Blocked Coronary Artery Due To Coronary Spasm Treated With Stent Insertion: A Sub-Optimal Result?

Myocardial infarction (MI) is an extremely common cause of chest pain. MI can be acute with ST elevation (STEMI) or non-STEMI (NSTEMI). Coronary artery spasm can be severe enough to cause occlusion of the coronary arteries particularly with an exaggerated response in regions of coronary atheroma and plaque ulceration. It is not uncommon for coronary spasm to be mistaken with acute thrombotic occlusion of the coronary artery. We describe a case of a 42-year old man with known cardiac risk factors presents with chest pain for few hours to a tertiary centre hospital. A coronary angiogram showed occlusion of the right epicardial coronary artery with a severe spasm at the level of the atheroma. The initial coronary stent which was deformed because of intense pressure of spasm required another stent to be placed within the first stent. Diltiazem and Nitrates were started as secondary prevention treatment to reduce effect of coronary spasm. The patient made an uneventful recovery and was discharged home with no sequelae over the next 3 years follow up.

Shone Complex: An Under-recognized Congenital Heart Disease With Substantial Morbidity in Adulthood.

BACKGROUND: Shone complex consists of a constellation of left-sided, usually obstructive, cardiac lesions, including supravalvar mitral ring, parachute mitral valve, subaortic stenosis, and aortic coarctation. Incomplete Shone complex consists of a mitral valve anomaly associated with lesions involving the subaortic region, aortic valve, or thoracic aorta. There is a paucity of data regarding long-term outcomes in adults with Shone complex. METHODS: We reviewed records of adults with complete or incomplete Shone complex followed at the Montreal Heart Institute between 1982 and 2014. RESULTS: Among 4189 adults with congenital heart disease, 28 (0.67%) patients (mean age, 35 ± 11 years; 50% women) had complete or incomplete Shone complex and were followed for a median of 8 years. Only 39% were previously diagnosed as having Shone complex. The most common defects were congenital mitral stenosis (93%), aortic coarctation (75%), and bicuspid aortic valve (71%). Heart transplantation was required in 2 patients (7.1%) at age 22 and 28 years, respectively. Overall, 48% had cardiovascular hospitalizations during adulthood, predominantly for arrhythmias or heart failure. Freedom from cardiovascular intervention was 55%, 18%, and 8% at 10, 20, and 30 years of age, respectively. Although aortic coarctation was the most common indication for initial intervention (61%), adult interventions occurred predominantly for aortic valve/left ventricular outflow tract (60%) and mitral valve (33%) lesions. CONCLUSIONS: Shone complex is an under-recognized entity associated with relatively low mortality in adulthood but substantial morbidity related to arrhythmias, heart failure, and interventions. Increased awareness of this condition and associated complications may allow for more tailored follow-up.

Spontaneous coronary artery dissection in men presenting with acute coronary syndrome, successfully managed by intravascular ultrasound-guided percutaneous coronary intervention.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. It is most commonly seen in young women, without atherosclerosis, in the peripartum period. Management options include conservative medical treatment, percutaneous coronary intervention or a surgical approach depending on the presentation, extent of dissection and luminal stenosis. We describe three unusual cases of spontaneous coronary artery dissection occurring in young/middle-aged men-the first in association with heavy mechanical work, the second in association with high levels of anxiety and emotional distress and the third in association with intense physical exercise. In each case we report the use of coronary angiography and intravascular ultrasound in the diagnosis of the condition, and their successful management using percutaneous coronary intervention.

Ranolazine (Ranexa) in the treatment of chronic stable angina.

Ischemic heart disease is the major cause of morbidity and mortality in the Western world. Patients often suffer a reduction in quality of life due to chronic stable angina, but therapeutic options can be limited due to concerns for heart rate and blood pressure, as well as side effect profiles. Even revascularization therapy has its limitations and newer agents are required to help in this battle for symptomatic relief. Ranolazine (Ranexa(R), A. Menarini Pharma UK, High Wycombe, UK) is a drug with a novel mechanism of action that has been shown in several large trials to be an efficacious adjunctive agent in reducing symptoms of chronic stable angina. It is thought to work by inhibiting the late sodium current in cardiac myocytes, thereby reducing sodium and calcium overload that follows ischemia. This improves myocardial relaxation and reduces left ventricular diastolic stiffness, which in turn enhances myocardial contractility and perfusion. The drug is generally well tolerated and the evidence so far is encouraging, with a clear clinical benefit achieved in the target groups. Its main strength is that it does not appear to affect either heart rate or blood pressure. This review provides an insight into this treatment option, describes the clinical trials evidence, proposed mechanism of action, and pharmacokinetics, and outlines the indications for its use in chronic stable angina.