The Role of Cardiac Magnetic Resonance in Myocardial Infarction and Non-obstructive Coronary Arteries

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) accounts for 5–15% of all presentations of acute myocardial infarction. The absence of obstructive coronary disease may present a diagnostic dilemma and identifying the underlying etiology ensures appropriate management improving clinical outcomes. Cardiac magnetic resonance (CMR) imaging is a valuable, non-invasive diagnostic tool that can aide clinicians to build a differential diagnosis in patients with MINOCA, as well as identifying non-ischemic etiologies of myocardial injury (acute myocarditis, Takotsubo Syndrome, and other conditions). The role of CMR in suspected MINOCA is increasingly recognized as emphasized in both European and American clinical guidelines. In this paper we review the indications for CMR, the clinical value in the differential diagnosis of patients with suspected MINOCA, as well as its current limitations and future perspectives.

MYOCARDIAL INFARCTION WITHOUT OBSTRUCTIVE CORONARY DISEASE: ROLE OF IMAGES

This manuscript about myocardial infarction with nonobstructive coronary arteries (MINOCA) based on published studies aims to enhance the awareness of primary health workers about this potentially serious condition that often poses diagnostic challenges. Two Brazilian, one Chilean, and one Turkish studies are commented on, and the role of imaging evaluations to establish the diagnosis is emphasized.

Characteristics and Outcomes of MI with Non-obstructive Coronary Arteries in a South-east Asian Cohort

Background: MI with non-obstructive coronary arteries (MINOCA) is caused by a heterogenous group of conditions with clinically significant sequelae. Aim: This study aimed to compare the clinical characteristics and prognosis of MINOCA with MI with obstructive coronary artery disease (MICAD). Methods: Data on patients with a first presentation of MI between 2011 and 2014 were extracted from the Singapore Cardiac Longitudinal Outcomes Database and patients were classified as having either MINOCA or MICAD. The primary outcomes were all-cause mortality (ACM) and major adverse cardiac events (MACE), defined as a composite of ACM, recurrent MI, heart failure hospitalisation and stroke. Results: Of the 4,124 patients who were included in this study, 159 (3.9%) were diagnosed with MINOCA. They were more likely to be women, present with a non-ST-elevation MI, have a higher left ventricular ejection fraction and less likely to have diabetes, previous stroke or smoking history. Over a mean follow-up duration of 4.5 years, MINOCA patients had a lower incidence of ACM (10.1% versus 16.5%) and MACE (20.8% versus 35.5%) compared with MICAD. On multivariable analysis, patients with MINOCA had a lower risk of ACM (HR 0.42; 95% CI [0.21–0.82]) and MACE (HR 0.42; 95% CI [0.26–0.69]). Within the MINOCA group, older age, higher creatinine, a ST-elevation MI presentation, and the absence of antiplatelet use predicted ACM and MACE. Conclusion: While patients with MINOCA had better clinical outcomes compared with MICAD patients, MINOCA is not a benign entity, with one in five patients experiencing an adverse cardiovascular event in the long term.

Risk Factors for Coronary Artery Disease in Patients Undergoing Coronary Angiogram at a Tertiary Level Hospital in Nepal

Background: Ischemic heart disease is the leading cause of CVD health loss globally, as well as in each world region, followed by stroke. In Nepal, CVD was found to be the second most common non-communicable disease among indoor patients of the non-specialist hospital. Age, gender, smoking, obesity, dyslipidemia, physical inactivity, hypertension, and diabetes mellitus (DM) are established risk factors for CVD. In Nepal, hypertension is found to be the most prevalent risk factor for CVD. Aims and Objectives: This study aimed to assess risk factors for coronary artery disease in patients undergoing coronary angiograms in Nepal. This study also investigated the socio-demographic characteristics of the participants and the nature of the involvement of coronary arteries. Materials and Methods: We examined in this cross-sectional study a total of 74 patients who underwent coronary angiography (CAG) at National Medical College between May 2020 and June 2021. Patients were grouped according to the number of major epicardial coronary arteries involved in SVD, DVD, and TVD. Patients were checked for risk factors like smoking, diabetes mellitus, hypertension, dyslipidemia, family history of coronary artery disease, and obesity. Microsoft Office Excel and SPSS version 21.0 were used for data analysis. The study was approved by the ethical committee. Results: Among 74 participants 53 were male. The mean age was 59.65±10.74 years. Premature coronary artery disease was present in six patients. SVD was the commonest CAD type. Hypertension was the commonest risk factor followed by Diabetes mellitus. Hypertension, Diabetes mellitus, Family history of premature CAD, and obesity were found to be statistically significant. Keywords: CAD, Risk factors for CAD, Premature CAD, Hypertension, Diabetes, obesity, family history of CAD, dyslipidemia, Smoking, SVD, DVD, TVD, Nepal

A Single Coronary Artery Originating from the Right Coronary Sinus with a Typical Course of the Right Coronary Artery and the Interarterial Course of the Left Main, Left Anterior Descending, and Left Circumflex as an Example of a Rare Case of High-Risk Coronary Anomaly

In the typical course of the coronary arteries, the right coronary artery comes from the right coronary sinus and descends in the right atrioventricular groove. The left coronary artery trunk begins from the left coronary sinus. It crosses the pulmonary trunk and divides into left anterior descending and left circumflex arteries. Anatomical differences of the coronary arteries can be observed in 0.3–5.6% of the population. The interarterial course of coronary branches between the aorta and the pulmonary trunk is a malignant anomaly of the coronary arteries. Such abnormalities have been associated with an increased risk of sudden cardiac death. We present a rare case of coronary arteries anomaly involving the presence of a single right coronary artery and the interarterial course of its atypical branches documented by computed tomography angiography (CTA). In summary, the accurate assessment of the anatomical topography of coronary anomalies, possible in CTA, is necessary in the analysis of the risk of sudden cardiac death and its prevention.

Extension of Endocardium-Derived Vessels Generate Coronary Arteries in Neonates

Background: Unraveling how new coronary arteries develop may provide critical information for establishing novel therapeutic approaches to treating ischemic cardiac diseases. There are two distinct coronary vascular populations derived from different origins in the developing heart. Understanding the formation of coronary arteries may provide insights into new ways of promoting coronary artery formation after myocardial infarction. Methods: To understand how intramyocardial coronary arteries are generated to connect these two coronary vascular populations, we combined genetic lineage tracing, light-sheet microscopy, fluorescence micro-optical sectioning tomography, and tissue-specific gene knockout approaches to understand their cellular and molecular mechanisms. Results: We show that a subset of intramyocardial coronary arteries form by angiogenic extension of endocardium-derived vascular tunnels in the neonatal heart. Three-dimensional whole-mount fluorescence imaging showed that these endocardium-derived vascular tunnels or tubes adopt an arterial fate in neonates. Mechanistically, we implicate Mettl3 and Notch signaling in regulating endocardium-derived intramyocardial coronary artery formation. Functionally, these intramyocardial arteries persist into adulthood and play a protective role after myocardial infarction. Conclusions: A subset of intramyocardial coronary arteries form by extension of endocardium-derived vascular tunnels in the neonatal heart.

The impact of the radiotherapy technique in sparing the heart substructures in central tumor irradiation in lung cancer

Introduction: In thoracic radiotherapy (RT), heart sparing is very essential, as the high cardiac dose is associated with poor survival in patients with locally advanced non-small-cell lung cancer (NSCLC). The study aims to determine the doses exposed to heart substructures and coronary arteries by different RT techniques in central tumor irradiation in lung cancer. Methods: Twenty patients with NSCLC, irradiated between January 2018 and December 2020 in our department, were included in this study. Patients whose primary tumor was centrally located in the left lung were selected. The heart substructures [left atrium, right atrium (RA), left ventricle, and right ventricle] and coronary arteries (left main, left anterior descending, circumflex, and right coronary arteries) were delineated by the same physician. The doses of 60 Gy external RT were prescribed in 30 fractions using three-dimensional conformal radiotherapy (3D-CRT), static intensity-modulated radiotherapy (s-IMRT), and dynamic intensity-modulated radiotherapy (d-IMRT) techniques in all patients. The obtaining plans using three different techniques were compared. Results: The d-IMRT plans were statistically the best optimal plan for planning target volume (PTV) [Dmean (p = 0 04), Dmax (p < 0 0001), V95 (p < 0 0001), V107 (p < 0 0001), CI (p < 0 0001) and HI (p < 0 0001)]. The s-IMRT plans were significantly superior to 3D-CRT plans for PTV. RA Dmax and V45 were not different between the three techniques [Dmax (p = 0 148) and V45 (p = 0 12)]. The d-IMRT technique was significantly better in other heart substructures and coronary arteries. Conclusions: Compared to 3D-CRT and s-IMRT techniques, the d-IMRT technique provided the best protection in all heart substructures except for a few parameters (RA Dmax and V45 doses).

Acute coronary syndrome in patients under 35 years old

Objective. To evaluate the clinical and demographic characteristics of a group of patients under 35 years old admitted with acute coronary syndrome, as well as the features of coronary bed damage and endovascular treatment.Material and methods. A retrospective analysis of the group of patients aged 30 to 35, admitted to the Regional Vascular Center with a diagnosis of acute coronary syndrome in the period from 2019 to June 2021, was carried out. The study included 72 patients with ACS, regardless of the ST segment changes on the electrocardiogram, were admitted to the hospital by the emergency medical service referral. Positive troponins were detected in all the patients by qualitative analysis. Upon admission, they were sent to a catheterization laboratory. An examination was carried out according to the recommendations of medical care, as well as selective coronary angiography and, if indicated, stenting of the coronary arteries was performed.Results. When analyzing the clinical and demographic characteristics of the group, attention has been drawn to the absolute predominance of males — 71 (98.7%), urban residents — 64 (88.9%), low frequency of bad habits: tobacco smoking in 13 (18.1%) and alcohol abuse in 2 (2.8%) patients, the absence of concomitant pathology, a signifi cant time from the onset of symptoms to calling an ambulance (165 [90; 263]). According to the results of angiography, it should be noted the possibility of acute coronary syndrome with intact coronary arteries is 9 (27.3%) among all ACS cases with ST segment elevation and 29 (74.3%) with ACS without ST segment elevation, while in one third of the above episodes (13 (34.2%)) ACS was caused by the presence of a muscle “bridge” in the basin of the anterior descending artery, a concomitant phenomenon of slowed blood fl ow. The attention has been also drawn to the almost equal proportions of acute thrombotic occlusion (19 (55.9%)) and haemodynamically signifi cant hemadostenosis (14 (41.2%)) as the cause of ACS.Conclusion. In patients under 35 years old with a typical clinical. picture, positive troponins, with a qualitative analysis, there is a high probability of pathological changes in the coronary bed, regardless of the ST segment changes, which requires X-ray endovascular methods of diagnosis and treatment. Angiographic features of the coronary artery lesion in young people are the discreteness of the lesion in the proximal or middle sections of the arteries, the high frequency of thrombotic occlusions, the predominant lesion of the anterior descending or right coronary arteries, the low frequency of calcifi cation of the coronary arteries.

Anesthetic management of cesarean section in a patient with Takayasu’s arteritis: a case report

Background Takayasu’s arteritis (TA) is a chronic, progressive, inflammatory arteritis. We presented the case of cesarean section in a patient with TA. Case presentation A 31-year-old pregnant woman with TA underwent a planned cesarean section at 34 weeks of pregnancy. She had stenosis of the cerebral and coronary arteries and heart failure due to aortic regurgitation. Spinal anesthesia was performed. In addition to standard monitoring, arterial blood pressure in the dorsalis pedis artery and regional cerebral tissue oxygen saturation were monitored. Intraoperative arterial blood pressure was maintained using continuous infusion of noradrenaline with a careful intermittent bolus infusion of phenylephrine. All the procedures were successfully performed without significant complications. Conclusions In a pregnant woman with TA, severe stenosis of the cerebral and coronary arteries, and heart failure due to valvular heart disease, careful anesthetic management by selecting catecholamines and assessing the perfusion pressure for critical organs is important.

Sex differences in coronary angiographic findings in patients with stable chest pain: analysis of data from the KoRean wOmen’S chest pain rEgistry (KoROSE)

Background Focused evaluations on potential sex differences in the angiographic findings of the coronary arteries are scarce. This study was performed to compare the angiographic extent and localization of coronary stenosis between men and women. Methods A total of 2348 patients (mean age 62.5 years and 60% women) with stable chest pain undergoing invasive coronary angiography (CAG) were recruited from the database of the nation-wide chest pain registry. Obstructive coronary artery disease (CAD) was defined as ≥ 50% stenosis of the left main coronary artery and/or ≥ 70% stenosis of any other epicardial coronary arteries. Results Although women were older than men (64.4 ± 10.3 vs. 59.5 ± 11.4 years, P < 0.001), men had worse risk profiles including high blood pressure, more frequent smoking and elevated triglyceride and C-reactive protein. The prevalence of obstructive CAD was significantly higher in men than in women (37.0% vs. 28.4%, P < 0.001). Men had a higher prevalence of LM disease (10.3% vs. 3.5%, P < 0.001) and three-vessel disease (16.1% vs. 9.5%, P = 0.007) compared to women. In multiple binary logistic regression analysis, the risk of men having LM disease or three-vessel disease was 7.4 (95% confidence interval 3.48–15.97; P < 0.001) and 2.7 (95% confidence interval 1.57–4.64; P < 0.001) times that of women, respectively, even after controlling for potential confounders. Conclusions In patients with chest pain undergoing invasive CAG, men had higher obstructive CAD prevalence and more high-risk angiographic findings such as LM disease or three-vessel disease.