Syncope as the Sole Presentation of Multi-Vessel Coronary Artery Disease.

Defining the etiology of syncope can be occasionally challenging. We present a case with no history of coronary artery disease (CAD) who presented exclusively with exertional syncope, and was found to have mildly reduced left ventricular systolic dysfunction on echocardiogram and severe multi-vessel CAD with chronic total occlusion (CTO) of the right coronary artery (RCA). Syncope as the initial presentation of advanced CAD in the absence of classic ischemic symptoms is rather an uncommon presentation in clinical practice.

Long-term Outcomes of Acute Myocardial Infarction in Pre-existing Coronary Artery Ectasia: A Systematic Review and Meta-Analysis.

Coronary artery ectasia is associated with an increased risk of acute myocardial infarction. This meta-analysis evaluates outcomes following acute myocardial infarction in patients with pre-existing coronary artery ectasia. A search strategy was designed to utilize PubMed/Medline, EMBASE, and Google scholar for studies including the outcomes of acute myocardial infarction in patients with coronary artery ectasia from inception to February 10, 2022. We reported effect sizes as odds ratio (OR) with a 95% confidence interval (CI). We used I2 statistics to estimate the extent of unexplained statistical heterogeneity. There were 7 studies comprising 13,499 patients in the final analysis. There was no significant difference between patients with coronary ectasia and patients without coronary ectasia in terms of all-cause mortality (OR 0.95; 95% CI 0.58 to 1.56; P = 0.79; I2 = 0%), major adverse cardiovascular events (MACE; OR 4.04; 95% CI 0.34 to 47.57; P = 0.17; I2 = 95%), myocardial re-infarction (OR 2.13; 95% CI 0.83 to 5.47; P = 0.08; I2 = 59%), target vessel revascularization (OR 1.31; 95% CI 0.69 to 2.48; P = 0.21; I2 = 0%), or requiring mechanical supportive devices (OR 1.32; 95% CI 0.22 to 7.83; P = 0.57; I2 = 56%). Acute myocardial infarction in the presence of coronary artery ectasia is not associated with an increased risk of death, MACE, myocardial infarction, or the need for mechanical circulatory support.

Treatment and outcomes of first troponin-negative non-ST-segment elevation myocardial infarction.

Little is known about non-ST-segment elevation myocardial infarction (MI) in patients with an initial negative troponin finding. The aim of this study was to determine in post hoc analysis of a large regional medical center presenting clinical characteristics, treatment differences, and in-hospital and 6-month outcomes of first troponin-negative MI (FTNMI). In this study, 659 of 1,855 consecutive patients with non-ST-segment elevation MI (35.5%) were classified as having FTNMI. In-hospital cardiac catheterization rates were similar between the 2 groups (70.1% vs 71.5%, p = 0.53) In hospital, patients with FTNMI were less likely to receive statins (48.9% vs 59.9%, p <0.001). On discharge, patients with FTNMI were less likely to be on clopidogrel (53.1% vs 59.0%, p = 0.019) and statins (67.7% vs 75.2%, p <0.001). At 6-month follow-up, patients with FTNMI were less likely to be on clopidogrel (43.5% vs 55.2%, p = 0.01) In-hospital recurrent ischemia was 2 times as common in FTNMI (20.1% vs 11.5%, p <0.001). There were no differences, however, in congestive heart failure, cardiogenic shock, cardiac arrest, stroke, or death in hospital. At 6 months, patients with FTNMI were 2 times as likely to have had recurrent MI (12.0% vs 6.6%, p <0.001). Combined end points of death at 6 months, MI, stroke, and rehospitalization were higher for FTNMI (47.7% vs 40.9%, p = 0.017); however, this was due to higher rates of recurrent MI. In conclusion, patients with FTNMI received less aggressive pharmacotherapy and were 2 times as likely to have recurrent MI at 6 months. FTNMI is common and represents a clinical entity that should be treated more aggressively.

Relation of kidney function and albuminuria with atrial fibrillation (from the Heart and Soul Study).

Atrial fibrillation (AF) is common in end-stage renal disease, but the relation between more modest decrements in kidney function or albuminuria with AF is uncertain. Among 956 outpatients with coronary artery disease, kidney function was assessed using 3 methods (cystatin C-based estimated glomerular filtration rate [eGFR(cys)], creatinine-based eGFR [eGFR(Cr)], and the urinary albumin/creatinine ratio [ACR]) and prevalent AF using surface electrocardiography. Multivariate logistic regression was used to evaluated the association of each measure of kidney function with AF. The mean eGFR(cys) was 71 +/- 23 ml/min/1.73 m(2), and the median ACR was 10 mg/g (interquartile range 6 to 19). Forty subjects (4%) had prevalent AF. Compared to participants with eGFR(cys) in the highest tertile (eGFR(cys) >79), those with eGFR(cys) in the lowest tertile (eGFR(cys) <62) had more than threefold greater odds of AF (odds ratio [OR] 3.43, 95% confidence interval [CI] 1.18 to 9.97) after multivariate adjustment for traditional cardiovascular disease risk factors. This association remained significant with further adjustment for ACR (OR 3.37, 95% 1.02 to 11.14). Results were similar for eGFR(Cr) but did not reach statistical significance (OR 1.59, 95% CI 0.57 to 4.40). Participants with ACRs in the highest tertile (ACR >15 mg/g) had more than fourfold greater odds of AF compared to participants in the lowest ACR tertile (ACR <7 mg/g); an association that remained significant after adjustment for eGFR(cys) (OR 4.36, 95% CI 1.45 to 13.05) or eGFR(Cr) (OR 4.61, 95% CI 1.56 to 13.66). In conclusion, among outpatients with coronary artery disease, lower eGFR(cys) and higher ACR were associated with prevalent AF, independent of each other.

N-terminal pro-B-type natriuretic peptide as a diagnostic test for ventricular dysfunction in patients with coronary disease: data from the heart and soul study.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing is useful for diagnosing acute decompensated heart failure. Whether NT-proBNP can be used to detect ventricular dysfunction in patients with stable coronary heart disease (CHD) and no history of heart failure is unknown. METHODS: We measured NT-proBNP levels and performed transthoracic echocardiography in 815 participants from the Heart and Soul Study, who had stable CHD and no history of heart failure. We hypothesized that NT-proBNP concentrations lower than 100 pg/mL would rule out ventricular dysfunction and concentrations higher than 500 pg/mL would identify ventricular dysfunction. We calculated sensitivities, specificities, likelihood ratios, and areas under the receiver operating characteristic curves for NT-proBNP as a case-finding instrument for systolic and diastolic dysfunction. RESULTS: Of the 815 participants with no history of heart failure, 68 (8%) had systolic dysfunction defined as a left ventricular ejection fraction of 50% or lower. Of the 730 participants for whom the presence or absence of diastolic dysfunction could be determined, 78 (11%) had diastolic dysfunction defined as a pseudonormal or restrictive filling pattern. The overall area under the receiver operating characteristic curve for detecting systolic or diastolic dysfunction was 0.78 (95% confidence interval, 0.74-0.82). Likelihood ratios were 0.28 for NT-proBNP concentrations lower than 100 pg/mL, 0.95 for concentrations between 100 and 500 pg/mL, and 4.1 for concentrations higher than 500 pg/mL. A test result lower than 100 pg/mL reduced the probability of ventricular dysfunction from a pretest probability of 18% to a posttest probability of 6%. A test result higher than 500 pg/mL increased the probability of ventricular dysfunction from a pretest probability of 18% to a posttest probability of 47%. A test result between 100 and 500 pg/mL did not change the probability of ventricular dysfunction. CONCLUSION: In patients with stable CHD and no history of heart failure, NT-proBNP levels lower than 100 pg/mL effectively rule out ventricular dysfunction, with a negative likelihood ratio of 0.28.