[Acute coronary syndrome: diagnosis and treatment].

INTRODUCTION: In Switzerland, about 20 000 people experience an acute coronary syndrome (ACS) event each year. Acute coronary syndromes comprise ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina. The diagnosis is made based on the clinical presentation, a rise in cardiac biomarkers, and ischemic ECG changes. In patients with acute STEMI, urgent coronary angiography with primary percutaneous coronary intervention (PCI) to open the occluded artery is indicated. In patients with NSTEMI and unstable angina, the timing of coronary angiography and PCI is based on the clinical presentation and on a comprehensive and individualized risk stratification. Optimal secondary prevention and aggressive cardiovascular risk factor control are important following the acute event. Keywords.

Intramural aortic stenting of an anomalous right coronary artery arising from the left valsalva sinus: A leap into the dark?

A 69-year-old man with unstable angina underwent coronary angiography showing no lesion in the left coronary artery and critical stenosis in the proximal right coronary artery (RCA) arising from the left sinus of Valsalva.

Complete surgical revascularization after NSTEMI and unstable angina in patients with multivessel coronary artery disease: Institutional experience.

INTRODUCTION: The feasibility and standardization of coronary artery bypass grafting (CABG) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unstable angina (UA) remain topics of ongoing debate. In this study, feasibility and early-term outcomes of CABG in patients with NSTE-ACS and UA were discussed. METHODS: This study enrolled 79 patients who underwent on-pump CABG with complete revascularization between January 2020 and May 2022. the survival rates analyzed using Kaplan Meier test with log rank test. The p value of statistical significance was taken as below 0.05. RESULTS: Preoperatively, the patients had a mean age of 60.9 years and a BMI of 28.0. The medical history included hypertension (50.6%), peripheral arterial disease and atrial fibrillation (12.7%), and other comorbidities such as COPD (22.8%) and type 2 diabetes mellitus (44.3%). Intraoperatively, the mean distal anastomosis count was 3.4, with average cardiopulmonary bypass and aortic cross-clamp times of 84.0 and 49.0 min, respectively. Early-term outcomes revealed low rates of mortality (2.5%) and complications such as myocardial infarction (1.3%), acute kidney injury (5.1%) and transient ischemic attack (5.1%). Post-discharge outcomes demonstrated low cardiac and all-cause mortality rates (2.5% and 3.8%, respectively) and a high overall survival rate (93.7%) at 12-month follow-up. CONCLUSION: This study demonstrated the feasibility and positive outcomes of complete surgical revascularization in patients with UA and NSTE-ACS. It showed no graft occlusion or stroke, low complication rates and promising survival outcomes. Further research is needed for confirmation and to establish the procedure's efficacy and safety in this patient population.

Increased transferase ratio is associated with adverse cardio-cerebral events in patients with unstable angina: A retrospective cohort study.

To investigate the prognostic role of the elevated aspartate and alanine aminotransferase (AST/ALT) ratio in patients with unstable angina (UA). In this observational study, all patients with UA undergoing percutaneous coronary intervention at our center from January 2019 to December 2020 were examined. Clinical presentations, laboratory parameters, and procedural characteristics were collected. The primary endpoint was a composite of major adverse cardio-cerebral events (MACCE), such as death, nonfatal myocardial infarction, nonfatal stroke, and target vessel revascularization. In total, 1123 eligible UA patients were enrolled in the present study (mean age 62.3 years; 54.5% of male). Patients in the upper tertile of the AST/ALT ratio were older, had more extensive coronary stenosis, and had poor nutritional status (P < .05). Meanwhile, the cumulative incidence of MACCE at 13 months of follow-up increased in a stepwise manner and across the tertile of the AST/ALT ratio, predominantly driven by target vessel revascularization (both log-rank P < .001). Importantly, the AST/ALT ratio was associated with MACCE in a multivariate analysis that was adjusted for potential covariates (hazard ratio 1.72, 95% confidence interval 1.48-1.99, P < .01). The optimal cutoff point of the AST/ALT ratio to predict MACCE was 1.29 (area under the curve 0.77, 95% confidence interval 0.69-0.84, P < .001), with sensitivity and specificity of 77.5% and 65.1%, respectively. The increased AST/ALT ratio, especially when above 1.29, is associated with MACCE in patients with UA undergoing percutaneous coronary intervention.

Association between the diagnostic classification of newly diagnosed coronary artery disease and future heart failure development.

OBJECTIVE: The first clinical manifestation of coronary artery disease (CAD) varies widely from unheralded myocardial infarction (MI) to mild, incidentally detected disease. The primary objective of this study was to quantify the association between different initial CAD diagnostic classifications and future heart failure. METHODS: This retrospective study incorporated the electronic health record of a single integrated health care system. Newly diagnosed CAD was classified into a mutually exclusive hierarchy as MI, CAD with coronary artery bypass graft (CABG), CAD with percutaneous coronary intervention, CAD only, unstable angina, and stable angina. An acute CAD presentation was defined when the diagnosis was associated with a hospital admission. New heart failure was identified after the CAD diagnosis. RESULTS: Among 28 693 newly diagnosed CAD patients, initial presentation was acute in 47% and manifested as MI in 26%. Within 30 days of CAD diagnosis, MI [hazard ratio (HR) = 5.1; 95% confidence interval: 4.1-6.5] and unstable angina (3.2; 2.4-4.4) classifications were associated with the highest heart failure risk (compared to stable angina), as was acute presentation (2.9; 2.7-3.2). Among stable, heart failure-free CAD patients followed on average 7.4 years, initial MI (adjusted HR = 1.6; 1.4-1.7) and CAD with CABG (1.5; 1.2-1.8) were associated with higher long-term heart failure risk, but an initial acute presentation was not (1.0; 0.9-1.0). CONCLUSION: Nearly 50% of initial CAD diagnoses are associated with hospitalization, and these patients are at high risk of early heart failure. Among stable CAD patients, MI remained the diagnostic classification associated with the highest long-term heart failure risk, however, having an initial acute CAD presentation was not associated with long-term heart failure.

Comparison Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Unstable Angina with Preserved Left Ventricular Systolic Function.

The present study evaluated the clinical results of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) treatment in patients with unstable angina (UA) with preserved left ventricular systolic function who underwent percutaneous coronary intervention (PCI) due to uncertainty regarding the long-term prognosis using ACEI or ARB. A total of 1627 UA patients with preserved left ventricular systolic function after PCI were enrolled. After propensity score matching, there were no differences in major adverse cardiovascular and cerebrovascular events (MACCEs) (hazard ratio (HR) = .860, 95% confidence interval (CI): .465-1.590, P = .630), all-cause death (HR = .334, 95% CI: .090-1.238, P = .101), nonfatal myocardial infarction (HR = 4.929, 95% CI: .576-42.195, P = .145), stroke (HR = 1.049, 95% CI: .208-5.290, P = .954) and target vessel revascularization (TVR) (HR = 1.276, 95% CI: .537-3.031, P = .581) between the ACEI and ARB groups. In conclusion, prognoses were comparable between ACEI or ARB treatment in UA patients who had preserved left ventricular systolic function after PCI.

Accidental and Late Diagnosis of Type A Aortic Dissection: Mimicking Unstable Angina Pectoris.

Aortic dissection is an infrequent diagnosis that usually presents with acute onset of sharp and severe tearing pain. It rarely presents with atypical symptoms, accompanied by a higher mortality risk that arises the delay in diagnosis. In this report, we discuss a type A aortic dissection case with a presentation of heaviness-like chest pain with no evidence of aortic dissection in his first echocardiography. The patient was treated for acute coronary syndrome (ACS), but on the follow-up, echocardiography aortic dissection was diagnosed accidentally. Differentiation between ACS and aortic dissection is critical in patient management. Each one has an entirely different treatment approach, and misdiagnosis can lead to catastrophic outcomes.

Use of Thrombus Aspiration for Patients With Acute Coronary Syndrome: Insights From the Nationwide J-PCI Registry.

Background There is significant regional or institutional variation in the use of thrombus aspiration (TA) in patients undergoing percutaneous coronary intervention (PCI). We investigated the temporal trend in TA use and its association with clinical outcomes in acute coronary syndrome using the nationwide J-PCI (Japanese PCI) registry. Methods and Results Between 2016 and 2018, patients with acute coronary syndrome undergoing PCI (n=282 606; median age, 71.0 years; interquartile range, 62.0-79.0 years; women, 24.7%) at 1124 hospitals were stratified on the basis of whether TA was performed (TA and non-TA). The patients were subdivided according to clinical presentation (ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina). Successful PCI, defined as the achievement of TIMI (Thrombolysis in Myocardial Infarction) 3 flow, and in-hospital mortality were assessed. During the study period, 83 422 patients (29.5%) underwent TA (52.9%, 23.5%, and 5.2% for ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, respectively), and the TA implementation rate remained relatively stable throughout. Patients treated with TA had higher rate of successful PCI than non-TA (98.7% versus 97.8%; P<0.001). TA was not associated with in-hospital death among patients with ST-segment-elevation myocardial infarction (adjusted odds ratio [aOR], 1.02 [95% CI, 0.94-1.12]). However, TA use was associated with higher rates of in-hospital death in patients with non-ST-segment-elevation myocardial infarction ( aOR, 1.51 [95% CI, 1.23-1.86]) or unstable angina ( aOR, 1.95 [95% CI, 1.37-2.79]). Conclusions In our retrospective analysis of the nationwide PCI registry, TA use was associated with a higher achievement of successful PCI without impairing in-hospital mortality among patients with ST-segment-elevation myocardial infarction. Nevertheless, its use should be cautioned in less-established indications (eg, non-ST-segment-elevation myocardial infarction and unstable angina).

Differences in Revascularization Strategy and Outcomes by Clinical Presentations in Spontaneous Coronary Artery Dissection.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI). However, the role of revascularization for SCAD according to presentation remains unclear. METHODS: We analyzed patients with SCAD who presented acutely and were participating in the Canadian SCAD Cohort Study. We compared revascularization strategy and clinical outcomes (in-hospital major adverse events and major adverse cardiovascular event [MACE] including recurrent MI at 1-year) in patients with SCAD presenting with ST-elevation MI (STEMI) vs unstable angina or non-STEMI (UA-NSTEMI). RESULTS: Among 750 patients with SCAD (mean 51.7 ± 10.5years; 88.5% were women; median follow-up was 373 days), 234 (31.2%) presented with STEMI. More patients with SCAD-STEMI (27.8%) were treated with revascularization (98.5% percutaneous coronary intervention [PCI]) compared with 8.7% of patients with UA-NSTEMI (93.3% PCI). For patients with SCAD and STEMI, 93.9% were planned procedures vs 71.1% for UA-NSTEMI. Successful or partially successful PCI was 65.5% for STEMI and 76.9% for UA-NSTEMI (P < 0.001). In revascularized patients, 1-year MACE was not different between STEMI and UA-NSTEMI. Revascularization was associated with higher in-hospital major adverse events and its association was more prominent in UA-NSTEMI (STEMI: 26.2% vs 10.7%, P < 0.001; UA-NSTEMI: 37.8% vs 3.6%, P < 0.001). The difference in adverse events according to revascularization diminished over time and was not evident at 1 year. CONCLUSIONS: Despite higher in-hospital events with revascularization in patients with SCAD, and higher revascularization with SCAD-STEMI, 1-year MACE was not different compared with UA-NSTEMI. This is reassuring, as revascularization may be required for ongoing ischemia at the time of initial presentation in STEMI-SCAD, and emphasizes the need for careful patient selection for revascularization in UA-NSTEMI.

Effect of Cardiac Rehabilitation Therapy Combined with WeChat Platform Education on Patients with Unstable Angina Pectoris after PCI.

Objective: The aim of this study is to explore the effect of cardiac rehabilitation therapy combined with WeChat platform education on patients with unstable angina pectoris (UAP) after percutaneous coronary intervention (PCI). Methods: Eighty-eight UAP patients undergoing PCI in our hospital from June 2018 to June 2021 were chosen as the study subjects and were grouped according to the intervention methods. Specifically, patients receiving routine treatment only were included as the control group (CG) and those receiving cardiac rehabilitation therapy combined with WeChat platform education based on the routine treatment were included as the study group (SG), with 44 cases in each group. The clinical efficacy was compared between the two groups after intervention. Results: Compared with CG, SG achieved notably better biochemical indexes of TC, TG, FBG, FIB, LDL-c, and HDL-c after 12 months of intervention (P < 0.05), lower systolic pressure (SBP), and diastolic pressure (DBP) after intervention (P < 0.05), and higher scores of limited mobility, anginal stability, anginal frequency, subjective perception, treatment satisfaction, and total SAQ after 12 months of intervention (P < 0.05). The LVEF levels of both groups increased after intervention (P < 0.05), and the LVEF level was higher in SG than in CG (P < 0.05). The incidence of adverse cardiac events such as heart failure, ventricular arrhythmia, and sudden cardiac death was slightly higher in CG than in SG within 12 months of intervention, with no statistical difference (P > 0.05). The UAP recurrence rate and incidence of myocardial infarction in CG were obviously higher than those in SG (P < 0.05). Conclusion: Cardiac rehabilitation therapy combined with WeChat platform education intervention measures for UAP patients after PCI can effectively control the biochemical indexes such as blood lipid and blood glucose, improve the cardiac function, stabilize the disease condition, lower the recurrence rate, and reduce the incidence of other cardiac adverse events.

A novel use of small ballons to reduce the risk of subintimal hematoma formation during recanalization of chronic total occlusion: two case reports.

BACKGROUND: Subintimal hematoma remains a major challenge associated with unnecessary technical complexity, failure of the antegrade approach or imperfection of revascularization in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Some techniques and devices release the hematoma after its formation. Here, we describe a novel use of small ballons to prevent the hematoma formation during antegrade approach in two cases. CASE PRESENTATION: We report two cases of CTO-PCI in which balloon occlusion was successfully applied to prevent haematoma formation. The first case, a 72-year-old female with diabetes, was hospitalized because of unstable angina. Angiography showed right coronary artery (RCA) CTO, which initiated from the proximal part to the trifurcation at the distal part of the RCA. Considering the high likelihood and serious consequences of subintimal haematoma, a small balloon is employed to prevent subintimal hematoma formation. A balloon and microcatheter or double-lumen microcatheter are placed in the proximal coronary CTO lesion; then the balloon was dilated beside the catheter, most of the antegrade blood flow was sealed which reduced the likelihood of haematoma formation. The procedure was successfully completed without subintimal hematoma formation. The second case a 62-year-old male with unstable angina, was hospitalized for PCI. Angiography showed left anterior descending coronary artery CTO. Similar to case 1, we also used a small balloon to prevent hematoma formation. Both patients underwent PCI, which employed a small balloon to prevent hematoma formation and both procedures were successful without complications. CONCLUSION: In patients who underwent CTO-PCI, balloon occlusion offers an alternative for reducing the incidence of subintimal haematomas.

Unstable Angina Induced by Fracture of a Recently Implanted Drug-Eluting Stent.

Stent fracture is a rather infrequent complication associated with in-stent restenosis, thrombosis, aneurysm formation, and ischemic events. Several stent-related parameters, such as the use of longer or multiple stents, stent overlapping, and balloon/stent overexpansion are potential predictors of stent fracture. Stents deployed in right coronary artery lesions with exaggerated motion, tortuosity, or severe calcification are also generally considered to be at higher risk for fracture. This case demonstrates that intravascular ultrasound imaging is extremely useful to confirm the diagnosis and identify the possible mechanism of the stent fracture, as well as to assess the final result after subsequent angioplasty.

Impact of Race/Ethnicity on Long Term Outcomes After Percutaneous Coronary Intervention with Drug-Eluting Stents.

Cardiovascular disease constitutes the leading cause of mortality worldwide, irrespective of race/ethnicity. Previous studies have shown that minority patients with acute coronary syndrome have distinct clinical, anatomic, and socioeconomic characteristics which may affect clinical outcomes. We included patients who underwent percutaneous coronary intervention with drug-eluting stents for ST-segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina in a single center. Patients were stratified into Caucasian, African-American, Hispanic, and Asian. Caucasians were the reference group. The primary end point was major adverse cardiac and cerebrovascular events, composite of death, spontaneous myocardial infarction, or stroke at 1 year. Of 6,800 patients included, 49.7% were Caucasian, 20.7% Hispanic, 17.0% Asian and 12.6% African-American. Caucasians were the oldest, Hispanics and Asians had the highest prevalence of diabetes mellitus whereas African-Americans had more chronic kidney disease. Hispanics and African-Americans had the highest STEMI rates, whereas Asians were more likely to present with unstable angina. Compared with Caucasians, Asians had a lower rate of major adverse cardiac and cerebrovascular events at 1 year (3.9% vs 7.1%; p <0.01) whereas Hispanics (6.2% vs 7.1%; p = 0.17) and African-Americans (8.0% vs 7.1%; p = 0.38) had comparable outcomes. Differences were driven by mortality. Findings remained unchanged after adjustment. In conclusion, in acute coronary syndrome patients who underwent percutaneous coronary intervention, Asian race/ethnicity was associated with favorable cardiovascular outcomes compared with Caucasians. No significant differences were observed for Hispanics and African-Americans.

Investigation on Risk Stratification and the Prognostic Value of hs-TnT Combined with MMP-2 in Patients with Acute Coronary Syndrome.

OBJECTIVE: The aim of this study was at investigating the risk stratification and prognostic value of hypersensitive troponin T (hs-TnT) combined with matrix metalloproteinase 2 (MMP-2) in patients with acute coronary syndrome (ACS). METHODS: 80 patients with coronary syndrome admitted to our hospital from January 2019 to January 2020 and 40 healthy people (control group) in the same period were selected. According to different types of diseases, the patients were divided into an acute group (n = 40) and stable group (n = 40). Besides, they all were monitored by the hs-TnT value, serum MMP-2, and coronary angiography at admission and the comparative analysis was carried out. The patients in both groups were followed up for 30 days, and the incidence of adverse cardiovascular events in the patients during this period was recorded. RESULTS: Compared with those in the control group, the MMP-2 and hs-TnT levels in the acute group and the stable group were significantly higher and the MMP-2 and hs-TnT levels in the acute group were significantly higher than those in the stable group, with statistically significant differences (P < 0.05). The 30-day follow-up results showed that the incidence of adverse cardiovascular events in the acute group was significantly higher than that in the stable group, with statistically significant differences (P < 0.05). The hs-TnT and MMP-2 levels in the acute myocardial infarction (AMI) group were significantly higher than those in the unstable angina pectoris (UAP) group, with statistically significant differences (P < 0.01). The hs-TnT and MMP-2 levels in the non-single-vessel group were significantly higher than those in the single-vessel group, with statistically significant differences (P < 0.01). CONCLUSION: The hs-TnT and MMP-2 high expression levels are closely associated with myocardial injury, and they can effectively predict the severity of patients' disease. In addition, the hs-TnT and MMP-2 elevated levels can be considered as an important index to judge the short-term treatment efficacy and the risk stratification of early ACS, playing an important role in clinical treatment and rehabilitation in the later stage.

The Relationship between Serum and Gene Expression Levels of RANK, RANKL and Osteoprotegerin Inflammatory Pathway with Unstable Angina: A Case-control Study.

 Osteoprotegerin (OPG), receptor activator of nuclear factor-kappa B (RANK) and receptor activator of nuclear factor-kappa B ligand (RANKL), the members of the tumor necrosis factor (TNF) family, have multiple effects on bone metabolism, endocrine functions and, as an inflammatory pathway, in the immune system. This study tried to determine the association of the OPG/RANKL/RANK axis with the severity of unstable angina (UA) as an inflammatory condition. Our study involved 50 patients with UA and 50 healthy people. Serum and peripheral blood mononuclear cells were isolated from all participants. Serum levels and gene expression of OPG, RANKL, and RANK in mononuclear cells were measured by enzyme-linked immunosorbent assay (ELISA) and real-time polymerase chain reaction (RT-PCR), respectively. For each patient with UA, the thrombolysis in myocardial infarction (TIMI) and the global registry of acute coronary events (GRACE) scores were determined to evaluate the severity of the disease. Then we analyzed the relation of OPG, RANKL, and RANK levels with TIMI and GRACE scores in patients with UA. Discriminate analysis was used to predict the combinational models of such factors on the prediction of UA. Serum levels of OPG and RANKL (p<0.001) and gene expression of RANKL (p<0.001) were significantly more in patients than those in healthy ones. No relation was seen between the OPG/RANKL/RANK axis and the severity of UA according to TIMI and GRACE scores. Our study shows that serum level, as well as gene expression of OPG/RANKL/RANK axis neither, predicts the occurrence of UA nor shows any relationship with its severity.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

Epicardial adipose tissue volume predicts long term major adverse cardiovascular events in patients with Type 2 diabetes.

OBJECTIVE: Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot that plays an important role in coronary atherosclerosis. In this study, our aim was to investigate the relationship between long-term major adverse cardiovascular events (MACEs) and EAT volume detected by coronary computed tomography angiography (CCTA) in patients with Type 2 diabetes mellitus (T2-DM) without previous coronary events. METHODS: A total of 127 patients with diabetes who underwent CCTA between 2012 and 2014 were enrolled retrospectively. The study population was divided into 2 groups according to whether they experienced or did not experience MACE, which was defined as cardiac death, non-fatal myocardial infarction or unstable angina requiring hospitalization, coronary revascularizations (percutaneous coronary intervention or coronary artery bypass grafting surgery), heart failure, peripheral arterial disease, or ischemic stroke. In both groups, EAT volumes were measured by CCTA. RESULTS: During 60±7 months follow-up period, 22 participants experienced MACEs. Data were evaluated with univariate and multivariate analyses and receiver operating characteristic (ROC) analysis. Age, male sex, coronary artery disease, hemoglobin A1c, glucose, creatinine, C- reactive protein, and cholesterol levels were found to be associated with MACE. EAT volume (odds ratio [OR]: 1.027; 95% confidence interval [CI]: 1.010‒1.044, p=0.002) and low-density lipoprotein (OR: 1.015; 95% CI: 1.000‒1.030, p=0.050) were found to be independent predictors for MACE. ROC analysis indicated that EAT volumes >123.2 mL had a 72.7% sensitivity and a 77.1% specificity for predicting long-term MACE in patients with T2-DM (area under the curve: 0.820; 95% CI: 0.733-0.908). CONCLUSION: EAT volume is an independent predictor of long-term MACE in patients with T2-DM without previous coronary events. EAT volume may be used additionally in risk stratification for MACE besides the well-known vascular risk factors in patients with T2-DM.