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1.
Medicine (Baltimore) ; 98(50): e18173, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852073

RESUMO

RATIONALE: Coronary artery aneurysms (CAAs) are uncommon in patients with acute coronary syndrome (ACS). We describe the clinical features and outcomes of stent-assisted coil embolization of a CAA in the trigeminal position. PATIENT CONCERNS: We present a 73-year-old woman with a history of paroxysmal episodes of precordial pain since 1 year. Coronary computed tomography angiography (CTA) revealed an aneurysm (diameter: 9 mm) at the junction of the distal left main coronary artery and the anterior descending branch. Troponin I, CK-MB, creatinine and routine blood investigations were within the normal range. DIAGNOSIS: Coronary artery aneurysm in the left main trigeminal position. INTERVENTIONS: The patient was treated with stent-assisted coil embolization. OUTCOMES: After complete filling of the aneurysm with coil, the microcatheter was withdrawn and the stent released in the descending branch. Two stents were successfully implanted. LESSONS: There is no clear consensus on the optimal therapy for patients with CAAs. Clinicians should be aware of the possible complications of stent-assisted coil embolization of CAA in the main trunk of the coronary artery.


Assuntos
Implante de Prótese Vascular/métodos , Aneurisma Coronário/terapia , Estenose Coronária/cirurgia , Vasos Coronários/diagnóstico por imagem , Embolização Terapêutica/métodos , Stents , Idoso , Angiografia Digital , Aneurisma Coronário/complicações , Aneurisma Coronário/diagnóstico , Angiografia Coronária , Estenose Coronária/complicações , Estenose Coronária/diagnóstico , Vasos Coronários/cirurgia , Feminino , Humanos , Doenças Raras
2.
World J Pediatr Congenit Heart Surg ; 10(3): 351-354, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31084302

RESUMO

We describe our management of a 2-year-old patient with Kawasaki disease with a giant proximal right coronary artery (RCA) aneurysm and a >99% RCA ostial stenosis. After median sternotomy and cardioplegic arrest of the heart, we opened the aorta and cut into the RCA ostium past the stenosis and giant aneurysm. The RCA was reconstructed with an autologous pericardial patch. Cross-clamp and cardiopulmonary bypass times of 84 minutes and 114 minutes, respectively, were required. Our approach avoids mammary harvesting and grafting in such small patients while successfully treating ischemia and hopefully prevents further aneurysmal dilation over time.


Assuntos
Angioplastia/métodos , Aneurisma Coronário/cirurgia , Estenose Coronária/cirurgia , Vasos Coronários/cirurgia , Síndrome de Linfonodos Mucocutâneos/complicações , Pericárdio/transplante , Aneurisma Coronário/diagnóstico , Aneurisma Coronário/etiologia , Angiografia Coronária , Estenose Coronária/diagnóstico , Estenose Coronária/etiologia , Vasos Coronários/diagnóstico por imagem , Humanos , Imagem Tridimensional , Lactente , Masculino , Síndrome de Linfonodos Mucocutâneos/diagnóstico , Tomografia Computadorizada por Raios X , Transplante Autólogo
3.
Dtsch Arztebl Int ; 116(12): 205-211, 2019 03 22.
Artigo em Inglês | MEDLINE | ID: mdl-31056086

RESUMO

BACKGROUND: Approximately 800 000 coronary angiography procedures are per- formed in Germany each year, mainly in order to identify coronary artery stenoses. As a rule, revascularization is indicated only when coronary artery stenoses cause relevant ischemia, but this cannot be determined unequivocally by angiography alone. Pressure wire measurement and the measurement of fractional flow reserve (FFR) enable direct evaluation of the hemodynamic relevance of coronary artery stenoses during diagnostic coronary angiography. METHODS: This review is based on publications retrieved by a selective search in PubMed focusing especially on large randomized trials, registry studies, and meta- analyses on either pressure wire measurement or FFR. RESULTS: According to a registry study from France, the hemodynamic evaluation of a stenosis during coronary angiography affected decisions about revascularization in 43% of cases. Randomized multicenter trials have shown that a combined end- point consisting of death, myocardial infarction, or revascularization arose signifi- cantly less commonly in the FFR group than in the group receiving angiography without FFR (13.2% versus 18.3%; p = 0.02), and that patients with one or more hemodynamically significant coronary artery stenoses (FFR ≤ 0.80) benefited more from revascularization than from medical management alone (event rate, 8.1% versus 19.5%; p <0.001). It was also shown that revascularization yields no benefit if relevant ischemia has been ruled out, even if the angiogram shows high-grade coronary artery stenoses. CONCLUSION: All cardiac catheter laboratories should be capable of performing pres- sure wire measurements and measurements of FFR and should do so regularly if ischemia due to coronary artery stenosis cannot be demonstrated non-invasively. A pathological FFR measurement is an indication for revascularization.


Assuntos
Angiografia Coronária/métodos , Estenose Coronária/diagnóstico , Estenose Coronária/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Alemanha , Hemodinâmica/fisiologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Transdutores de Pressão
4.
Biomed Res Int ; 2019: 5828931, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31119175

RESUMO

Background: Fractional flow reserve (FFR), as a functional measurement of coronary stenosis, is recommended for guiding revascularization in intermediate coronary lesions. However, it still remains underutilized for potential reasons including time consumption, costs, or contraindications associated with adenosine administration. Here we performed this meta-analysis to assess the diagnostic performance of two adenosine-free indices, instantaneous wave free-ratio (iFR), and quantitative flow ratio (QFR) in evaluating coronary stenosis severity with FFR as the reference standard. Methods: PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to include relevant studies with the diagnostic accuracy of iFR or QFR referenced to FFR. A bivariate model was applied to pool diagnostic parameters. We used Cochran's Q test and I2 index to assess heterogeneity and identify the potential source of heterogeneity by meta-regression. Results: A total of 8213 lesions from 28 studies (19 for iFR and 9 for QFR) were included in this meta-analysis. The pooled sensitivity and specificity were 0.79 (95% CI, 0.75 to 0.83) and 0.85 (95% CI, 0.82 to 0.87) for iFR and 0.90 (95% CI, 0.84 to 0.93) and 0.88 (95% CI, 0.86 to 0.90) for QFR, respectively. Significantly higher sensitivity and specificity were observed in the bivariate analysis for QFR than for iFR (P < 0.001 for both). The area under summary receiver-operating curve of iFR and QFR was 0.89 (95% CI, 0.86 to 0.92) and 0.92 (95% CI, 0.89 to 0.94). Conclusion: Evidence suggests that both of the two indices have good performance in detecting functional ischemia of coronary arteries and QFR might be a promising method without requiring the pressure wire. Further application of QFR may potentially provide important information to clinicians in the assessment of coronary lesions.


Assuntos
Estenose Coronária/diagnóstico , Vasos Coronários/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico , Adenosina , Velocidade do Fluxo Sanguíneo/fisiologia , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Hemodinâmica , Humanos , Vasodilatadores/uso terapêutico
5.
Vasc Health Risk Manag ; 15: 57-67, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30936712

RESUMO

Background: Acute myocardial infarction (AMI) with no evidence of relevant stenosis of the coronary artery, known as myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA), has a prevalence of up to 14%. The various causes of MINOCA lead to damage of the myocardium, and there are marked differences in diagnoses, prognoses, and treatments. Although the number of patients affected is considerable owing to the high prevalence of acute coronary syndrome (ACS), the causes of MINOCA have received little attention with the result that some patients may not receive appropriate treatment. Awareness of this disease among clinicians has started only to improve since the beginning of the current century. The aim of this study was to develop a score that enables patients with MINOCA to be distinguished from patients with MI with coronary artery disease (MI-CAD) and thus to facilitate appropriate diagnosis and therapy. Patients and methods: A multicenter observational cohort study was designed. All patients aged ≥18 years from the ARIAM-SEMICYUC (Analysis of Delay in AMI-Spanish Society of Intensive Care Medicine and Coronary Unit) registry, diagnosed with AMI, and admitted to critical care units or coronary care units (CCUs) were included. Patients were classified into two groups: MINOCA, comprising patients with no significant lesions on angiography, and MI-CAD, comprising patients with lesions of the coronary artery tree. Results: A score based on standard variables to assess the probability of MINOCA on admission was designed, showing a maximum value corresponding to a 40% probability of MINOCA. The discriminative power of the model was 0.756 (P-value for the Hosmer-Lemeshow test was >0.05). At 30-day follow-up, the mortality rate was higher for MI-CAD patients. Conclusion: Patients with MINOCA constitute a population that differs from other patients with AMI. Their differential characteristics require a certain diagnostic effort to align therapy with the disease causing the ischemic event. This score could prove useful in establishing additional diagnostic procedures.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Estenose Coronária/diagnóstico , Técnicas de Apoio para a Decisão , Infarto do Miocárdio/diagnóstico , Fatores Etários , Idoso , Biomarcadores/sangue , Angiografia Coronária , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Estenose Coronária/sangue , Estenose Coronária/epidemiologia , Estenose Coronária/terapia , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Valor Preditivo dos Testes , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Espanha/epidemiologia , Troponina/sangue , Regulação para Cima
6.
Chin Med J (Engl) ; 132(8): 905-913, 2019 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-30958431

RESUMO

BACKGROUND: Asymptomatic coronary artery stenosis (ACAS) ≥50% is common in patients with acute ischemic cerebrovascular disease (AICVD), which portends a poor cardiovascular and cerebrovascular prognosis. Identifying ACAS ≥50% early may optimize the clinical management and improve the outcomes of these high-risk AICVD patients. This study aimed to investigate whether aortic arch plaque (AAP), an early atherosclerotic manifestation of brain blood-supplying arteries, could be a predictor for ACAS ≥50% in AICVD. METHODS: In this cross-sectional study, atherosclerosis of the coronary and brain blood-supplying arteries was simultaneously evaluated using one-step computed tomography angiography (CTA) in AICVD patients without coronary artery disease history. The patients were divided into ACAS ≥50% and non-ACAS ≥50% groups according to whether CTA showed stenosis ≥50% in at least one coronary arterial segment. The AAP characteristics of CTA were depicted from aspects of thickness, extent, and complexity. RESULTS: Among 118 analyzed patients with AICVD, 29/118 (24.6%) patients had ACAS ≥50%, while AAPs were observed in 86/118 (72.9%) patients. Increased AAP thickness per millimeter (adjusted odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.18-2.05), severe-extent AAP (adjusted OR: 13.66, 95% CI: 2.33-80.15), and presence of complex AAP (adjusted OR: 7.27, 95% CI: 2.30-23.03) were associated with ACAS ≥50% among patients with AICVD, independently of clinical demographics and cervicocephalic atherosclerotic stenosis. The combination of AAP thickness, extent, and complexity predicted ACAS ≥50% with an area under the receiver-operating characteristic curve of 0.78 (95% CI: 0.70-0.85, P < 0.001). All three AAP characteristics provided additional predictive power beyond cervical and intracranial atherosclerotic stenosis for ACAS ≥50% in AICVD (all P < 0.05). CONCLUSIONS: Thicker, severe-extent, and complex AAP were significant markers of the concomitant ACAS ≥50% in AICVD, possibly superior to the indicative value of cervical and intracranial atherosclerotic stenosis. As an integral part of atherosclerosis of brain blood-supplying arteries, AAP should not be overlooked in predicting ACAS ≥50% for patients with AICVD.


Assuntos
Aorta Torácica/patologia , Transtornos Cerebrovasculares/diagnóstico , Estenose Coronária/diagnóstico , Placa Aterosclerótica/diagnóstico , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de Risco
7.
Indian Heart J ; 71(1): 74-79, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31000187

RESUMO

OBJECTIVE: Fractional flow reserve (FFR) using adenosine has been the gold standard in the functional assessment of intermediate coronary stenoses in the catheterization laboratory. We aim to study the correlation of adenosine-free indices such as whole cycle Pd/Pa [the ratio of mean distal coronary pressure (Pd) to the mean pressure observed in the aorta (Pa)], instantaneous wave-free ratio (iFR), and contrast-induced submaximal hyperemia (cFFR) with FFR. METHODS: This multicenter, prospective, observational study included patients with stable angina or acute coronary syndrome (>48 h since onset) with discrete intermediate coronary lesions (40-70% diameter stenosis). All patients underwent assessment of whole cycle Pd/Pa, iFR, cFFR, and FFR. We then evaluated the correlation of these indices with FFR and assessed the diagnostic efficiencies of them against FFR ≤0.80. RESULTS: Of the 103 patients from three different centers, 83 lesions were included for analysis. The correlation coefficient (r value) of whole cycle Pd/Pa, iFR, and cFFR in relation to FFR were +0.84, +0.77, and +0.70 (all p values < 0.001), respectively, and the c-statistic against FFR ≤0.80 were 0.92 (0.86-0.98), 0.89(0.81-0.97), and 0.91 (0.85-0.97) (all p values < 0.001), respectively. The best cut-off values identified by receiver-operator characteristic curve for whole cycle Pd/Pa, iFR, and cFFR were 0.94, 0.90, and 0.88, respectively, for an FFR ≤0.80. By the concept of "adenosine-free zone" (iFR = 0.86-0.93), 59% lesions in this study would not require adenosine. CONCLUSION: All the three adenosine-free indices had good correlation with FFR. There is no difference in the diagnostic accuracies among the indices in functional evaluation of discrete intermediate coronary stenoses. However, further validation is needed before adoption of adenosine-free pressure parameters into clinical practice.


Assuntos
Adenosina/administração & dosagem , Cateterismo Cardíaco/métodos , Estenose Coronária/fisiopatologia , Vasos Coronários/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Hiperemia/induzido quimicamente , Angiografia Coronária , Estenose Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/efeitos dos fármacos , Feminino , Humanos , Hiperemia/fisiopatologia , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Vasodilatadores/administração & dosagem
8.
Eur Radiol ; 29(7): 3647-3657, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30903334

RESUMO

OBJECTIVES: The present study aimed to compare the diagnostic performance of a machine learning (ML)-based FFRCT algorithm, quantified subtended myocardial volume, and high-risk plaque features for predicting if a coronary stenosis is hemodynamically significant, with reference to FFRICA. METHODS: Patients who underwent both CCTA and FFRICA measurement within 2 weeks were retrospectively included. ML-based FFRCT, volume of subtended myocardium (Vsub), percentage of subtended myocardium volume versus total myocardium volume (Vratio), high-risk plaque features, minimal lumen diameter (MLD), and minimal lumen area (MLA) along with other parameters were recorded. Lesions with FFRICA ≤ 0.8 were considered to be functionally significant. RESULTS: One hundred eighty patients with 208 lesions were included. The lesion length (LL), diameter stenosis, area stenosis, plaque burden, Vsub, Vratio, Vratio/MLD, Vratio/MLA, and LL/MLD4 were all significantly longer or larger in the group of FFRICA ≤ 0.8 while smaller minimal lumen area, MLD, and FFRCT value were noted. The AUC of FFRCT + Vratio/MLD was significantly better than that of FFRCT alone (0.935 versus 0.873, p < 0.001). High-risk plaque features failed to show difference between functionally significant and insignificant groups. Vratio/MLD-complemented ML-based FFRCT for "gray zone" lesions with FFRCT value ranged from 0.7 to 0.8 and the combined use of these two parameters yielded the best diagnostic performance (86.5%, 180/208). CONCLUSIONS: ML-based FFRCT simulation and Vratio/MLD both provide incremental value over CCTA-derived diameter stenosis and high-risk plaque features for predicting hemodynamically significant lesions. Vratio/MLD is more accurate than ML-based FFRCT for lesions with simulated FFRCT value from 0.7 to 0.8. KEY POINTS: • Machine learning-based FFR CT and subtended myocardium volume both performed well for predicting hemodynamically significant coronary stenosis. • Subtended myocardium volume was more accurate than machine learning-based FFR CT for "gray zone" lesions with simulated FFR value from 0.7 to 0.8. • CT-derived high-risk plaque features failed to correctly identify hemodynamically significant stenosis.


Assuntos
Estenose Coronária/diagnóstico , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Aprendizado de Máquina , Isquemia Miocárdica/diagnóstico , Placa Aterosclerótica/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Angiografia Coronária/métodos , Estenose Coronária/complicações , Estenose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/complicações , Isquemia Miocárdica/fisiopatologia , Placa Aterosclerótica/complicações , Placa Aterosclerótica/fisiopatologia , Estudos Retrospectivos
9.
Angiology ; 70(7): 613-620, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30813747

RESUMO

Endothelial dysfunction is common in patients with type 2 diabetes mellitus (T2DM) and is associated with atherosclerotic disease. This study aimed to determine prognostic factors for endothelial dysfunction and identify relationships between reactive hyperemia index (RHI) score, clinically relevant coronary artery disease (>50% stenosis), and major adverse cardiovascular events (MACEs) in patients with T2DM. Endothelial function was assessed using peripheral arterial tonometry and correlated with patient characteristics and cardiovascular outcomes during a median follow-up of 22.8 months. Among 235 patients with a median duration of T2DM of 13 years, mean (standard deviation) RHI score was 2.00 (0.76). Serum low- and high-density lipoprotein cholesterol levels positively (P = .004) and negatively (P = .02) predicted RHI score, respectively. Median coronary artery calcium (CAC) score was 109 Agatston units, but no correlation between CAC and RHI scores was observed. The RHI score did not predict the number or severity of coronary plaques identified using computed tomography coronary angiography. Additionally, there was no association between RHI score and the risk of an MACE during follow-up. Overall, endothelial function was not predictive of CAC score, extent, and severity of coronary plaque or MACEs and did not demonstrate utility in cardiovascular risk stratifying patients with T2DM.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Estenose Coronária/diagnóstico , Diabetes Mellitus Tipo 2/complicações , Angiopatias Diabéticas/diagnóstico , Endotélio Vascular/fisiopatologia , Dedos/irrigação sanguínea , Manometria/métodos , Idoso , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/fisiopatologia , Estenose Coronária/etiologia , Estenose Coronária/fisiopatologia , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/fisiopatologia , Angiopatias Diabéticas/etiologia , Angiopatias Diabéticas/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença
11.
Am J Case Rep ; 20: 159-162, 2019 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-30723187

RESUMO

BACKGROUND Spontaneous coronary artery dissection (SCAD) is primarily found in females. SCAD can have many precipitating factors such as exercise, trauma, pregnancy, drugs, and connective tissue disease. Prognosis is poor for left main stem, left anterior descending (LAD) artery, and multivessel involvement, especially for females. CASE REPORT We present a case of young African American male with sickle cell disease who presented with chest pain associated with shortness of breath. He was found to have non-ST elevation myocardial infarction (NSTEMI). He was diagnosed with SCAD during catheterization with the help of intravascular ultrasound imaging. Three drug-eluting stents were placed to cover the proximal LAD vessel along its whole length until resolution of the lesion. The patients' hospital course was complicated by an additional finding of left ventricular thrombus, possibly a complication of NSTEMI, which was treated with anticoagulation to complete resolution. CONCLUSIONS SCAD is fatal, it can proceed to cause myocardial infarction as in this particular patient's case, and sudden death if not recognized early. It can be missed on angiography alone; further intracoronary imaging such as intravascular ultrasound and optical computed tomography should be used to confirm the diagnosis of SCAD so that early and appropriate treatment can ensue.


Assuntos
Anomalias dos Vasos Coronários/diagnóstico , Doenças Vasculares/congênito , Adulto , Anemia Falciforme , Cateterismo Cardíaco , Dor no Peito/etiologia , Angiografia Coronária , Estenose Coronária/diagnóstico , Diagnóstico Diferencial , Dispneia/etiologia , Humanos , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Ultrassonografia de Intervenção , Doenças Vasculares/diagnóstico
12.
Clin Imaging ; 54: 148-152, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30654226

RESUMO

We report the case of a 49-year-old man with a history of diabetes and hypertension who presented to the emergency room with intermittent chest pain radiating to the back for one day. An electrocardiogram-gated CT aortogram excluded the emergency department's primary consideration of aortic dissection, but incidentally revealed a myocardial perfusion defect and corresponding coronary artery stenosis. Cardiac catheterization performed the following day confirmed the CT findings and the patient underwent angioplasty and stent placement. We show that despite a different protocol than coronary CTA or myocardial perfusion CT, a gated CTA for dissection (CT aortogram) is capable of detecting resting perfusion abnormalities in patients presenting to the emergency room with chest pain.


Assuntos
Aneurisma Dissecante/diagnóstico , Aneurisma da Aorta Torácica/diagnóstico , Aortografia/métodos , Estenose Coronária/complicações , Eletrocardiografia , Isquemia Miocárdica/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Aneurisma Dissecante/complicações , Aneurisma da Aorta Torácica/complicações , Angiografia Coronária , Estenose Coronária/diagnóstico , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/etiologia
13.
14.
Am J Case Rep ; 20: 117-120, 2019 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-30686820

RESUMO

BACKGROUND Acute chest pain is a common presentation in emergency departments worldwide. Ruling out acute coronary syndrome is essential in ensuring patient safety. Workup includes electrocardiogram (ECG) and cardiac biomarkers. Wellens syndrome is characterized by a history of chest pain, normal or minimally elevated biomarkers, no STEMI/Q-waves, and specific ECG changes. These changes consist of biphasic T waves in lead V2 and V3 or deep symmetrically inverted T waves in leads V1-V4. CASE REPORT A 55-year-old male presented to the emergency department with acute chest pain in a background of active smoking, hypertension, and hyperlipidemia. His ECG was characteristic of Wellens syndrome type 1 and negative cardiac biomarkers. His TIMI (thrombolysis in myocardial infarction) score was 2, however, he failed conservative management necessitating urgent coronary angiogram. Critical stenosis of the proximal left anterior descending (LAD) coronary artery was found which required 2 drug eluting stents. He was discharged home asymptomatic on optimal medical therapy. CONCLUSIONS Conventional management of patients with NSTEMI (non-ST-elevation myocardial infarction) and unstable angina with risk stratification utilizing TIMI score may not be appropriate in patient with Wellens syndrome. This highlights the importance of ECG recognition and urgent percutaneous intervention in patients with Wellens syndrome. Failure to identify this clinical syndrome could result in significant morbidity and mortality because it relates to critical stenosis and imminent large myocardial infarction.


Assuntos
Dor no Peito/etiologia , Estenose Coronária/diagnóstico , Eletrocardiografia , Estenose Coronária/complicações , Estenose Coronária/terapia , Humanos , Hiperlipidemias/complicações , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Fumantes , Síndrome
15.
Cardiovasc Interv Ther ; 34(3): 269-274, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30460666

RESUMO

The aim of this study was to examine the clinical value of iFR for AS patients. Functional evaluation of coronary stenosis in patients with aortic valve stenosis (AS) is challenging because the stress-induced test is often thought to be a contraindication. AS patients have a unique coronary flow pattern dependent on the diastolic phase. The instantaneous wave-free ratio (iFR) is a vasodilator-free, invasive pressure wire index of the functional severity of coronary stenosis and is calculated under resting conditions. And iFR calculated during a specific period of diastole may have the potential benefit to assess the functional severity of coronary stenosis in AS patients. We examined 158 consecutive patients (217 stenoses) whose iFR and fractional flow reserve (FFR) were measured simultaneously. Among the 158 patients, AS was observed in 13 (8.2%). The iFR showed good correlation with FFR in AS patients. The best cut-off value of iFR for the receiver-operator curve analysis to predict FFR of 0.8 was 0.9 for non-AS patients. However, it was 0.73 for AS patients. The present study demonstrated good correlation between iFR and FFR for AS patients. Vasodilator-free assessment using iFR may provide potential benefits when evaluating coronary stenosis in patients with AS. In AS patients, the best cut-off of iFR value predicting FFR value of 0.8 was lower than 0.9 that is the standard predictive value of iFR.


Assuntos
Estenose da Valva Aórtica/diagnóstico , Estenose Coronária/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Idoso , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/fisiopatologia , Cateterismo Cardíaco , Angiografia Coronária , Estenose Coronária/complicações , Estenose Coronária/diagnóstico , Feminino , Humanos , Masculino , Curva ROC , Índice de Gravidade de Doença
16.
Ann Thorac Surg ; 107(3): 740-746, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30395856

RESUMO

BACKGROUND: Internal thoracic artery (ITA) grafts are the most durable conduits available for coronary artery bypass grafting (CABG). However, little is known about long-term angiographic outcomes of ITA grafts used in different configurations and whether sequential or Y grafting compromises patency of the inflow ITA graft. METHODS: From January 1972 to August 2016, 60,500 patients underwent primary isolated CABG, of whom 326 received ITA grafts placed in sequential or Y configuration and were studied angiographically (median 4.8 years to first follow-up angiogram). Each sequential or Y segment was studied individually using a mixed-effects longitudinal model with the patient as the random effect. RESULTS: At 15 years, patency of the proximal ITA segment (n = 331) was 99%; of a sequential segment (n = 222), 97%; and of the segment beyond anastomosis of a Y graft (n = 109), 99%. Patency of the Y grafts (n = 109) was 92% at 5 years, 91% at 10 years, and 90% at 15 years. After adjusting for proximal stenosis and graft location, Y grafts were associated with greater occlusion than the inflow segment of ITA grafts (odds ratio; 51, 95% confidence interval, 6.1 to 422; p = 0.003) and of sequential grafts (odds ratio, 12; 95% confidence interval, 1.14 to 120; p = 0.04). CONCLUSIONS: Long-term patency of ITA grafts in sequential or Y configuration is similar qualitatively, but not quantitatively, to the known patency of single ITA-to-left anterior descending grafts. Sequential or Y grafting does not compromise patency of the inflow portion of an ITA graft. Y-graft patency is lower than sequential graft patency but is still better than known patency of saphenous vein grafts.


Assuntos
Estenose Coronária/cirurgia , Previsões , Anastomose de Artéria Torácica Interna-Coronária/métodos , Artéria Torácica Interna/transplante , Grau de Desobstrução Vascular/fisiologia , Angiografia Coronária , Estenose Coronária/diagnóstico , Estenose Coronária/fisiopatologia , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Artéria Torácica Interna/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos
18.
Eur Radiol ; 29(5): 2378-2387, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30523456

RESUMO

OBJECTIVES: We sought to investigate the diagnostic performance of coronary CT angiography (cCTA)-derived plaque markers combined with deep machine learning-based fractional flow reserve (CT-FFR) to identify lesion-specific ischemia using invasive FFR as the reference standard. METHODS: Eighty-four patients (61 ± 10 years, 65% male) who had undergone cCTA followed by invasive FFR were included in this single-center retrospective, IRB-approved, HIPAA-compliant study. Various plaque markers were derived from cCTA using a semi-automatic software prototype and deep machine learning-based CT-FFR. The discriminatory value of plaque markers and CT-FFR to identify lesion-specific ischemia on a per-vessel basis was evaluated using invasive FFR as the reference standard. RESULTS: One hundred three lesion-containing vessels were investigated. 32/103 lesions were hemodynamically significant by invasive FFR. In a multivariate analysis (adjusted for Framingham risk score), the following markers showed predictive value for lesion-specific ischemia (odds ratio [OR]): lesion length (OR 1.15, p = 0.037), non-calcified plaque volume (OR 1.02, p = 0.007), napkin-ring sign (OR 5.97, p = 0.014), and CT-FFR (OR 0.81, p < 0.0001). A receiver operating characteristics analysis showed the benefit of identifying plaque markers over cCTA stenosis grading alone, with AUCs increasing from 0.61 with ≥ 50% stenosis to 0.83 with addition of plaque markers to detect lesion-specific ischemia. Further incremental benefit was realized with the addition of CT-FFR (AUC 0.93). CONCLUSION: Coronary CTA-derived plaque markers portend predictive value to identify lesion-specific ischemia when compared to cCTA stenosis grading alone. The addition of CT-FFR to plaque markers shows incremental discriminatory power. KEY POINTS: • Coronary CT angiography (cCTA)-derived quantitative plaque markers of atherosclerosis portend high discriminatory power to identify lesion-specific ischemia. • Coronary CT angiography-derived fractional flow reserve (CT-FFR) shows superior diagnostic performance over cCTA alone in detecting lesion-specific ischemia. • A combination of plaque markers with CT-FFR provides incremental discriminatory value for detecting flow-limiting stenosis.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico , Diagnóstico por Computador/métodos , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Aprendizado de Máquina , Placa Aterosclerótica/diagnóstico , Estenose Coronária/etiologia , Estenose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/complicações , Placa Aterosclerótica/fisiopatologia , Curva ROC , Estudos Retrospectivos
19.
Heart ; 105(7): 524-530, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30269079

RESUMO

OBJECTIVE: The medium-term outcome and cause of death in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not well characterised. The aim of this study was to compare mortality and rates of recurrent events in post myocardial infarction (MI) patients with obstructive coronary artery disease (CAD) and in patients with MINOCA compared with an age and sex-matched cohort without cardiovascular disease (CVD). METHODS: We performed a national cohort study of consecutive patients undergoing coronary angiography for MI during 2 years between 2013 and 2015 from the All New Zealand Acute Coronary Syndrome-Quality Improvement (ANZACS QI) registry. MI patient registry data were linked anonymously to national hospitalisation and mortality records. Age and sex matched patients without known CVD formed the comparison group. RESULTS: Of the 8305 patients with MI, 897 (10.8%) were classified as MINOCA. Compared with those without known CVD, the adjusted HRs for the primary outcome (all-cause death or recurrent non-fatal MI) were 7.81 (95% CI 6.64 to 9.19, p<0.0001) in those with obstructive CAD and 4.64 (95% CI 3.54 to 6.10, p<0.0001) in those with MINOCA. Kaplan-Meier all-cause mortality at 2 years was 7.9% for those with obstructive CAD, with nearly half being CVD deaths (3.6% CVD deaths and 4.5% non-CVD deaths, respectively). In contrast, MINOCA all-cause mortality was 4.9% with non-CVD death (4.5%) predominating. CONCLUSIONS: MINOCA is common and has an adverse outcome rate approximately half than that of those with obstructive CAD. The predominant contributor to mortality is non-CVD death. The rate of events in MINOCA is significantly greater than the population without CVD.


Assuntos
Síndrome Coronariana Aguda , Estenose Coronária , Vasos Coronários , Infarto do Miocárdio/epidemiologia , Síndrome Coronariana Aguda/etiologia , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Estudos de Coortes , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico , Estenose Coronária/patologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Nova Zelândia/epidemiologia , Sistema de Registros/estatística & dados numéricos , Fatores de Risco
20.
Eur Radiol ; 29(5): 2369-2377, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30552479

RESUMO

OBJECTIVES: To investigate the prognostic role of early post-infarction cardiac magnetic resonance (CMR) on long-term risk stratification of ST segment elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF). METHODS: Seventy-seven STEMI patients treated by primary percutaneous coronary intervention (PCI) and LVEF > 50% at CMR were included. The median time between STEMI and CMR was 5 days (IQR 2-8). LV volumes and function, area at risk (on T2 weighted images), infarcted myocardium (on late enhanced images), intramyocardial hemorrhage, and early and late microvascular obstruction (MVO) were detected and measured. CMR tissue determinants were correlated with the incidence of major adverse cardiovascular events (MACEs) over a 5-year follow-up. RESULTS: During median follow-up of 4 years (range 3 to 5 years), eight (10%) patients experienced MACE, yielding an annualized event rate of 2.1%. All CMR tissue markers were not significantly different between MACE and no-MACE patients, except for the presence of late MVO (50% vs. 16%, respectively; p = 0.044) and its extent (2.30 ± 1.64 g vs. 0.18 ± 0.12 g, respectively; p = 0.000). From receiver-operating characteristic (ROC) curve (area under the curve 0.89; 95% confidence interval, 0.75-1.0; p = 0.000), late MVO extent > 0.385 g was a strong independent predictor of MACE at long-term follow-up (sensitivity = 87%, specificity = 90%; hazard ratio = 2.24; 95% confidence interval, 1.51-3.33; p = 0.000). CONCLUSIONS: Late MVO extent after primary PCI on CMR seems to be a strong predictor of MACE at 5-year follow-up in patients with LVEF > 50%. Noticeably, late MVO extent > 0.385 g provided relevant prognostic insights leading to improved long-term risk stratification. KEY POINTS: • Tissue markers provided by cardiac magnetic resonance aid in prognostic stratification after myocardial infarction • The occurrence of late microvascular obstruction after acute myocardial infarction increases risk of major adverse events at 5-year follow-up. • The greater microvascular obstruction extent on late gadolinium enhanced images is related to an increased risk of adverse events in patients with myocardial infarction and preserved left ventricular function.


Assuntos
Circulação Coronária/fisiologia , Estenose Coronária/diagnóstico , Microcirculação/fisiologia , Complicações Pós-Operatórias , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Estenose Coronária/epidemiologia , Estenose Coronária/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Progressão da Doença , Feminino , Seguimentos , Humanos , Incidência , Itália/epidemiologia , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Prognóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Taxa de Sobrevida/tendências , Fatores de Tempo
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