483 Minoca in a young patient with elevated platelet count

Aims Ischaemic heart disease is rare in young women, especially in the absence of a positive family history and strong cardiovascular risk factors, such as insulin-dependent diabetes. However, the correct diagnosis of ischaemic heart disease in young population is mandatory, and the specific aetiology should be identified to ensure a proper treatment. Methods and results We present the case of a 35-year-old caucasian woman who underwent ambulatory cardiological evaluation after episodes of chest pain and worsening dyspnoea (NYHA class II). The patient was asymptomatic at rest, BP was normal, heart rate was 80/minute in sinus rhythm, with no clinical signs of acute heart failure. ECG showed sinus rhythm with Q wave (lead DIII) and negative T waves (inferior leads). At echocardiographic evaluation LV was severely dilated (EDVi 105 ml/mq, EDD 66 mm) with akinesia and scar in the infero-posterior wall determining moderate reduction in ejection fraction (LVEF 40%), associated with secondary moderate mitral regurgitation; the right ventricle, the other valves and the aortic root were normal. The young lady was then admitted to Cardiology Unit for further investigations. She underwent cardiac MRI, which confirmed LV dilatation and dysfunction (EDV 198 ml/mq, LVEF 42%), associated with akinesia and infero-postero-lateral wall scar, with transmural myocardial fibrosis in the same segments, and subendocardial fibrosis on the basal segment of the anterior wall. Analysis of blood samples revealed elevated haemoglobin levels (Hb: 17.5 g/dl, n.v. 12–16 g/dl) and extremely elevated platelet count (PLT 945 000/mmc, n.v. 130 000–400 000/mmc). Cardiac troponin I (cTnI) was negative on serial determinations. All findings were suggestive for subacute infero-posterior myocardial infarction. Coronary angiography was performed via radial access: the exam was negative for significant stenosis in any coronary segment, only mild stenosis of proximal dominant left circumflex (LCX) artery was identified; moreover, there were no angiographic signs of coronary dissection. Eventually, SCAD and aortic defects were ruled out by coronary CT scan, which was negative for both coronary and aortic dissection. New blood samples examinations confirmed high values of Hb and PLT. Low levels of EPO (1.4 mU/ml) and JAK-2 mutation V617F positivity suggested the clinical diagnosis of essential thrombocythemia, later confirmed by bone marrow aspiration. Hydroxyurea was prescribed, as well as haematologic follow-up. Conclusions This is an interesting case of ischaemic heart disease, confirmed by ECG, echocardiography, and cardiac MRI, in presence of non-obstructive coronary artery disease. The aetiology of this specific case of MINOCA is potentially to be sought in the haematologic disorder. It is possible to hypothesize that a platelet/RBC clot might have determined acute obstruction of the proximal dominant LCX artery, then followed by spontaneous recanalization. Only mild stenosis on the proximal vessel was identified, and stenting was considered not appropriate for this lesion.

Carotid Plaques From Symptomatic Patients With Mild Stenosis Is Associated With Intraplaque Hemorrhage

Carotid plaque vulnerability features beyond the degree of stenosis may play a key role in the pathogenesis and recurrence of ischemic cerebrovascular events. This study sought to compare intraplaque hemorrhage (IPH) as a marker of plaque vulnerability in symptomatic patients with mild (<50%), moderate (50%–69%), and severe (≥70%) carotid artery stenosis. We included patients who experienced ischemic cerebrovascular events with no other identifiable sources and underwent carotid endarterectomy for mild (n=32), moderate (n=47), and severe (n=58) carotid artery stenosis. The degree of stenosis and imaging hallmarks were assessed by computed tomography angiography or magnetic resonance angiography. Plaque specimens were stained with hematoxylin and eosin and Movat pentachrome staining. Carotid plaques of patients with mild stenosis had a higher extent of IPH (%) on tissue analysis compared with patients with moderate (mild, 15.7% [interquartile range, 7.8%–26.7%]; moderate, 3.9% [0.0%–9.2%]; P <0.001) and severe carotid artery stenosis (mild, 15.7% [interquartile range, 7.8%–26.7%]; severe, 2.5% [interquartile range, 0.0%–11.2%]; P <0.001). When considering the degree of carotid artery stenosis as a continuous variable, a lower lumen narrowing was associated with higher extent of IPH ( P <0.001; R, −0.329). Our major finding is the association of IPH with mild carotid artery stenosis based on histological analysis. The current study may suggest that IPH potentially plays a role in the mechanism of stroke in patients with nonobstructive carotid stenosis.

Insight into the Significance of Hall Current and Joule Heating on the Dynamics of Darcy–Forchheimer Peristaltic Flow of Rabinowitsch Fluid

This paper aims to present the significance of the Hall current and Joule heating impacts on a peristaltic flow of a Rabinowitsch fluid through tapered tube. The Darcy–Forchheimer scheme is used for a porous medium; a mild stenosis is considered to study the impacts of radiative heat transfer and chemical reactions. Convective conditions are postulated for heat and mass transfer. In the meantime, the slip conditions are presumed for the velocity distribution. Soret and Dufour features bring the coupled differential systems. The hypotheses of a long wavelength and low Reynolds number are employed to approximate the governing equations of motion, and finally the homotopy perturbation method is adopted for numerical study. Pumping characteristics are revealed and the trapping procedure correlated with peristaltic transport is elucidated. The present study is very important in many medical applications, such as the gastric juice motion in the small intestine and the flow of blood in arteries. The mechanism of peristaltic transport with mild stenosis has been exploited for industrial applications like sanitary fluid transport and blood pumps in heart-lung machine. The influences of various physical parameters of the problem are debated and graphically drawn across a set of figures. It is noted that the axial velocity is reduced with the increase of the Hartmann number. However, enhancing both the Rabinowitsch parameter and the Forchheimer parameter gives rise to the fluid velocity. As well, it is debated that Rabinowitsch fluid produces a cubic term of pressure gradient. Therefore, the relation between mean flow rate and the pressure rise does not stay linear. It is recognized that the temperature rises with the enhancement of both Dufour number and Soret number. Furthermore, it is illustrated that the concentration impedes with the increase of the mass transfer Biot number. Also, it is revealed that the trapped bolus contracts in size by enlarging the maximum height of stenosis.

Coronary Flow and Reserve by Enhanced Transthoracic Doppler Trumps Coronary Anatomy by Computed Tomography in Assessing Coronary Artery Stenosis

We report the case of a 71-year-old patient with many risk factors for coronary atherosclerosis, who underwent computed coronary angiography (CTA), in accordance with the guidelines, for recent onset atypical chest pain. CTA revealed critical (>50% lumen diameter narrowing) stenosis of the proximal anterior descending coronary, and the patient was scheduled for invasive coronary angiography (ICA). Before ICA he underwent enhanced transthoracic echo-Doppler (E-Doppler TTE) for coronary flow detection by color-guided pulsed-wave Doppler recording of the left main (LMCA) and whole left anterior descending coronary artery (LAD,) along with coronary flow reserve (CFR) in the distal LAD calculated as the ratio, of peak flow velocity during i.v. adenosine (140 mcg/Kg/m) to resting flow velocity. E-Doppler TTE mapping revealed only mild stenosis (28% area narrowing) of the mid LAD and a CFR of 3.20, in perfect agreement with the color mapping showing no flow limiting stenosis in the LMCA and LAD. ICA revealed only a very mild stenosis in the mid LAD and mild atherosclerosis in the other coronaries (intimal irregularities). Thus, coronary stenosis was better predicted by E-Doppler TTE than by CTA. Coronary flow and reserve as assessed by E-Doppler TTE trumps coronary anatomy as assessed by CTA, without exposing the patient to harmful radiation and iodinated contrast medium.

MATHEMATICAL MODEL FOR POROUS INFLUENCE THROUGH MILD STENOSIS THROMBOSISIS OVER DELIVERY OF OXYGEN AND NUTRIENTS ARTERIES

In order to understand the irregular flow conditions of blood in a locally constricted blood vessel, analytical results are obtained for a porous effect on oscillatory blood flow that acts as a Newtonian flow. Compared to the radius of the unconstricted tube, the surface roughness is presumed to be cosine-shaped and the maximum height of the roughness is very small. The main focus of investigation of the porous effect on oscillatory arterial blood flow with mild stenosis, a mathematical model has been developed.

ESC 2019 guidelines on chronic coronary syndromes: can calcium scoring improve the risk underestimation associated with the updated pre-test probability risk score?

Funding Acknowledgements Type of funding sources: None. Introduction The European Society of Cardiology (ESC) published an updated stable chest pain guideline in 2019. It recommends the use of an updated pre-test probability (PTP) risk score (RS) to assess the likelihood of coronary artery disease (CAD), to try and reduce the risk overestimation associated with previous risk scores. We sought to assess the performance of the 2019 PTPRS in a contemporary cohort of patients undergoing CT coronary angiography (CTCA). Furthermore, we focussed on patients with PTPRS &lt;15%, and assessed the utility of CT calcium scores as a discriminator of risk. Methods 652 patients who were investigated with CTCA for stable chest pain between January 2017 and May 2018 were included in a retrospective analysis. CTCA reported CAD degree of stenosis as normal/minimal stenosis, mild (30-50%), moderate (50-70%), or severe (&gt;70%). ESC 2019 pre-test probability risk scores were retrospectively calculated and compared. Results A total of 652 patients underwent CTCA between 01 January 2017 and 31 May 2018, of which 330 were male and 322 were female, with an average age of 55 years ±11 years. Using the ESC 2019 PTPRS there were no patients with PTPRS &gt;85%. 2 patients had PTPRS 50-85%; one patient had moderate stenosis and one mild stenosis on CTCA. There were 267 patients with PTPRS 15-50%; 23 (9%) patients had severe CTCA stenosis, 37 (14%) a moderate stenosis, and 34 (13%) a mild stenosis. A further 379 patients had PTPRS &lt;15%; 11 (3%) had severe stenosis and 20 (5%) moderate stenosis. A further 27 (7%) patients had mild CTCA stenosis. A total of 357 of 379 patients with PTPRS &lt;15% based on ESC 2019 had a CT calcium score. 236 patients were found to have a calcium score of zero, and 121 patients had a score greater than zero, with a range between 1 and 930. Of patients with zero calcium score, only 1 (0.4%) patient had severe stenosis, 2 (0.8%) moderate stenoses and 6 (2.5%) mild stenosis. In contrast, in patients with positive calcium scores, 10 (8%) had severe stenosis, 18 (15%) moderate stenosis, and 22 (18%) mild stenosis. Conclusions The ESC 2019 PTPRS classified this as an overall low risk cohort. The downward risk modification of PTPRS has led to a large number of patients being classified as low risk with PTPRS &lt;15%. No or deferred investigation is recommended by the ESC in this cohort. However, the use of CT calcium scores in patients with PTPRS &lt;15%, detected the majority of patients with any degree of CAD. CT calcium scores are a simple and low cost risk modifier, and may help identify patients who may benefit from primary prevention as per SCOT-Heart. Patients with calcium score greater than zero could be investigated with CTCA.