Coronary artery thromboembolism as a cause of myocardial infarction with non-obstructive coronary arteries (MINOCA).

Acute myocardial infarction (AMI) usually represents the clinical manifestation of atherothrombotic coronary artery disease (CAD) resulting from atherosclerotic plaque rupture. However, there are cases in which coronary angiography or coronary computed tomography angiography reveals patients with acute coronary syndrome with non-obstructive CAD. This clinical entity is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA) and often considered as a clinical dynamic working diagnosis that needs further investigations for the establishment of a final etiologic diagnosis. The main causes of a MINOCA working diagnosis include atherosclerotic, non-atherosclerotic (vessel-related and non-vessel-related), and thromboembolic causes This literature review aimed to investigate the major thromboembolic causes in patients presenting with MINOCA regarding their etiology and pathophysiologic mechanisms, as well as diagnostic and treatment methods.

Machine learning assisted reflectance spectral characterisation of coronary thrombi correlates with microvascular injury in patients with ST-segment elevation acute coronary syndrome.

Aims: We set out to further develop reflectance spectroscopy for the characterisation and quantification of coronary thrombi. Additionally, we explore the potential of our approach for use as a risk stratification tool by exploring the relation of reflectance spectra to indices of coronary microvascular injury. Methods and results: We performed hyperspectral imaging of coronary thrombi aspirated from 306 patients presenting with ST-segment elevation acute coronary syndrome (STEACS). Spatially resolved reflected light spectra were analysed using unsupervised machine learning approaches. Invasive [index of coronary microvascular resistance (IMR)] and non-invasive [microvascular obstruction (MVO) at cardiac magnetic resonance imaging] indices of coronary microvascular injury were measured in a sub-cohort of 36 patients. The derived spectral signatures of coronary thrombi were correlated with both invasive and non-invasive indices of coronary microvascular injury. Successful machine-learning-based classification of the various thrombus image components, including differentiation between blood and thrombus, was achieved when classifying the pixel spectra into 11 groups. Fitting of the spectra to basis spectra recorded for separated blood components confirmed excellent correlation with visually inspected thrombi. In the 36 patients who underwent successful thrombectomy, spectral signatures were found to correlate well with the index of microcirculatory resistance and microvascular obstruction; R 2: 0.80, p < 0.0001, n = 21 and R 2: 0.64, p = 0.02, n = 17, respectively. Conclusion: Machine learning assisted reflectance spectral analysis can provide a measure of thrombus composition and evaluate coronary microvascular injury in patients with STEACS. Future work will further validate its deployment as a point-of-care diagnostic and risk stratification tool for STEACS care.

A Case of Giant Cell Arteritis Presenting As Catastrophic Posterior Circulation Stroke: A Diagnostic Dilemma.

Giant cell arteritis (GCA) is an immune-mediated systemic vasculitis usually seen in the older population. We describe a case of a 75-year-old woman who presented with jaw claudication and temporal headache. A colour duplex ultrasonography and later biopsy of the temporal arteries confirmed GCA and she was commenced on oral steroids. She was subsequently readmitted with a new worsening vision of both eyes and confusion. Her brain images revealed acute bilateral vertebral artery thrombus with haemorrhagic transformation. She was loaded on intravenous steroids. The next day she developed vomiting, bilateral visual loss and a cardiac arrest from ventricular fibrillation. Following the return of spontaneous circulation, she was taken to the cardiac catheterisation laboratory for a coronary angiogram, which showed diffuse thrombus at the apical left anterior descending artery. A bedside echocardiogram revealed a sizable left ventricular thrombus. She was managed with heparin and antiplatelet therapy. This case presented a complex diagnostic dilemma to the medical team as vasculitis, atherosclerosis, and cardiac emboli could have contributed to her stroke and visual loss. This patient also had some vascular risk factors for occlusive cerebrovascular disease, potentially suggesting a clinical event with multiple aetiologies. Stroke and visual loss are rare but serious complications of GCA, which require a high index of suspicion and early treatment with corticosteroids to improve prognosis. Although a temporal artery biopsy remains to be the definitive diagnostic modality for GCA, the use of radiological investigations in the diagnosis of GCA is increasingly common. A non-invasive colour duplex ultrasonography of the temporary arteries could be used to assess GCA in highly suspected patients. Echocardiograms and contrast-enhanced body imaging should be performed in patients with suspected or established GCA to assess for secondary thromboembolic and vascular complications.

Obesity Paradox in Coronary Thrombus Burden of Patients with Acute Coronary Syndrome.

Background: Acute coronary syndrome (ACS) remains a major cause of morbidity and mortality worldwide. Although obesity is a risk factor for ACS, decreased mortality has been shown in overweight individuals. This study aims to determine the association of body fat parameters such as body fat percentage (BFP), relative fat mass (RFM), and coronary thrombus burden with angiographic thrombotic grade in a series of patients presenting with ACS. Methods: Three hundred ninety patients who underwent percutaneous coronary intervention were enrolled in the study. BFP was calculated using the U.S. Navy formula. RFM index was calculated using gender, height, and waist circumference regardless of weight. Body mass index (BMI) is calculated as the weight in kilograms divided by the square of body length in meters (kg/m2). Two experienced interventional cardiologists reviewed coronary angiograms according to the TIMI thrombus scale. Patients were divided into groups according to thrombus classification and clinical status. Results: RFM, which is an anthropometric measurement parameter for obesity, was inversely related to thrombus burden in patients with ACS. There were no significant differences between ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) groups according to demographic, clinical characteristics, and coronary risk factors. Likewise, RFM, BFP, and BMI were comparable between the two groups. BFP and RFM were lower in patients with thrombus present STEMI group compared with no thrombus group. Thrombus presence was also compared in the NSTEMI group, and BMI, BFP, and RFM were lower in patients with thrombus present NSTEMI group. Conclusions: Our analysis demonstrated that RFM was better than BFP and BMI for predicting thrombus presence in patients with ACS.

Role of Acute Thrombosis in Coronavirus Disease 2019.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are prone to venous, cerebrovascular, and coronary thrombi, particularly those with severe coronavirus disease 2019 (COVID-19). The pathogenesis is multifactorial and likely involves proinflammatory cascades, development of coagulopathy, and neutrophil extracellular traps, although further investigations are needed. Elevated levels of D-dimers are common in patients with COVID-19 and cannot be used in isolation to predict venous thromboembolism in people with SARS-CoV-2. If given early in hospital admission, therapeutic-dose heparin improves clinical outcomes in patients with moderate COVID-19. To date, antithrombotics have not improved outcomes in patients with severe COVID-19.

Case Report: Free-Floating Intracoronary Thrombus: Who Is the Convict?

In young patients, especially with no traditional coronary risk factors, hypercoagulable states may always be considered as an alternative cause of acute coronary syndromes. The concomitant thrombotic and bleeding risk associated with myeloproliferative disorders complicates the decision-making, particularly regarding long-term dual antiplatelet therapy. The chosen therapy may need to be frequently revisited, depending on the patient's bleeding complications. We reported the case of a 49-year-old woman with acute myocardial infarction with no traditional risk factors for coronary artery disease where a myeloproliferative neoplasm was diagnosed.

Systemic Immune-Inflammation Index: A Novel Predictor of Coronary Thrombus Burden in Patients with Non-ST Acute Coronary Syndrome.

Background and Objectives: Excessive coronary thrombus burden is known to cause an increase in mortality and major adverse cardiac events (MACEs) in NSTE-ACS (non-ST acute coronary syndrome) patients. We investigated the association between the systemic immune-inflammation index (SII) and coronary thrombus burden in patients with non-ST segment elevation myocardial infarction (NSTEMI) who underwent coronary angiography and percutaneous coronary intervention (PCI). Materials and Methods: A total of 389 patients with the diagnosis of NSTEMI participated in our study. Coronary thrombus burden was classified in the TIMI (thrombolysis in myocardial infarction) thrombus grade scale and patients were divided into two groups: a TIMI thrombus grade 0-1 group (n = 209, 157 males) and a TIMI thrombus grade 2-6 group (n = 180, 118 males). Demographics, angiographic lesion images, coronary thrombus burden, clinical risk factors, laboratory parameters, and SII score were compared between the two groups. Results: The high thrombus burden patient group had a higher neutrophil count, WBC count, platelet count, and systemic immune-inflammation index (SII) (p < 0.001). The receiver operating characteristic (ROC) curve analysis showed that at a cutoff of 1103, the value of SII manifested 74.4% sensitivity and 74.6% specificity for detecting a high coronary thrombus burden. Conclusions: Our study showed that the SII levels at hospital admission were independently associated with high coronary thrombus with NSTEMI.

Adjunctive Catheter-Directed Thrombolysis during Primary PCI for ST-Segment Elevation Myocardial Infarction with High Thrombus Burden.

BACKGROUND: High coronary thrombus burden has been associated with unfavorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI), the optimal management of which has not yet been established. METHODS: We assessed the adjunctive catheter-directed thrombolysis (CDT) during primary percutaneous coronary intervention (PCI) in patients with STEMI and high thrombus burden. CDT was defined as intracoronary infusion of tissue plasminogen activator (t-PA; monteplase). RESULTS: Among the 1849 consecutive patients with STEMI, 263 had high thrombus burden. Moreover, 41 patients received t-PA (CDT group), whereas 222 did not receive it (non-CDT group). No significant differences in bleeding complications and in-hospital and long-term mortalities were observed (9.8% vs. 7.2%, p = 0.53; 7.3% vs. 2.3%, p = 0.11; and 12.6% vs. 17.5%, p = 0.84, CDT vs. non-CDT). In patients who underwent antecedent aspiration thrombectomy during PCI (75.6% CDT group and 87.4% non-CDT group), thrombolysis in myocardial infarction grade 2 or 3 flow rate after thrombectomy was significantly lower in the CDT group than in the non-CDT group (32.2% vs. 61.0%, p < 0.01). However, the final rates improved without significant difference (90.3% vs. 97.4%, p = 0.14). CONCLUSIONS: Adjunctive CDT appears to be tolerated and feasible for high thrombus burden. Particularly, it may be an option in cases with failed aspiration thrombectomy.

Optical Coherence Tomography-OCT for Characterization of Non-Atherosclerotic Coronary Lesions in Acute Coronary Syndromes.

Cardiovascular diseases are the main cause of death worldwide, with coronary artery disease being the predominant underlying etiology. The most prevalent coronary lesions are represented by the atherosclerotic plaques, in more than 85% of cases, but there are several other non-atherosclerotic lesions such as spontaneous coronary artery dissection and/or hematoma and spontaneous recanalization of coronary thrombus, which are less common, approximately 5% of cases, but with similar clinical manifestations as well as complications. There are insufficient data regarding the pathological mechanism, true prevalence and optimal treatment of these kind of coronary lesions. Optical coherence tomography (OCT) is an intracoronary imaging technique, developed in order to overcome the diagnostic limitations of a standard coronary angiography and has an extremely high resolution, similar to that of a usual histological evaluation of a biopsy sample, thus, OCT provides a histological-like information, but in a in vivo environment. The aim of this article is to review the current knowledge regarding non-atherosclerotic coronary lesions, with an emphasis on the importance of OCT for optimal identification, characterization of pathogenic mechanisms and optimal treatment selection.

ST-elevation myocardial infarction in a 39-year-old patient with "normal" coronary arteries as a thrombotic complication of COVID-19.

We report the case of a 39-year-old male without traditional risk factors for coronary artery disease (CAD), i.e. smoking, hypercholesterolemia, hypertension, diabetes mellitus, familial history of premature CAD, admitted with anterior ST-segment elevation myocardial infarction and concurrent coronavirus disease-2019 infection. Coronary angiography showed high intracoronary thrombus burden and thrombotic occlusion of the proximal segment of left anterior descending artery, while optical coherence tomography revealed intact endothelium after thromboaspiration.

Impact of a micro-net mesh technology covering stent on coronary microvascular dysfunction in patients with high thrombus burden.

BACKGROUND: Highly thrombotic coronary lesions continue to be a serious and clinically significant problem that is not effectively and completely addressed by current technology. OBJECTIVES: We aimed to investigate whether a micro-net mesh (MNM) technology covering stent could preserve the index of microcirculatory resistance (IMR) after percutaneous coronary intervention (PCI) in patients with high thrombus burden. METHODS AND RESULTS: Fifty-two patients with non-ST elevation myocardial infarction or ST Elevation Myocardial Infarction and high thrombus burden (TIMI thrombus grade ≥ 3) were randomized into two groups, PCI with a MNM covering stent (MNM group, n = 25) and PCI with any commercially available stent (DES group, n = 27). As the primary endpoint, IMR was measured immediately after PCI using a pressure-temperature sensor-tipped coronary wire. The secondary endpoint was left ventricular ejection fraction (LVEF) at 6 months of follow-up. The IMR in the MNM group was significantly lower in comparison to the DES group (33.2 [21.3, 48.9] vs. 57.2 [39.9, 98.0], p = 0.005). No significant differences were observed in baseline LVEF (54.5 ± 10.2% vs. 53.1 ± 6.87%, p = .57), while LVEF was significantly improved at follow-up in the MNM group (61.1 ± 7.1% vs. 53.9 ± 6.35%, p = .0001). CONCLUSION: MNM technology significantly improved coronary microvascular dysfunction after PCI in patient with acute coronary syndrome and appears as a useful technological option for thrombus management.

Massive perinatal left ventricle infarction treated with tissue plasminogen activator: No ECMO - A case report.

Neonatal myocardial infarction due to coronary thrombus is a rare cause of acute heart failure and is associated with high morbidity and mortality. We present a rare case of a full-term newborn who developed coronary artery thrombus treated with intracoronary recombinant tissue plasminogen activator infusion while undergoing therapeutic hypothermia. Also, we describe a unique treatment strategy to support systemic circulation sparing the patient from neonatal extracorporeal membrane oxygenation and its complications. Neonatal myocardial infarction should be suspected and ruled out in sick newborns.

Optical coherence tomography characterization of spontaneous recanalized coronary thrombus - Single center experience.

Introduction: Recanalized thrombus is an under diagnosed clinical entity. Aim was to investigate the utility of optical coherence tomography (OCT) in identifying spontaneously recanalized thrombi (SRCT) for management in clinical practice. Methods: This was a retrospective study analyzing 2678 coronary angiograms over a 4-year period which included intravascular imaging guidance in 75.8% of the percutaneous coronary interventions (PCI). Angiographic suspicion of SRCT has hazy appearance seen in 34 patients. Results: Eight patients (7 males and 1 female) were confirmed with SRCT on OCT and two underwent intravascular ultrasound (IVUS). Median age was 52 years (range 33-67 years). Based on clinical symptoms, diagnosis was STEMI-2, NSTEMI-1, unstable angina-3 and chronic stable angina-2. Angiographic patterns were veiled/hazy appearances in 3; braided in 2; pseudo dissection in 2; and near occlusion in 1 patient. OCT findings displayed multiple small cavities, signal-rich with high backscattering and thin septa with smooth inner borders dividing the lumen and intercommunications. Presence of multiple holes conferred typical "Swiss cheese" or 'lotus root' like appearance, characteristic of recanalized thrombi. SRCT lesion length was (median interquartile ranges [IQR], 16.5[12.07-21.5] mm) and minimal luminal area (median [IQR], 1.77 [0.93-3.26] mm2) with significant stenosis (median [IQR], 74.0[67.0-81.0] %). Minimum/maximum number of channels were (median [IQR], 2.0[2.0-2.0]) and (median [IQR], 4.50[4.0-6.75]) respectively. Lipid rich plaque was predominant. IVUS demonstrated echo-lucent channels with small cavities. All but one patient underwent PCI. Conclusion: Intravascular imaging by OCT delineates the characteristics of recanalized thrombi and distinguishes ambiguous lesions. Majority of the lesions involving SRCT were significant both symptomatic and stenosis severity wise on OCT requiring PCI.

[Myocardial Infarction in an Athlete]. / Myokardinfarkt bei einem Sportler.

Myocardial Infarction in an Athlete Abstract. We report the case of a male athlete with a myocardial infarction caused by intracoronary thrombus formation, which was associated with prior cannabis consumption. Cannabis is a rare cause of myocardial infarction and is poorly recognized as a cardiovascular risk factor. Because of the ongoing process of marijuana legalization in many countries, there is concern about an increasing number of cannabis-related myocardial infarctions especially in young patients. Several pathophysiological mechanisms have been proposed and warrant further investigation.

Impact of COVID-19 on Thrombus Burden and Outcome in Acute Myocardial Infarction.

Background Cardiovascular manifestations are one of the most common complications in coronavirus disease 2019 (COVID-19) infection and are associated with increased mortality. However, the impact of COVID-19 infection on thrombus burden and the outcome of acute myocardial infarction (AMI) has not been studied. Methods This was a retrospective, observational study that included all adult patients (>18 years) diagnosed with AMI with or without COVID-19 infection. Epidemiological, laboratory, clinical, interventional, and outcome data were extracted and the impact of COVID-19 on thrombus burden and the primary clinical composite endpoint of all-cause death during hospital admission or 30 days after discharge was studied. Results The study population included 336 patients, including 56 patients with COVID and AMI and 280 patients with AMI without COVID-19 infection. Chest pain was the most common symptom (84.8%) while one or more co-morbidity was present in 117 (34.8%) patients. Forty-eight patients in the AMI with COVID group had ST-segment elevation myocardial infarction (STEMI) while 256 patients in the AMI without COVID group had STEMI, eight patients in the AMI with COVID group had non-ST-segment elevation myocardial infarction (NSTEMI), and 24 in the AMI without COVID group had NSTEMI. Patients with COVID-19 co-infection had a higher thrombus burden as compared to the patients without COVID-19 AMI group (p-value 0.008). The primary outcome in the form of all-cause mortality was seen in 13 (3.9%) patients, which was also more in the AMI with COVID group. Conclusion COVID-19 in AMI is a state of high thrombus burden associated with higher mortality, especially in patients with chronic co-morbidities.

Hyperhomocysteinemia as the only risk factor in a young man presenting with ST-elevation myocardial infarction.

Hyperhomocysteinemia has been established as a risk factor for cardiovascular events. This case of a 23-year-old male, presenting with acute coronary thrombosis and unremarkable past medical history, highlights the importance of measuring homocysteine levels in young individuals with acute coronary syndromes, especially those without conventional risk factors. .

The relationship between hemoglobin A1c levels and thrombus load in patients with type 2 diabetes mellitus and non-ST-segment elevation myocardial infarction.

BACKGROUND: We aimed to investigate the relationship between hemoglobin A1c (HbA1c) and coronary thrombus load in type-2 diabetes mellitus (T2DM) patients with non-ST segment elevation myocardial infarction (NSTEMI). MATERIALS AND METHODS: Ninety diabetic patients with NSTEMI were recruited for the study. They were separated into two groups according to HbA1c levels. Forty-seven patients having HbA1c ≤6.5% formed Group-I (35 male, mean age 58 ± 10.5 years) and the remaining 43 patients with HbA1c >6.5% formed Group-II (23 male, mean age 58 ± 11.1 years). Both the groups were evaluated in terms of thrombolysis in myocardial infarction (TIMI) thrombus score and Syntax score. RESULTS: Baseline patient characteristics were comparable in both the groups. TIMI thrombus score and Syntax score were higher in Group II than in Group I (3.2 ± 1.4 vs. 4.7 ± 0.5 and 20.2 ± 3.4 vs. 26.3 ± 3.0 respectively, P < 0.05). No significant difference was found in other parameters. In stepwise linear regression analysis, prepercutaneous coronary intervention (PCI) and post-PCI TIMI frame number and HbA1c were significantly related to the coronary thrombus scale. However, no significant relationship has been found between thrombus formation and hypertension, previous PCI history, pre-PCI heart rate, pre-PCI cholesterol status, and high-sensitive troponin T. CONCLUSION: In NSTEMI with T2DM, increased HbA1c (HbA1c >6.5%) is related with coronary thrombus in the target vessel. In those patient population, strict anticoagulation should be considered to prevent potential adverse events.

Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1): a crucial driver of atherosclerotic cardiovascular disease.

Cardiovascular diseases (CVDs), specifically lipid-driven atherosclerotic CVDs, remain the number one cause of death worldwide. The lectin-like oxidized low-density lipoprotein (LDL) receptor-1 (LOX-1), a scavenger receptor that promotes endothelial dysfunction by inducing pro-atherogenic signalling and plaque formation via the endothelial uptake of oxidized LDL (oxLDL) and electronegative LDL, contributes to the initiation, progression, and destabilization of atheromatous plaques, eventually leading to the development of myocardial infarction and certain forms of stroke. In addition to its expression in endothelial cells, LOX-1 is expressed in macrophages, cardiomyocytes, fibroblasts, dendritic cells, lymphocytes, and neutrophils, further implicating this receptor in multiple aspects of atherosclerotic plaque formation. LOX-1 holds promise as a novel diagnostic and therapeutic target for certain CVDs; therefore, understanding the molecular structure and function of LOX-1 is of critical importance. In this review, we highlight the latest scientific findings related to LOX-1, its ligands, and their roles in the broad spectrum of CVDs. We describe recent findings from basic research, delineate their translational value, and discuss the potential of LOX-1 as a novel target for the prevention, diagnosis, and treatment of related CVDs.

Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1): a crucial driver of atherosclerotic cardiovascular disease.

Cardiovascular diseases (CVDs), specifically lipid-driven atherosclerotic CVDs, remain the number one cause of death worldwide. The lectin-like oxidized low-density lipoprotein (LDL) receptor-1 (LOX-1), a scavenger receptor that promotes endothelial dysfunction by inducing pro-atherogenic signalling and plaque formation via the endothelial uptake of oxidized LDL (oxLDL) and electronegative LDL, contributes to the initiation, progression, and destabilization of atheromatous plaques, eventually leading to the development of myocardial infarction and certain forms of stroke. In addition to its expression in endothelial cells, LOX-1 is expressed in macrophages, cardiomyocytes, fibroblasts, dendritic cells, lymphocytes, and neutrophils, further implicating this receptor in multiple aspects of atherosclerotic plaque formation. LOX-1 holds promise as a novel diagnostic and therapeutic target for certain CVDs; therefore, understanding the molecular structure and function of LOX-1 is of critical importance. In this review, we highlight the latest scientific findings related to LOX-1, its ligands, and their roles in the broad spectrum of CVDs. We describe recent findings from basic research, delineate their translational value, and discuss the potential of LOX-1 as a novel target for the prevention, diagnosis, and treatment of related CVDs.