Crescendo Angina Secondary to Congenital Absence of the Left Circumflex Coronary Artery: A Case Report.

Congenital coronary artery abnormalities (CAAs) are very rare in the general population. Among these congenital anomalies, left circumflex artery (LCx) anomaly is the most common. Although many are asymptomatic, a small percentage of patients with this anomaly present with angina-like symptoms. Usually, a majority of these cases are found incidentally during coronary angiography. We present a 71-year-old male with crescendo angina with a positive chemical stress test. Coronary angiography showed an absent LCx and a superdominant right coronary artery (RCA). Although congenital LCx absence is a benign finding, the coexistence of this abnormality with significant atherosclerotic disease in the coronary artery can lead to significant morbidity and mortality in this population. Understanding the embryological and morphological significance of these anomalies is important in adequately diagnosing and managing these patients.

Left Internal Mammary Artery-to-Pulmonary Vein Fistula: A Rare Cause of Unstable Angina.

The incidence of acquired left internal mammary artery-to-pulmonary vein fistulas has been increasing in the last few decades. This has been attributed to the increase in coronary artery bypass surgery (CABG). The most commonly reported symptoms are angina and dyspnea. The timing of the presentation varies widely from a few months to several years after CABG. Medical management is the treatment of choice and usually controls the symptoms in most patients. Percutaneous intervention is, however, indicated when medical therapy fails. In this case report, a 72-year-old man with a history of CABG presented with progressively worsening chest pain and dyspnea. Troponin was negative and the electrocardiogram showed no acute ischemic changes. He was found to have left internal mammary artery-to-pulmonary vein fistula on coronary angiogram. His symptoms improved upon intensifications of his guideline-directed therapy for coronary artery disease. This represents an unusual cause of unstable angina.

The Destabilized Artery: A Case of Spontaneous Coronary Artery Dissection Presenting as Unstable Angina.

Spontaneous coronary artery dissection (SCAD) is increasingly being recognized as a cause of acute coronary syndrome (ACS). This increased recognition of SCAD has been noted in patients with and without traditional cardiovascular risk factors such as diabetes mellitus, hyperlipidemia, and cigarette smoking. The increasing incidence is believed to be due to recent advances in diagnostic and coronary imaging modalities. The most common presenting feature is chest pain or discomfort. Normal troponin level does not rule out SCAD as the definitive diagnosis is made on coronary angiography. Percutaneous intervention (PCI) for SCAD has been associated with lower success rates compared to PCI for atherosclerotic coronary artery disease. Medical management is, therefore, the initial treatment of choice.

Medical therapy following hospitalization for heart failure with reduced ejection fraction and association with discharge to long-term care: a cross-sectional analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) population.

BACKGROUND: Less intensive treatment for heart failure with reduced ejection fraction (HFrEF) may be appropriate for patients in long-term care settings because of limited life expectancy, frailty, comorbidities, and emphasis on quality of life. METHODS: We compared treatment patterns between REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants discharged to long-term care versus home following HFrEF hospitalizations. We examined medical records and Medicare pharmacy claims for 147 HFrEF hospitalizations among 80 participants to obtain information about discharge disposition and medication prescriptions and fills. RESULTS: Discharge to long-term care followed 22 of 147 HFrEF hospitalizations (15%). Participants discharged to long-term care were more likely to be prescribed beta-blockers and less likely to be prescribed aldosterone receptor antagonists and hydralazine/isosorbide dinitrate (96%, 14%, and 5%, respectively) compared to participants discharged home (81%, 22%, and 23%, respectively). The percentages of participants discharged to long-term care and home who had claims for filled prescriptions were similar for beta-blockers (68% versus 66%) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs) (45% versus 47%) after 1 year. Smaller percentages of participants discharged to long-term care had claims for filled prescriptions of other medications compared to participants discharged home (diuretics: long-term care-50%, home-72%; hydralazine/isosorbide dinitrate: long-term care-5%, home-23%; aldosterone receptor antagonists: long-term care-5%, home-23%). CONCLUSIONS: Differences in medication prescriptions and fills among individuals with HFrEF discharged to long-term care versus home may reflect prioritization of some medical therapies over others for patients in long-term care.

Comparison of Expert Adjudicated Coronary Heart Disease and Cardiovascular Disease Mortality With the National Death Index: Results From the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study.

BACKGROUND: The National Death Index (NDI) is widely used to detect coronary heart disease (CHD) and cardiovascular disease (CVD) deaths, but its reliability has not been examined recently. METHODS AND RESULTS: We compared CHD and CVD deaths detected by NDI with expert adjudication of 4010 deaths that occurred between 2003 and 2013 among participants in the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort of black and white adults in the United States. NDI derived CHD mortality had sensitivity 53.6%, specificity 90.3%, positive predictive value 54.2%, and negative predictive value 90.1%. NDI-derived CVD mortality had sensitivity 73.4%, specificity 84.5%, positive predictive value 70.6%, and negative predictive value 86.2%. Among NDI-derived CHD and CVD deaths, older age (odds ratios, 1.06 and 1.04 per 1-year increase) was associated with a higher probability of disagreement with the adjudicated cause of death, whereas among REGARDS adjudicated CHD and CVD deaths a history of CHD or CVD was associated with a lower probability of disagreement with the NDI-derived causes of death (odds ratios, 0.59 and 0.67, respectively). CONCLUSIONS: The modest accuracy and differential performance of NDI-derived cause of death may impact CHD and CVD mortality statistics.

Characteristics and prognosis of acute myocardial infarction by discharge diagnosis: the Reasons for Geographic and Racial Differences in Stroke study.

PURPOSE: To compare the characteristics and prognosis of acute myocardial infarctions (AMIs) that were not the primary reason for hospitalization, and thus not primary discharge diagnosis, to AMIs that were the primary reason for hospitalization. METHODS: Primary discharge diagnoses for Reasons for Geographic and Racial Differences in Stroke study participants (black and white men and women age ≥45 years) with adjudicated AMIs were categorized as "AMI" or "other". Cox models were used to compare mortality up to 5 years post-AMI between primary discharge diagnoses of AMI and other. RESULTS: Of 871 AMIs, primary discharge diagnosis was not AMI in 550 (63%). When primary discharge diagnosis was not AMI, average troponin elevations were smaller and heart failure was more common. Adjusted for participant and hospitalization characteristics, all-cause, coronary heart disease, and cardiovascular disease mortality after AMI were similar between groups (hazard ratios [95% confidence intervals]: 1.08 [0.80-1.47]; 1.29 [0.76-2.18]; and 0.86 [0.58-1.27], respectively). CONCLUSIONS: Studies limited to individuals with primary discharge diagnosis of AMI may underestimate the burden of AMI and exclude a group with elevated risk of all-cause, coronary heart disease, and cardiovascular disease mortality.