Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score.

AIMS: CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS). METHODS AND RESULTS: Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98). CONCLUSION: In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a 'gatekeeper' in this patient cohort, obviating the need for further more expensive tests.

Temporo-mandibular joint dislocation: an unusual complication of transoesophageal echocardiography.

Temporo-mandibular joint (TMJ) dislocation is an unusual complication of transoesophageal echocardiography (TEE). We report a rare case of bilateral TMJ dislocation in an 84-year-old man prior to DC cardioversion (DCCV) for atrial flutter. Shortly after TEE and DCCV, the patient complained of bilateral facial pain. An orthopantomogram revealed bilateral TMJ dislocation. A closed reduction was performed by maxillo-facial surgeons under intravenous anaesthesia. Although very uncommon, the physician should be aware of the complication and its management.

Myocardial fibrosis in an veteran endurance athlete.

This study reports the cardiac structure and function of a lifelong male endurance athlete, who has run over 148 000 miles, who presented with symptoms of chest discomfort, dyspnoea and loss of competitive running performance. Importantly, the athlete documented several periods of regular intensive endurance activity while suffering with flu-like symptoms. Cardiovascular MRI demonstrated a pattern of late gadolinium enhancement, which indicated myocardial scarring as a result of previous myocarditis.Myocarditis is a non-ischaemic inflammatory disease of the myocardium associated with cardiac dysfunction and arrhythmogenic substrate. The clinical course of viral myocarditis is mostly insidious with limited cardiac inflammation and dysfunction. However, as in the present case, overwhelming inflammation may occur in a subset of patients leading to myocardial fibrosis due to recurrent inflammation.

Treat the patient not the blood test: the implications of an increase in cardiac troponin after prolonged endurance exercise.

Collapse after prolonged endurance exercise is common and usually benign. This case study reports a triathlete who suffered a vaso-vagal associated collapsed after exercise. Misdiagnosis of myocardial injury in the presence of elevated cardiac troponins and ECG anomalies led to inappropriate management and highlights the difficulty in treating the collapsed athlete following arduous exercise.

Differentiation of RVOT-VT and ARVC in an elite athlete.

BACKGROUND: Differentiation of right ventricular outflow tract-ventricular tachycardia (RVOT-VT) and arrhythmogenic right ventricular cardiomyopathy (ARVC) can be problematic in athletes. The high incidence of sudden death as the first clinical manifestation in ARVC highlights the importance of correct diagnosis and treatment. We report on the case of RVOT-VT in an elite female sprinter, and we review the literature on ventricular tachycardia (VT) in the absence of structural heart disease and ARVC. DISCUSSION: Of patients who present with VT, 10% have no obvious structural disease. In the case of idiopathic VT from the RVOT and LVOT, the arrhythmia is monomorphic and generally not familial. In both disorders, the resting ECG has no identifiable abnormalities, and the echocardiogram and coronary angiography are usually normal. ARVC is a heart muscle disorder characterized by structural and functional abnormalities of the right ventricle due to a fibro-fatty replacement of the myocardium. The natural history of ARVC is considered to include four distinct phases. The early concealed phase of ARVC demonstrates ECG abnormalities concomitant to right and left ventricular dyskinesias. Differential diagnosis during this phase is problematic due to the presence of left bundle branch block morphology VT together with ECG anomalies commonly observed in athletes in RVOT-VT. Furthermore, long-standing VT in RVOT-VT may result in ventricular wall motion abnormalities mimicking ARVC. Radiofrequency ablation may be a valuable tool in the differential diagnosis, because this technique is highly effective in the treatment of RVOT-VT and of limited value in ARVC. Continued follow-up evaluation is an important for the confirmation of disease status after the diagnosis of idiopathic RVOT-VT.