Potential Sunitinib-Induced Coronary Artery and Aortic Dissections.

Small-molecule multitargeted tyrosine kinase inhibitor (TKI) therapy is used in different types of cancer. These drugs have been associated with cardiovascular toxicity, including aortic dissection. To our knowledge, this is the first time that a coronary dissection potentially associated with a TKI treatment has been described.

Corticosteroid Therapy Might be Associated with the Development of Coronary Aneurysm in Children with Kawasaki Disease.

BACKGROUND: Coronary artery lesions (CALs) are known to be the main complication in children with Kawasaki disease (KD). Instead of intravenous immunoglobulin (IVIG), corticosteroid therapy has been accepted to be used for children with KD who are unresponsive to IVIG. This study aimed to evaluate risk factors for CALs in children with KD. METHODS: We retrospectively reviewed the clinical records of 2331 children with KD from January 2005 to December 2014. To identify the independent risk factors for CALs, multivariable logistic regression models were constructed using significant variables identified from univariate logistic regression analysis. RESULTS: The incidence of CALs was 36.0% (840 of 2331), including 625 (26.8%) coronary artery dilations and 215 (9.2%) coronary artery aneurysms (CAAs). Multivariable logistic regression analysis identified that male, incomplete KD, longer fever duration, and C-reactive protein (CRP) >100 mg/L were independent risk factors for coronary artery dilatations. On the other hand, male, incomplete KD, longer fever duration, prolonged days of illness at the initial treatment, corticosteroid therapy, sodium ≤133 mmol/L, and albumin <35 g/L were the independent risk factors for CAAs. In addition, corticosteroid therapy, prolonged days of illness at the initial treatment, and albumin <35 g/L were the independent risk factors for giant CAAs. CONCLUSIONS: CALs might be associated with male sex, incomplete KD, longer fever duration, prolonged days of illness at the initial treatment, albumin <35 g/L, sodium ≤133 mmol/L, CRP >100 mg/L, and corticosteroid therapy. Corticosteroid therapy was an independent risk factor for CAAs and giant CAAs. Thus, corticosteroids should be used with caution in the treatment of KD with the risk for CALs.

Immune-monitoring in Kawasaki disease patients treated with infliximab and intravenous immunoglobulin.

The expansion of regulatory T cells (Treg ) controls inflammation in children with acute Kawasaki disease (KD). Blockade of tumour necrosis factor (TNF)-α is an emerging therapy for KD patients with refractory inflammation, but there is concern that this therapy could impede the host immune regulation. To define the effect of TNF-α blockade, we conducted ex-vivo immune-monitoring in KD subjects who participated in a randomized, double-blind, placebo-controlled clinical trial of the addition of infliximab to standard intravenous immunoglobulin (IVIG) therapy. We enumerated circulating myeloid and plasmocytoid dendritic cells (DC), regulatory T cells (Treg ) and memory T cells (Tmem ) in 14 consecutive, unselected KD patients (seven treated with IVIG, seven with IVIG + infliximab) at three time-points: (i) acute phase prior to treatment, (ii) subacute phase and (iii) convalescent phase. Myeloid DC (mDC), but not plasmacytoid DC (pDC), were numerous in the peripheral blood in acute KD subjects and decreased in the subacute phase in both IVIG(-) and IVIG (+) infliximab-treated groups. The co-stimulatory molecule for antigen presentation to T cells and CD86 decreased in mDC from acute to subacute time-points in both treatment groups, but not in the single patient who developed coronary artery aneurysms. We also defined tolerogenic mDC that expand in the subacute phase of KD not impaired by infliximab treatment. Treg and Tmem expanded after treatment with no significant differences between the two groups. Treatment of KD patients with infliximab does not adversely affect generation of tolerogenic mDC or the development of T cell regulation and memory.

A spontaneous coronary arterial dissection associated with a calcineurin inhibitor.

We present the case of a 55-year-old lady presenting 5 months after a liver transplant with acute coronary syndrome. She was on maintenance-dose tacrolimus. An angiogram diagnosed a spontaneous coronary artery dissection, which was successfully stented. This is the third case in the literature associating a calcineurin inhibitor with a spontaneous coronary arterial dissection. The detrimental effect of calcineurin inhibitors on vasculature is well recognised. This report highlights their potentially serious side-effects. It should be appreciated that calcineurin inhibitors have the potential to cause or contribute to this rare vascular phenomenon and the diagnosis should therefore be considered in those taking such drugs.

Spontaneous coronary artery dissection during cabergoline therapy.

Although spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, it should be considered during the evaluation of patients who have chest pain. Coronary vasospasm can lead to spontaneous dissection. The dopamine agonist cabergoline is known to cause digital vasospasm. Herein, we report a case of spontaneous right coronary artery dissection in a 43-year-old woman who was taking cabergoline as therapy for prolactinoma. To our knowledge, this is the first report of an apparent relationship between cabergoline therapy and spontaneous coronary artery dissection. The possible association of cabergoline with coronary artery spasm and dissection should be considered in patients who present with chest pain while taking this medication.

Corticosteroid administration for patients with coronary artery aneurysms after Kawasaki disease may be associated with impaired regression.

INTRODUCTION: Corticosteroid administration in Kawasaki disease (KD) is controversial but accepted as treatment for patients who do not respond to initial treatment. The impact of corticosteroids on evolving coronary artery aneurysms (CAA) and future vascular remodelling is unknown. METHODS AND RESULTS: The clinical history of 80 patients (73% male; median age at diagnosis 2.2 years) seen from 1990 to 2008 with CAAs after KD were reviewed, 19 (24%) of whom received systemic corticosteroids in the acute phase (14 for ≤ 3 days, 5 for 4+ days). CAA z-scores were assessed at baseline, 2-3 months, and 1 year after the acute phase. Linear regression models adjusted for repeated measures were used to determine the association between change in CAA z-score over time and corticosteroid use, adjusting for patient age at diagnosis, gender, intravenous immunoglobulin use, total days of fever, albumin level, hemoglobin level and platelet count. RESULTS: The corticosteroid treated group had longer duration of fever in the acute phase (median 17 vs. 11 days, p=0.04). Adjusted CAA z-scores at diagnosis, 2-3 months and 1 year follow-up for CAA in the left anterior descending decreased (from +5.5 to +3.5 to +1.9) in those not treated with corticosteroids, but progressed for those treated with corticosteroids (from +7.4 to +17.5 to +15.8), regardless of duration of corticosteroid treatment. Similar results were noted for CAA of the right coronary artery and the left main coronary artery. CONCLUSIONS: The use of corticosteroids in the acute phase of KD for patients with evolving CAAs may be associated with worsening involvement and impaired vascular remodelling and warrants further study.

Coronary artery angiographic changes in veterans poisoned by mustard gas.

OBJECTIVES: We aimed to identify coronary artery involvement in mustard gas-poisoned patients. METHODS: We conducted a case-control study on 40 mustard gas-poisoned patients who underwent coronary artery angiography due to cardiac pain. The study was performed during a 3-year interval on patients who were referred to three main hospitals of Mashhad, Iran. The nonexposed control group consisted of 40 normal individuals who had undergone angiography for the same reasons. The primary outcome measurement was coronary artery involvement and its location. Data were collected through studying the angiography films. RESULTS: Among the 40 poisoned patients studied, 15 (37.5%) had coronary artery ectasia, mainly in the left anterior descending artery, but 25 (62.5%) did not. The same values were 2 (5%) and 38 (95%) in the nonexposed group, respectively, which was significantly different compared to the exposed group (p = 0.001). The odds ratio was 11.40. CONCLUSIONS: The prevalence of coronary artery ectasia in mustard gas-poisoned patients was 7.5 times more than in nonexposed controls. Considering the proposed odds ratio, the occurrence of coronary artery ectasia is around 11.4 times greater in mustard gas-poisoned veterans. This is the first study to suggest a strong correlation between mustard gas poisoning and coronary artery ectasia.

Coronary artery aneurysm and thrombosis following chronic ephedra use.

Ephedra, also known as Ma Huang, was commonly used to enhance athletic performance, "fat burning", and weight loss before its removal from the United States in April 2004 due to acute adverse health reactions including lethal arrhythmias, stroke, vasoconstriction, and myocardial infarction. We report the case of a 29-year-old patient with acute myocardial infarction, secondary to coronary artery aneurysms and thrombosis who reported use of Ma Huang, Xenadrine(r)RFA, and Hydroxycut at recommended dosages for a combined total of approximately 2 years. Other causes of coronary artery aneurysm and hypercoagulability were ruled out. Our case exemplifies the long-term (as opposed to acute) danger of ephedrine products and the first case of coronary artery aneurysm associated with its use.

An unusual case of chronic coronary artery dissection: did cisplatin play a role?

Spontaneous coronary artery dissection is an unusual cause of acute myocardial ischemia. The natural history of spontaneous coronary artery dissection that persists on angiography after the acute event has not been well characterized. A case of a 36-year-old man who presented with monomorphic ventricular tachycardia 12 years following a myocardial infarction that occurred during his last course of bleomycin-etoposide-cisplatin therapy for testicular cancer is reported. On further investigation, coronary angiography revealed a long chronic dissection of the right coronary artery. The patient was successfully treated with medical management and insertion of an implantable cardioverter defibrillator. The case also highlights the increased cardiovascular morbidity in testicular cancer survivors and evokes the possibility of mechanisms of myocardial ischemia other than atherosclerotic disease in these young patients.

A multicenter prospective randomized trial of corticosteroids in primary therapy for Kawasaki disease: clinical course and coronary artery outcome.

OBJECTIVE: To investigate the role of corticosteroids in the initial treatment of Kawasaki disease (KD). STUDY DESIGN: Between September 2000 and March 2005, we randomly assigned 178 KD patients from 12 hospitals to either an intravenous immunoglobulin (IVIG) group (n = 88; 1 g/kg for 2 consecutive days) or an IVIG plus corticosteroid (IVIG+PSL) group (n = 90). The primary endpoint was coronary artery abnormality (CAA) before a 1-month echocardiographic assessment. Secondary endpoints included duration of fever, time to normalization of serum C-reactive protein (CRP), and initial treatment failure requiring additional therapy. Analyses were based on intention to treat. RESULTS: Baseline characteristics of groups were similar. Fewer IVIG+PSL patients than IVIG patients had a CAA before 1 month (2.2% vs 11.4%; P = .017). The duration of fever was shorter (P < .001) and CRP decreased more rapidly in the IVIG+PSL group than in the IVIG group (P = .001). Moreover, initial treatment failure was less frequent (5.6% vs 18.2%; P = .010) in the IVIG+PSL group. All patients assigned to the IVIG+PSL group completed treatment without major side effects. CONCLUSIONS: A combination of corticosteroids and IVIG improved clinical course and coronary artery outcome without causing untoward effects in children with acute KD.

Clinical responses of patients with Kawasaki disease to different brands of intravenous immunoglobulin.

OBJECTIVE: To determine whether different brands of intravenous immunoglobulin (IVIG) administered to children with Kawasaki disease (KD) result in different outcomes. STUDY DESIGN: We analyzed children with KD and divided them into 4 groups according to the brand of IVIG. A coronary artery abnormality (CAA) was defined as having a lumen diameter (inner border to inner border) of > or =3 mm in KD cases <5 years old and > or =4 mm in cases > or =5 years old, and giant aneurysm was defined as a lumen diameter > or =8 mm. Patients were considered nonresponsive to IVIG therapy if fever persisted longer than 2 days after completion of treatment and needed retreatment with IVIG. RESULTS: We collected 437 cases, 29 (6.6%) were nonresponsive, 17 (3.9%) had CAA at convalescence, and 3 (0.7%) had giant aneurysm, 2 of whom had development of myocardial infarcts. Patients receiving Brand C IVIG, prepared with beta-propiolactone, had higher rates (10%, 9/93, P = .01) of CAA at convalescence and nonresponsiveness (13%, 12/93, P = .001); giant aneurysm occurred in 3/93 (3%) receiving Brand C IVIG and in 0/344 who received the other 3 brands (P = .008). CONCLUSIONS: IVIG, prepared with beta-propiolactone, was most significantly associated with nonresponsiveness, CAA at convalescence, and giant aneurysm. Physicians should be cautious when using IVIG prepared with beta-propiolactone or enzyme digestion to treat KD.

Spontaneous coronary artery dissection associated with oral contraceptive use: a case report and review of the literature.

Spontaneous coronary artery dissection (SCAD) represents a rare cause of acute coronary syndromes with complex pathohysiology. We briefly describe a 50-year-old woman, without traditional cardiovascular risk factors, hospitalized for an acute ST-elevation myocardial infarction and treated with thrombolytic therapy. Notably, the patient was on oral contraceptives for the past 10 years. Coronary angiography showed a dissection of the distal left anterior descending artery. She was treated conservatively and her clinical status improved without evidence of continuing ischemia, while a repeated catheterization 6 months later showed a complete resolution of the dissection. It has been speculated that the female hormones may be responsible for the increased incidence of SCAD among women particularly during the peripartum period or during the exogenous administration of such agents. A systematic review of the literature revealed 4 further cases reporting an association of SCAD with oral contraceptive use.

Increased prevalence of coronary artery aneurysms among cocaine users.

BACKGROUND: Cocaine abuse has been implicated in multiple cardiovascular complications. Coronary artery aneurysms (CAAs) and ectasia occur in 0.2% to 5.3% of patients referred for angiography and are associated with atherosclerosis, Kawasaki's disease, and several rare disorders. After observing CAAs in multiple young cocaine users, we investigated the prevalence of CAAs among cocaine users undergoing coronary angiography. METHODS AND RESULTS: Clinical and angiographic characteristics of 112 consecutive patients with a history of cocaine use and coronary angiography were compared with a control group of similar age and risk factors from an existing angiographic database over the same time period. Coronary angiograms were independently read by 3 reviewers blinded to cocaine use. Cocaine users were young (mean age, 44 years), predominantly male (80%), and cigarette smokers (95%). Control patients had higher rates of diabetes (33%) and more severe coronary artery disease (P=0.01). Previous myocardial infarction was common in both groups (45% of cocaine users, 38% of control patients). Despite the frequent history of myocardial infarction among cocaine users, 48% had nonobstructive coronary artery disease. Among cocaine users, 34 of 112 (30.4%) had CAAs compared with 6 of 79 (7.6%) in the control group (P<0.001). Cocaine use was a strong predictor of CAA by univariate and multivariate analyses. CONCLUSIONS: This is the first description of an association between cocaine use and CAA. The prevalence of CAA among cocaine users was higher than expected (30.4%), given such a young cohort. Cocaine use may predispose to the formation of CAA, which may in turn be a contributing factor to myocardial infarction.

Coronary aneurysm after implantation of a paclitaxel-eluting stent.

Formation of coronary aneurysm is a rare complication of stenting with bare metal stents, but based on experimental studies drug-eluting stents may induce toxic effects on the vessel wall with incomplete stent apposition, aneurysm formation and with the potential of stent thrombosis or vessel rupture. We present a 43-year-old man who developed a coronary aneurysm in the right coronary artery 6 months after receiving a paclitaxel-eluting stent. The patient was asymptomatic and the aneurysm was detected in a routine control. Angiography and intracoronary ultrasound demonstrated lack of contact between stent and vessel wall in a 15-mm long segment with maximal aneurysm diameter of 6.0 mm. The patient was successfully treated with a graft stent.