Spontaneous coronary artery dissection and ST-segment elevation myocardial infarction: Does clinical presentation matter?

BACKGROUND: Some patients with spontaneous coronary artery dissection (SCAD) present as ST-segment-elevation myocardial infarction (STEMI). This study evaluates the characteristics, management and outcomes of SCAD patients presenting as STEMI compared to non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: We analysed data from consecutive patients included in the prospective Spanish Registry on SCAD. All coronary angiograms were centrally reviewed. All adverse events were adjudicated by an independent Clinical Events Committee. RESULTS: Between June 2015 to December 2020, 389 patients were included. Forty-two percent presented with STEMI and 56% with NSTEMI. STEMI patients showed a worse distal flow (TIMI flow 0-1 38% vs 19%, p < 0.001) and more severe (% diameter stenosis 85 ± 18 vs 75 ± 21, p < 0.001) and longer (42 ± 23 mm vs 35 ± 24 mm, p = 0.006) lesions. Patients with STEMI were more frequently treated with percutaneous coronary intervention (PCI) (31% vs 16%, p < 0.001) and developed more frequently left ventricular systolic dysfunction (21% vs 8%, p < 0.001). No differences were found in combined major adverse events during admission (7% vs 5%, p = 0.463), but in-hospital reinfarctions (5% vs 1.4%, p = 0.039) and cardiogenic shock (2.6% vs 0%, p = 0.019) were more frequently seen in the STEMI group. At late follow-up (median 29 months) no differences were found in the incidence of major adverse cardiac and cerebrovascular events (13% vs 13%, p-value = 0.882) between groups. CONCLUSIONS: Patients with SCAD and STEMI had a worse angiographic profile and were more frequently referred to PCI compared to NSTEMI patients. Despite these disparities, both short and long-term prognosis were similar in STEMI and NSTEMI SCAD patients.

Multivessel spontaneous coronary artery dissection: Clinical features, angiographic findings, management, and outcomes.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Multivessel (MV) SCAD is a challenging clinical presentation that might be associated to a worse prognosis compared with patients with single-vessel (SV) involvement. METHODS: The Spanish multicentre nationwide prospective SCAD registry included 389 consecutive patients. Patients were classified, according to the number of affected vessels, in SV or MV SCAD. Major adverse events (MAE) were analyzed during hospital stay and major cardiac or cerebrovascular adverse events (MACCE) at long-term clinical follow-up. RESULTS: A total of 41 patients (10.5%) presented MV SCAD. These patients had more frequently a previous history of hypothyroidism (22% vs 11%, p = 0.04) and anxiety disorder (32% vs 16%, p = 0.01). MV SCAD patients presented more often as non-ST segment elevation myocardial infarction (73% vs 52%, p = 0.01) and showed less frequently type 1 angiographic lesions (12% vs 21%, p = 0.04). An impaired initial Thrombolysis In Myocardial Infarction (TIMI) flow 0-1 was less frequent (14% vs 29%, p < 0.01) in MV SCAD. In both groups, most patients were treated conservatively (71% vs 79%, p = NS). No differences were found regarding in-hospital MAE or MACCE at late follow-up (median 29 ± 11 months). However, the rate of stroke was higher in MV SCAD patients, both in-hospital (2.4% vs 0%, p < 0.01) and at follow-up (5.1% vs 0.6%, p = 0.01). CONCLUSIONS: Patients with MV SCAD have some distinctive clinical and angiographic features. Although composite clinical outcomes, in-hospital and at long-term follow-up, were similar to those seen in patients with SV SCAD, stroke rate was significantly higher in patients with MV SCAD.

Cardiopatía asociada a infección por VIH / HIV-associated heart disease

Resumen La infección por VIH continúa representando un problema sanitario de primer orden en el mundo. El aumento de la esperanza de vida gracias a la terapia antirretroviral ha aumentado la prevalencia de la enfermedad de manera importante. La infección por VIH es una causa importante de cardiopatía adquirida, en especial en relación con el desarrollo de cardiopatía isquémica (manifestación cardiovascular más frecuente en los países desarrollados en la actualidad). Se presenta el caso de una paciente de 42 años, con infección por VIH, sin factores de riesgo cardiovascular clásicos, quien presentó un síndrome coronario agudo de alto riesgo. Se discuten la etiopatogenia de la cardiopatía isquémica asociada a la infección por VIH y sus aspectos particulares diagnósticos y terapéuticos.

Abstract Human immunodeficiency virus (HIV) infection continues to be a leading health problem worldwide. Increased life expectancy due to antiretroviral therapy has significantly increased the prevalence of the disease. Human immunodeficiency virus infection is an important cause of acquired heart disease, especially the development of ischemic heart disease (the most common cardiovascular manifestation in developed countries today). We present the case of a 42-year-old patient with HIV infection with no classical cardiovascular risk factors who developed a high-risk acute coronary syndrome. We discuss the etiopathogenesis of HIV-associated ischemic heart disease and its particular diagnostic and therapeutic aspects.

Improved prediction of electrical storm in patients with prior myocardial infarction and implantable cardioverter defibrillator.

AIMS: To evaluate predictors of electrical storm (ES), including chronic total occlusion in an infarct-related coronary artery (infarct-related artery CTO, IRACTO), in a cohort of patients with prior myocardial infarction (MI) and implantable cardioverter-defibrillators (ICD). METHODS: Multicenter observational cohort study including 643 consecutive patients with prior MI and a first ICD implanted between 2005 and 2018 at three tertiary hospitals. All the patients included in the study had undergone a diagnostic coronary angiography before ICD implantation. The variable prior ventricular arrhythmias (VA+) was positive in patients with secondary prevention ICDs and in those with at least one appropriate ICD therapy after primary prevention implantation. RESULTS: During a median follow-up of 42 months 59 patients (9%) suffered ES. The presence of at least one IRACTO not revascularized (IRACTO-NR) was associated with a significantly higher cumulative incidence of ES (14.5% vs 4.8%, p < 0.001). IRACTO-NR maintained a significant association with ES after adjustment for potential confounders (HR 2.3, p = 0.005) and was an independent predictor of ES together with VA+ and LVEF. The best cut-off of LVEF to predict ES was ≤38%. A risk-prediction model based on IRACTO-NR, VA+ and LVEF≤38% identified three categories of ES risk (low, intermediate and high), with progressively increasing cumulative incidence of ES (2.2%, 9% and 20%). CONCLUSION: In a cohort of patients with prior MI and ICD, IRACTO-NR is an independent predictor of ES. A new risk-prediction model allowed the identification of three categories of risk, with potentially important clinical implications.

Triflusal in Patients with Acute Coronary Syndrome and Acetylsalicylic Acid Hypersensitivity.

BACKGROUND: Acetylsalicylic acid hypersensitivity (ASAH) limits therapeutic options in patients with acute coronary syndrome (ACS), who benefit from dual antiplatelet therapy (DAPT), especially when undergoing stent implantation. Our aim was to evaluate the safety and efficacy of triflusal in patients with ACS and ASAH. METHODS AND RESULTS: Two-center retrospective study of patients diagnosed with ACS and ASAH from January 1, 2000, to May 1, 2020. Sixty-six patients were treated with triflusal. ASAH was confirmed with tests in 15 patients (22.7%). Forty-nine patients (74.2%) presented history of other drug allergies. Fifty-nine patients (89.4%) underwent stent implantation. DAPT was prescribed for ≥12 months in 54 patients. No adverse reactions to triflusal were reported. During a median follow-up of 5.12 years [IQR 2.7-9.9], rate of cardiovascular (CV) mortality was 6.1%, nonfatal myocardial infarction 12.1%, and ischemic stroke 4.5%. No cases of definite stent thrombosis occurred. Bleeding Academic Research Consortium grade ≥2 was observed in 3 patients during follow-up. CONCLUSION: In this series of patients presenting with ACS and ASA hypersensitivity, triflusal showed good tolerability and was associated with a low rate of CV and bleeding events.

Risk predictors in a Spanish cohort with cardiac laminopathies. The REDLAMINA registry.

INTRODUCTION AND OBJECTIVES: According to sudden cardiac death guidelines, an implantable cardioverter-defibrillator (ICD) should be considered in patients with LMNA-related dilated cardiomyopathy (DCM) and ≥ 2 risk factors: male sex, left ventricular ejection fraction (LVEF) <45%, nonsustained ventricular tachycardia (NSVT), and nonmissense genetic variants. In this study we aimed to describe the clinical characteristics of carriers of LMNA genetic variants among individuals from a Spanish cardiac-laminopathies cohort (REDLAMINA registry) and to assess previously reported risk criteria. METHODS: The relationship between risk factors and cardiovascular events was evaluated in a cohort of 140 carriers (age ≥ 16 years) of pathogenic LMNA variants (54 probands, 86 relatives). We considered: a) major arrhythmic events (MAE) if there was appropriate ICD discharge or sudden cardiac death; b) heart failure death if there was heart transplant or death due to heart failure. RESULTS: We identified 11 novel and 21 previously reported LMNA-related DCM variants. LVEF <45% (P=.001) and NSVT (P <.001) were related to MAE, but not sex or type of genetic variant. The only factor independently related to heart failure death was LVEF <45% (P <.001). CONCLUSIONS: In the REDLAMINA registry cohort, the only predictors independently associated with MAE were NSVT and LVEF <45%. Therefore, female carriers of missense variants with either NSVT or LVEF <45% should not be considered a low-risk group. It is important to individualize risk stratification in carriers of LMNA missense variants, because not all have the same prognosis.

Revascularization of coronary chronic total occlusions in an infarct-related artery and recurrence of ventricular arrhythmias among patients with secondary prevention implantable cardioverter defibrillator.

OBJECTIVES: To evaluate whether the revascularization of a coronary chronic total occlusion in an infarct-related artery (IRACTO) may be associated with lower recurrence of ventricular arrhythmias (VA) among patients with a secondary prevention implantable cardioverter defibrillator (ICD). BACKGROUND: IRACTO is increasingly recognized as an independent predictor of VA. It is unknown whether IRACTO revascularization can reduce the burden of VA. METHODS: Multicenter observational cohort study that included consecutive patients with prior myocardial infarction and secondary prevention ICD. The primary endpoint was any appropriate ICD therapy. RESULTS: Among the 460 patients included, 269 (58%) had at least one IRACTO at the coronary angiogram performed before ICD implantation; of these, 20 (7%) had their IRACTO successfully revascularized (IRACTO-R) afterwards. During a median follow-up of 48 months, 229 patients (49%) had at least one appropriate ICD therapy. Patients with IRACTO not revascularized (IRACTO-NR) had the highest incidence of ICD therapies (65%) while patients with IRACTO-R had the lowest (10%, p < .001). In the entire cohort, IRACTO-NR was an independent predictor of appropriate ICD therapies (HR 2.85, p < .001) and appropriate ICD shocks (HR 2.94, p < .001). Among patients with IRACTO at baseline, IRACTO-R was independently associated with a marked reduction of appropriate ICD therapies (HR 0.12, p = .002) and appropriate ICD shocks (HR 0.21, p = .03). CONCLUSIONS: In patients with prior myocardial infarction and secondary prevention ICD, IRACTO revascularization was independently associated with a markedly lower incidence of appropriate ICD therapies and shocks. These results should be corroborated by larger prospective studies.

Fibroelastoma papilar mitral como causa de ictus en paciente joven / Mitral papillary fibroelastoma as a cause of stroke in a young patient

RESUMEN El fibroelastoma papilar es un tumor poco frecuente, con una prevalencia estimada entre el 1 y el 7,9% de todos los tumores cardíacos primarios, los que -a su vez- presentan una muy baja incidencia (entre 0,001 y 0,28%), pues la gran mayoría de ellos (casi un 90%) son benignos. Se presenta el caso de un hombre de 41 años de edad que debutó con un accidente cerebrovascular. En el estudio ecocardiográfico se halló un tumor cardíaco en la valva anterior mitral sugerente de fibroelastoma papilar. Se decidió la intervención quirúrgica ante la posibilidad de complicaciones embólicas derivadas, con recurrencia de episodios isquémicos cerebrovasculares. Se realizó resección triangular de dicha tumoración y anuloplastia mitral con buen resultado. El estudio anatomopatológico confirmó el diagnóstico.

ABSTRACT Papillary fibroelastoma is an infrequent tumor, with a prevalence estimated between 1 and 7.9% of all primary cardiac tumors, which -at the same time- have a very low incidence (between 0.001 and 0.28%), because the great majority of them (almost a 90%) are benign. Here is presented the case of a 41-year-old man who had a stroke. A cardiac tumor in the anterior mitral valve suggestive of papillary fibroelastoma was found in the echocardiographic study. The surgical intervention was decided because of the possibility of resulting embolic complications with recurrence of cerebrovascular ischemic events. A triangular resection of the tumor and mitral annuloplasty were performed with good results. The pathological study confirmed the diagnosis.

Utilidad de copeptina en el diagnóstico de síndrome coronario agudo en el departamento de urgencias de un hospital de tercer nivel / Usefulness of copeptin in the diagnosis of acute coronary syndrome in the emergency department of a tertiary hospital

Objetivos: Valorar la utilidad de copeptina (fragmento estable del precursor de vasopresina-arginina) en el diagnóstico diferencial del dolor torácico agudo de posible origen coronario. Material y métodos: Se han incluido en el estudio 82 pacientes que fueron evaluados inicialmente de acuerdo con el protocolo de pacientes con sospecha de síndrome coronario agudo (SCA) de nuestro Servicio de Urgencias, incluyendo la determinación de troponina y copeptina con seriación en admisión y a las 6 h. Resultados: Obtuvimos diferencias estadísticamente significativas en la concentración de copeptina a tiempo 0 entre los pacientes diagnosticados de SCASEST: 42,1±38,7pmol/L y los pacientes no SCASEST: 15,6±21,2pmol/L (p<0,01). Sin embargo, las diferencias no alcanzaron a ser estadísticamente significativas a las 6 h (p=0,093). El análisis del área bajo la curva ROC para la copeptina en los pacientes SCASEST a tiempo 0 fue de 0,713 con un intervalo de confianza del 95% de 0,592 a 0,834 y un grado de significación de p=0,001. Conclusiones: La concentración de copeptina representa un valor adicional en la diferenciación entre pacientes SCASEST y pacientes no SCASEST, así como entre pacientes SCA y pacientes con angina estable. El punto de corte de 10pmol/L proporciona los mejores valores de sensibilidad, valor predictivo negativo (VPN), cociente de probabilidad positivo (CPP) y cociente de probabilidad negativo (CPN) en el diagnóstico de pacientes SCASEST

Objectives: This study was conducted in order to evaluate the usefulness of copeptin (a stable fragment of the precursor of arginine vasopressin) in the differential diagnosis of acute chest pain of probable coronary origin. Material and methods: The study includes 82 patients who were initially evaluated according to the protocol of a patient with suspected acute coronary syndrome (ACS) in our Emergency Department, including the determination of troponin and copeptin with specimens taken on admission (time 0) and at 6h. Results: Statistically significant differences were observed in copeptin concentrations at time 0 among patients diagnosed with non-ST-segment elevation (NTEACS): 42.1±38.7pmol/L and non-NSTEACS patients: 15.6±21.2pmol/L (P<. 01). However, the differences did not reach statistical significance at 6h (P=.093). The analysis of the area under the ROC curve for Copeptin in NSTEACS patients at time 0 was 0.713, with a confidence interval of 95% from 0.592 to 0.834 and a significance level of P=.001. Conclusions: The concentration of copeptin represents an additional value in the differentiation between NSTEACS patients and non-NSTEACS patients, as well as between ACS patients and patients with stable angina. The cut-off point of 10pmol/L provides the best values for sensitivity, negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) in the diagnosis of NSTEACS patients

[Usefulness of copeptin in the diagnosis of acute coronary syndrome in the emergency department of a tertiary hospital]. / Utilidad de copeptina en el diagnóstico de síndrome coronario agudo en el departamento de urgencias de un hospital de tercer nivel.

OBJECTIVES: This study was conducted in order to evaluate the usefulness of copeptin (a stable fragment of the precursor of arginine vasopressin) in the differential diagnosis of acute chest pain of probable coronary origin. MATERIAL AND METHODS: The study includes 82 patients who were initially evaluated according to the protocol of a patient with suspected acute coronary syndrome (ACS) in our Emergency Department, including the determination of troponin and copeptin with specimens taken on admission (time 0) and at 6h. RESULTS: Statistically significant differences were observed in copeptin concentrations at time 0 among patients diagnosed with non-ST-segment elevation (NTEACS): 42.1±38.7pmol/L and non-NSTEACS patients: 15.6±21.2pmol/L (P<. 01). However, the differences did not reach statistical significance at 6h (P=.093). The analysis of the area under the ROC curve for Copeptin in NSTEACS patients at time 0 was 0.713, with a confidence interval of 95% from 0.592 to 0.834 and a significance level of P=.001. CONCLUSIONS: The concentration of copeptin represents an additional value in the differentiation between NSTEACS patients and non-NSTEACS patients, as well as between ACS patients and patients with stable angina. The cut-off point of 10pmol/L provides the best values for sensitivity, negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) in the diagnosis of NSTEACS patients.