brádar kransaedathraedingar á Islandi.

INTRODUCTION: Acute coronary angiography with primary percutaneous coronary intervention (PCI), if executed with sufficient expertise and without undue delay, is the best therapy for patients with ST-elevation myocardial infarction (STEMI). At Landspitali-University Hospital 24 hour on-call service has been provided since December the 1st 2003. This hospital is the single center for all coronary catherizations in Iceland. This report is a review of this service during the first year. PATIENTS AND METHODS: Retrospective review was carried out of all hospital records and PCI worksheets of those who had an acute coronary angiography from December 1st 2003 until November 30th 2004. RESULTS: A total of 124 patients were investigated with acute coronary angiography, 94 men (76%) and 30 women (24%). The average age of men was 61 years (range 19 to 85 years) and women 67 years (range 38 to 84 years). The primary indication for acute coronary angiograpy was STEMI (83%), 8% non ST-elevation myocardial infarction (NSTEMI) and for the remaining 9% the procedure was performed for other reasons. Eleven patients (9%) suffered cardiac arrest prior to angiography and ten (8%) were in cardiogenic shock upon arrival to the hospital. The mean door-to-needle time was 47 minutes for all STEMI patients. In 76% of the cases the procedure started within 60 minutes and in 91% within the recommended 90 minutes. Mean hospital stay was 5 (1/2) days. Total mortality was 7% (9 patients). Of those 9 patients 5 were in cardiogenic shock at the arrival to the hospital and 4 had suffered cardiac arrest. The mortality rate among those who were neither in cardiogenic shock upon admission nor having suffered cardiac arrest was 1,7% (2 patients). During follow up for 15-27 months nine of the patients needed CABG and nine needed a repeat PCI. CONCLUSION: The experience of a 24 hour on-call service at Landspitali-University Hospital to carry out primary PCI for all patients in Iceland with STEMI proved excellent during its first year, with a short door-to-needle time, short hospital stay and low mortality.

[Diagnostic accuracy of 64-slice computed tomography compared with coronary angiography]. / Greiningarhaefni 64 sneida tövusneidmyndataekni til samanburdar vid hefdbundna kransaedapraedingu.

OBJECTIVE: The aim of this study was to evaluate the diagnostic accuracy (sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)) of 64-slice multidetector computed tomography (MDCT) compared with quantitative coronary angiography (QCA) for detection of coronary artery disease (CAD). MATERIAL AND METHODS: Sixty-nine patients participating in a study of coronary in-stent restenosis were investigated. After a 64-slice MDCT scan patients were evaluated by QCA. The coronary arteries were divided into 15 segments and stenosis was graded for each segment by both methods. The diagnostic accuracy of 64-slice MDCT was evaluated using the QCA as the gold standard. RESULTS: Among the 69 patients included in the study 13 (19%) were female and 56 male. The mean age was 63 (SD 10) years. The following risk factors were present: high blood pressure 67%, elevated blood cholesterol 54%, diabetes 12% and family history of CAD 71%. Current smokers were 22% and previous smokers were 48%. Altogether 663 segments were examined. Of those 221 (33%) segments were excluded; 103 because of stents, 48 because of heavy calcification, 41 because of motion artifacts and 29 because the segments were less than 1.5 mm in diameter. The mean time between MDCT and QCA was 6.3 (SD 12.1) days. The sensitivity of 64-slice MDCT for diagnosing significant stenosis (>or= 50% according to QCA) was 20%, the specificity was 94%, PPV was 16%, NPV was 95% and the accuracy was 89%. CONCLUSION: High NPV and specificity indicates that MDCT is useful for accurately excluding significant CAD but the low sensitivity and low PPV indicate that the method is not accurate in diagnosing coronary artery stenosis of 50% or more according to QCA.

[Percutaneous coronary intervention in women compared with men.].

INTRODUCTION: The literature gives contradictory findings as to whether percutaneous coronary intervention (PCI) is equally successful in women and men. The objectives of this study were to compare between the sexes success and complications after PCI in Iceland. METHODS: During the years 1987 to 2000 a total of 3355 PCI s were performed, 798 (24%) in women and 2557 (76%) in men. Detailed records are held for all patients regarding clinical background, the outcome of PCI and in-hospital complications, and these were retrospectively assessed. RESULTS: Compared with men, relatively more women were older than 65 years, hypertensive, hyperlipidemic, and non-smokers, but the prevalence of diabetes was similar. A prior history of myocardial infarction, or thrombolytic therapy was comparable for the sexes, while women less frequently had a history of a previous coronary bypass operation or PCI. Unstable angina pectoris was more common in women, they more often underwent subacute PCI, and were less likely than the men to have 3-vessels disease. PCI on two or more lesions, restenosis, or vein grafts, was comparable in the sexes. The primary success rate for PCI was comparable in women and men (93% versus 91%; p=0.06), and the use of stents was similar. Complications after PCI and in-hospital mortality (0.5% versus 0.3%; NS) was equally frequent, with the exception that women had more groin bleeding at the entry-site (1.25% versus 0.12%; p<0.001) and pseudoaneurysms (2.1% versus 0.6%; p<0.001). CONCLUSION: The primary success of PCI in Iceland is similar in the sexes. In-hospital mortality is low and complications comparable, with the exception that women more frequently developed entry-site groin sequels than men.

[Percutaneous coronary intervention in icelandic diabetic patients.].

INTRODUCTION: Several studies suggest that the primary success of percutaneous coronary intervention (PCI) is less in diabetic patients than others and that complications and restenosis are more frequent. This was therefore assessed in icelandic diabetic patients. METHODS: From 1987 to 2002 a total of 4435 PCI s were performed and of these 377 (8.5%) were in diabetic patients. The clinical background of the patients, primary success after PCI, and in-hospital complications, were retrospectively assessed. RESULTS: The relative frequency of diabetics undergoing PCI increased significantly during the study period from 5.7% to 10.6% (p=0.001). In diabetic compared with non-diabetic patients, the mean age was higher (64 +/- 10 versus 62 +/- 10 years; p=0.002), and women were more frequent. Hypertension and hypercholesterolaemia were more common in the diabetics and a larger proportion of them were current smokers. Further more, diabetics more frequently had a previous history of myocardial infarction, coronary artery bypass surgery, PCI, unstable angina and triple-vessel disease. The overall use of stents was similar in the groups, as was PCI for clinical restenosis (13.3% versus 10.8%; p=0.15). The primary success rate was comparable in diabetics and non-diabetics (93% versus 92%). The need for acute coronary bypass post-PCI was similar in the groups, whereas diabetics more rarely had a three fold increase in creatinine kinase-MB values. Overall, in-hospital mortality was low (0.4%), but higher in diabetic than non-diabetic patients (1.1% versus 0.3%; p=0.04). By multivariate analysis, significant independent predictors of in-hospital mortality were: Primary PCI for acute ST-elevation infarction, number of stenotic coronary vessels, diabetes and age, while the presence of hypercholesterolemia was an inverse predictor. CONCLUSION: The primary success rate for PCI is comparable in icelandic diabetic and non-diabetic patients. Although few patients died in hospital after PCI, the diabetic patients did have a higher in-hospital mortality rate.