STEMI patients and nonculprit lesions: To treat or not to treat? and when? A review of most recent literature.

Patients with ST segment elevation myocardial infarction and multivessel disease represent a high percentage of ischemic patient with a worse outcome than patient with single coronary artery disease. Therefore, initial management of these patients is of high importance, but unfortunately this is not clarified yet. We analyze the available literature trying to afford current doubts to determine which way of revascularization is to be preferred. © 2015 Wiley Periodicals, Inc.

Angiographic Evaluation of Coronary Microvascular Dysfunction in Patients with Heart Failure and Preserved Ejection Fraction.

BACKGROUND: The aim of this study was to evaluate myocardial perfusion and coronary blood flow through validated angiography indices to assess whether there is greater MVD in patients with microvascular angina and HFPEF compared to those who do not have. METHODS: Our study was performed on a population of 286 patients with stable angina that underwent coronary angiography and echocardiography. They showed epicardial coronary arteries free from stenosis. We divided the sample into two categories: patients with HFPEF and those without. We calculated indices for each patient based on angiographic images, including TFC, MBG, and TMBS. RESULTS: Our sample compared two groups: HFPEF (n = 155) and non-HFPEF (n = 135) patients. We showed that patients with HFPEF had a longest TFC of three major coronary arteries (TFC LAD 44.7 ± 12.5; TFC RCA 26.2 ± 6.9; TFC CX 27 ± 5.9) than non-HFPEF patients (TFC LAD 40.7 ± 11.6; TFC RCA 25 ± 6.3; TFC CX 21 ± 4.7). On the other hand, we found lower MBG on three coronary arteries (MBG LAD 2.1 ± 0.3; MBG RCA 2.1 ± 0.3; MBG CX 2.0 ± 0.32) in HFPEF than non-HFPEF patients (MBG LAD 2.6 ± 0.5; MBG RCA 2.2 ± 0.47; MBG CX 2.3 ± 0.4). CONCLUSION: Analysis of microcirculation through angiography indices in patients with and without HFPEF has led to assess that the HFPEF population has a greater involvement of microcirculation than patients without HFPEF.

A simple method to analyze overall individual physical fitness in firefighters.

The aim of this study was to identify the main components that determine firefighters' level of physical fitness using a stair-climbing test. The age, weight, height, body fat, and VO(2max) of the firefighters were recorded before the trial, and percentage of heart rate reserve (%HRR) was recorded during the stair climbing. Nonlinear modeling of HRR time series and Principal Component Analysis (PCA) was applied to the data to isolate a small number of variables that quantify overall individual physical fitness. The HRR was represented as a function of time using the sum of linear and trigonometric functions. Four main factors that influence performance, obtained from PCA analysis, emerged (78.2% of total explained variance): the capacity to carry the extra load (22.8% of total variance); the effect of body fat (19.6% of total variance); the influence of age in the task (19.3% of total variance); and the overall fitness level (16.4% of total variance). This approach allowed us to make a rapid assessment of each subject's fitness level. Such an assessment could be used in planning individualized functional training programs to improve each firefighter's job performance and reduce injuries and hence save time, energy, and financial resources.

Plasma Viscosity and NLR in Young Subjects with Myocardial Infarction: Evaluation at the Initial Stage and at 3 and 12 Months.

In the "Sicilian study on juvenile myocardial infarction," we had evaluated plasma viscosity (PV) and neutrophil/lymphocyte ratio (NLR) in patients with acute myocardial infarction (AMI) at the age of ⩽45 years. Now, we examined the relationship between these 2 parameters in 120 subjects (109 men and 11 women) aged ⩽45 years with recent AMI. The patients were classified according to the number of cardiovascular risk factors, the electrocardiographic criteria (ST-segment elevation myocardial infarction [STEMI] or non-ST-segment elevation myocardial infarction [NSTEMI]), and the extent of coronary stenosis, evaluated with coronary angiography. On fasting venous blood, we measured PV at the shear rate of 450 s-1 and NLR. The control group included 50 healthy subjects (mean age = 35.1 ± 7.8 years). At the initial stage, PV and NLR were significantly increased in comparison with controls. Subdividing AMI patients according to the median value of NLR, in the group with high NLR PV was significantly higher, whereas subdividing the patients according to the PV median value, NLR was not different between the 2 groups; 3 and 12 months after AMI, we observed only a significant decrease in NLR. Only PV was discriminant regarding the cardiovascular complications registered during an 18-month follow-up. The evaluation of PV may be of prognostic value in juvenile AMI.

Analysis of the Blood Viscosity Behavior in the Sicilian Study on Juvenile Myocardial Infarction.

Considering the role of hemorheology in coronary circulation, we studied blood viscosity in patients with juvenile myocardial infarction. We examined whole blood viscosity at high shear rate using the cone-on-plate viscosimeter Wells-Brookfield ½ LVT and at low shear rate employing a viscometer Contraves LS30 in 120 patients (aged <46 years) with myocardial infarction, at the initial stage and subsequently 3 and 12 months after. At the initial stage, patients had an increased whole blood viscosity in comparison to normal controls. This hemorheological profile was not influenced by the cardiovascular risk factors, nor by the extent of coronary lesions, even if some differences were evident between patients with ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). The blood viscosity pattern at the initial stage did not influence recurring ischemic events or the onset of heart failure during an 18 months' follow-up. The neutrophil to lymphocyte ratio did not affect the blood viscosity pattern. We reevaluated 83 patients 3 months after and 70 patients 12 months after the acute coronary syndrome, and we found that the hemorheological parameters were still altered in comparison to normal controls at both times. We observed an impairment of the hemorheological pattern in young patients with myocardial infarction, partially influenced by the infarction type (STEMI and NSTEMI) and persisting in the long term.

[Coronary microvascular dysfunction: past, present, and future of an evolving disease]. / Disfunzione del microcircolo coronarico: passato, presente e futuro di una malattia in evoluzione.

Coronary atherosclerosis is the main cause of myocardial ischemia. Nevertheless 10-30% of patients with angina has angiographically normal coronary arteries. In the last 30 years, several studies showed that in these patients the symptoms can be caused by dysfunction of the coronary microcirculation. Coronary microvascular dysfunction (CMVD) occurring in patients affected by specific cardiac or systemic diseases may be due to mechanisms of the underlying disease. On the other hand, in several patients affected by angina with angiographically normal coronary arteries, there is no specific disease, and CMVD only is responsible for the clinical picture. This condition can be defined as leading microvascular angina in order to distinguish it from other forms of microvascular angina where CMVD is related to the presence of a specific disease. As regards pathogenesis, there are still many uncertainties, though evidence suggesting a role for certain risk factors rather than others is gradually emerging, along with the demonstration of new alterations of endothelial function. Also as regards therapy, and prognosis above all, the debate is still open.

Recurrent in-stent restenosis, certainty of its origin, uncertainty about treatment.

Treatment of recurrent in-stent restenosis is a real brainteaser for the interventional cardiologist who cannot resort to the guidelines to have indications about the type of treatment to be preferred. The use of intracoronary imaging may provide insights into the underlying mechanisms of this complication and use of drug-coated balloons may be a valid alternative and especially a thoughtful treatment when the repeated and perseverant use of drug-eluting stents clearly fails. In this setting, we present a review of the literature about this interesting topic, going deep into the heart of the problem, its origin and possible treatment options.

Understanding and managing in-stent restenosis: a review of clinical data, from pathogenesis to treatment.

The lumen diameter reduction after percutaneous coronary intervention (PCI) is well known as "restenosis". This phenomenon is due to vessel remodeling/recoil in case of no-stent strategy or, in case of stent employ, "neointimal proliferation" that consists in an excessive tissue proliferation in the luminal surface of the stent otherwise by a further new-occurring atherosclerotic process called "neoatherosclerosis". The exact incidence of in-stent restenosis (ISR) is not easy to determine caused by different clinical, angiographic and operative factors. In the pre-stent era the occurrence of restenosis ranged between 32-55% of all angioplasties, and drop to successively 17-41% in the bare metal stents (BMS) era. The advent of drug-eluting stent (DES), especially 2nd generation, and drug-coated balloon (DCB) further reduce restenosis rate until <10%. We here review the main characteristics of this common complication of coronary interventions, from its pathogenesis to the most appropriate treatment strategy.

The association between coronary microvascular dysfunction and carotid intima media thickness in patients with cardiac syndrome X.

OBJECTIVE: The aim of this study was to evaluate in patients with cardiac syndrome X (CSX), using validated angiography indices, coronary blood flow and myocardial perfusion of the microcirculation to assess whether there is greater microvascular dysfunction in patients with increase of carotid intima media thickness (C-IMT), compared to those who do not have. METHODS: Our study was performed on a population 124 patients with CSX that underwent coronary angiography and carotid ultrasound. We divided the sample into two categories: patients with increase of C-IMT and those without increase. We calculated Gibson and Yusuf indices for each patient based on angiographic images, including TIMI Frame Count (TFC), Myocardial Blush Grade (MBG) and Total Myocardial Blush Score (TMBS). RESULTS: Our sample compared two groups: patients with increase of C-IMT (n-63) and patients without increase of C-IMT (n-61). We showed that patients with increase C-IMT had a longest TFC of three major coronary arteries (TFC LAD 44.7±12.5; TFC RCA 26.2±6.9; TFC CX 27±5.9), than control group. We found lower MBG on three coronary arteries (MBG LAD 2.5±0.3; MBG RCA 2.3±0.3; MBG CX 2.1±0.32) in patients with increase of C-IMT than control group, with good statistical significance. CONCLUSION: Analysis of microcirculation trough angiography indexes in patients with CSX with increase of C-IMT and without has led to asses that patients with increase of C-IMT population has a greater involvement of microcirculation than patients without.

Effect of Drug-Coated Balloons in Native Coronary Artery Disease Left With a Dissection.

OBJECTIVES: The authors sought to understand the clinical and angiographic outcomes of dissections left after drug-coated balloon (DCB) angioplasty. BACKGROUND: Second-generation DCB may be an alternative to stents in selected populations for the treatment of native coronary lesions. However, the use of these devices may be hampered by a certain risk of acute vessel recoil or residual coronary dissection. Moreover, stenting after DCB has shown limited efficacy. Little is known about when a non-flow-limiting dissection is left after DCB angioplasty. METHODS: This was a prospective observational study whose aim was to investigate the outcome of a consecutive series of patients with native coronary artery disease treated with second-generation DCB and residual coronary dissection at 2 Italian centers. We evaluated patient clinical conditions at 1 and 9 months, and angiographic follow up was undertaken at 6 months. RESULTS: Between July 2012 and July 2014, 156 patients were treated with DCB for native coronary artery disease. Fifty-two patients had a final dissection, 4 of which underwent prosthesis implantation and 48 were left untreated and underwent angiographic follow-up after 201 days (interquartile range: 161 to 250 days). The dissections were all type A to C, and none determined an impaired distal flow. Complete vessel healing at angiography was observed in 45 patients (93.8%), whereas 3 patients had persistent but uncomplicated dissections, and 3 had binary restenosis (6.2%). Late lumen loss was 0.14 mm (-0.14 to 0.42). Major adverse cardiovascular events occurred in 11 patients in the entire cohort and in 4 of the dissection cohort (7.2% vs. 8.1%; p = 0.48). We observed 8 and 3 target lesion revascularizations, respectively (5.3% vs. 6.2%; p = 0.37). CONCLUSIONS: In this cohort of consecutive patients treated with new-generation DCB and left with a final dissection, this strategy of revascularization seemed associated with the sealing of most of dissections and without significant neointimal hyperplasia.

Coronary artery fistulas as a cause of angina: How to manage these patients?

Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery. Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms. In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.

An uncommon presentation of eosinophilic granulomatosis with polyangiitis: a case report.

INTRODUCTION: Eosinophilic granulomatosis with polyangiitis is a rare and potentially fatal disease if not readily diagnosed. Cerebral involvement is extremely rare and clinical presentation as hemorrhagic stroke is even rarer. CASE PRESENTATION: A 58-year-old Caucasian man was admitted to our medical unit because of a computed tomography-diagnosed hemorrhagic stroke with right-sided hemiparesis and fever. A chest computed tomography scan also revealed multiple bilateral pulmonary infiltrates; coronary artery, and carotid and left vertebral artery calcifications were also observed. Empiric antimicrobial therapy with cephalosporins was promptly undertaken; low-molecular-weight heparin was introduced as prophylaxis for venous thromboembolism. Over the following days, magnetic resonance imaging scans showed a regression of the hemorrhagic framework, also revealing hypoxic areas consistent with acute ischemic lesions. With a computed tomography scan showing a worsening of his pulmonary framework, antimicrobial therapy was modified and corticosteroids were introduced. A new blood cell count revealed further increased leukocytosis (17.49 × 10(3) µL), characterized by a surprising rise of eosinophilic cells (32.8%). Angiography of the coronary arteries found diffuse dilatations with severe signs of endothelial damage. Such an unexpected framework induced a strong suspicion that the stroke was the expression of a systemic vasculitis, which had triggered his cerebral, coronary, and pulmonary frameworks. The search for antineutrophil cytoplasmic antibody was positive for perinuclear antineutrophil cytoplasmic antibody, and eosinophilic granulomatosis with polyangiitis was diagnosed. Explaining to the patient the rarity of his disease, and what the most typical presentations of eosinophilic granulomatosis with polyangiitis were, he revealed that before admission he had had scalp injuries, in the nuchal region, and had taken corticosteroids as self-medication, with subsequent disappearance of the lesions. Therefore, high-dose corticosteroid treatment was started, and at discharge he was in good clinical condition with a slight right-sided hyposthenia. CONCLUSIONS: A diagnosis of eosinophilic granulomatosis with polyangiitis is often difficult, but we are convinced that intake of corticosteroids on a self-prescribed basis may have obscured the clinical presentation. Therefore, this case also suggests how the growing phenomenon of self-medication can be harmful, and that a careful investigation of clinical history is still an act of paramount importance.

An evaluation of coronary atherosclerosis using coronary CT in subjects with asymptomatic carotid lesions.

UNLABELLED: The evaluation of coronary lesions in patients with asymptomatic carotid plaque represents a very promising line of research to assess cardiovascular risk and the possible implementation of a more aggressive prevention therapy. METHODS: In this study we enrolled 102 patients with intermediate to high cardiovascular risk but no history of coronary artery disease. The first group, consisting of 51 patients, underwent a Coronary CT scan (CCT-group) as well as carotid ultrasonography. The second group, also consisting of 51 patients, underwent coronary angiography (CA) and carotid ultrasonography. RESULTS: The absence of a statistically significant difference between the involvement of both coronary and carotid sites, assessed by CCT and CA, confirms the role of coronary CT as a useful method in the preclinical evaluation of cardiovascular risk. In the CCT group, the correlation between atherosclerosis of carotid artery and coronary disease, as well as between the mean carotid intimal medial thickness and the number of involved coronary vessels, and between the maximum values of carotid plaque and the presence of coronary artery stenosis > 50%, were statistically significant. The Agatson calcium score was also statistically associated with carotid plaque size. CONCLUSION: The imaging biomarkers have a key role in the evaluation of subclinical atherosclerotic disease. Moreover, carotid ultrasound examination and a CT-scan of coronary arteries, in a particular sub-group of patients with intermediate to high cardiovascular risk, can play a crucial role to assess the preventive therapeutic strategies.

A rare case of a coronary artery anomaly detected on multidetector computed tomography.

An anomalous aortic origin of the coronary artery arising from the opposite sinus with an interarterial course is a rare condition that is associated with a high risk of sudden cardiac death during or after strenuous exertion. We herein report the case of a 47-year-old woman presenting with chest pain, syncope and palpitations who presented with a rare coronary artery anomaly on multidetector computed tomography coronary artery (MDCT-CA) with prospective electrocardiogram (ECG) gating.

Sistema de puntuación para el enfoque diagnóstico y terapéutico de la disección coronaria espontánea / Score system approach to diagnose and manage spontaneous coronary artery dissection

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