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Background: The main cause of acute coronary syndrome (ACS) is coronary artery obstruction due to atherosclerotic plaque growth or thrombus formation secondary to plaque rupture or erosion. However, there is a subgroup of patients with signs and symptoms suggestive of ACS but without relevant coronary artery obstruction on coronary angiography. This population is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA). The present study analyzes the clinical features and outcomes of very young patients with a diagnosis of MINOCA.Method: Nested case-control study of ≤40-year-old patients referred for coronary angiography due to clinical suspicion of ACS. Patients were divided into three groups: patients with obstructive coronary artery disease (CAD), patients diagnosed with MINOCA, and controls with non-coronary artery disease.Results: Of 19,321 coronary angiographies performed in our center in a period of 10 years, 408 (2.1%) were in patients ≤40 years old, and MINOCA was identified in 32 (21%) patients. The cardiovascular risk factors for obstructive CAD and MINOCA were very similar. The incidence of major adverse cardiovascular events (MACE) at follow-up was significantly higher in the MINOCA (HR 4.13 (95%CI 1.22-13.89) and obstructive CAD (HR 4.59 (95%CI 1.90-10.99) patients compared to controls. Cocaine use HR 14.58 (95%CI 3.08-69.02), family history of CAD HR 6.20 (95%CI 1.40-27.43), and depression HR 5.16 (95%CI 1.06-25.24) were associated with a poor outcome in the MINOCA population.Conclusion: Very young patients with MINOCA had a poor prognosis at long-term follow-up, similar to patients with obstructive CAD. Focusing efforts on secondary prevention is essential in this population. [ABSTRACT FROM AUTHOR]

Background. "Coronary anomaly" is defined as the coronary feature or pattern seen in <1% of the population. The most common CAAs are anomalies of origin, specifically having a separate LCX and LAD origin with an incidence of 0.41%. The second most common anomaly is the LCX arising from the RCA (0.37%). Treatment options include CABG, coronary unroofing, reimplantation, or medical therapy. Case Presentation. We present the case of an 85-year-old male who presents with an acute coronary syndrome who was found to have an extremely rare combination of different coronary anomaly patterns including left main coronary artery (LMCA) atresia, small LAD arising posteriorly from the right coronary cusp, anomalous left circumflex artery arising from the RCA, and an anomalous LAD arising from the left circumflex artery which is originating from the RCA. Conclusions. To the best of our knowledge, this is the first case report to describe four coronary anomalies in a single patient. When CAAs are diagnosed, it is of utmost importance for cardiologists to do further imaging and workup that might include a stress test to be able to offer patients the best management options. [ABSTRACT FROM AUTHOR]

Background. To explore the application value of layered strain technique in non-ST elevation acute coronary syndrome (NSTE-ACS). Methods. 120 patients with suspected NSTE-ACS undergoing coronary angiography in our hospital from December 2018 to December 2019 were prospectively selected. According to the results of coronary angiography, the patients were divided into the significant CAD group and the nonsignificant CAD group. Echocardiography was performed 1-2 hours before invasive coronary angiography. The long axis and circumferential strain of the endocardium, myocardial layer, and epicardium were evaluated by the layered strain technique. The territorial longitudinal strain (TLS), the global longitudinal strain (GLS) of the three myocardial layers, and the global circumferential strain (GCS) were calculated based on the perfusion region of the three coronary arteries and the 17-segment model of the left ventricle. The primary endopoints were TLS and GCS of the three-layer myocardium. Results. Compared with the nonsignificant CAD patients, the TLS and GCS of three-layer myocardium in significant CAD patients were decreased, especially in the endocardium. The absolute values of TLS and GCS of the endocardium and epicardium in significant CAD patients were lower than those in nonsignificant CAD patients. This indicates a significant decrease in endocardial function. Receiver operating characteristic (ROC) curve analysis showed that endocardial TLS was superior to LVEF, Troponin I (TnI), and other strain parameters in evaluating the extent of coronary lesions. Conclusions. The layered strain technique of 2D-STE can evaluate the severity of coronary lesions in patients with NSTE-ACS, and for significant CAD patients, endocardial function is significantly more impaired than epicardial function. [ABSTRACT FROM AUTHOR]

Background and Aims. Plasma levels of soluble triggering receptor expressed on myeloid cells (sTREM-1) reflect innate immune cell activation. We sought to evaluate sTREM-1 levels in patients with acute coronary syndrome (ACS) and their predictive value for disease severity and outcome. Methods. Plasma sTREM-1 levels were prospectively measured by ELISA in 121 consecutive patients with new-onset (≤24 h) chest pain at arrival to the emergency department (ED) and 73 healthy controls. Secondary endpoints were the association of plasma levels of sTREM-1 with day 30 and month 6 major adverse cardiovascular events (MACE) defined as death, ACS, stroke, and need for coronary revascularization, as well as with CAD severity. The primary endpoint of the study was the association of plasma sTREM-1 level at the time of admission to the ED with a diagnosis of ACS at day 30. Results. Fifty-nine patients (48.7%) were diagnosed with ACS and 62 (51.3%) with nonspecific chest pain (NSCP). Median plasma sTREM-1 level at admission was significantly higher in the ACS group than the NSCP group and the control group (539.4 ± 330.3 pg/ml vs. 432.5 ± 196.4 pg/ml vs. 230.1 ± 85.5 pg/ml, respectively; P < 0.001) and positively correlated with the number of stenosed/occluded coronary arteries on angiography (P < 0.001). On logistic regression analysis, higher sTREM-1 levels predicted definite ACS vs. NSCP determined on day 30 (OR 1.29, 95% CI 1.07-1.54, P = 0.01) as well as with recurrent ACS (P = 0.04) and stroke (P = 0.02) at 6 months. Conclusions. Plasma sTREM-1 levels are significantly elevated in patients with ACS and might serve as a biomarker differentiating ACS from NSCP in the ED as well as an inflammatory biomarker for coronary artery disease severity and outcome. [ABSTRACT FROM AUTHOR]

Background. Although rare, external compression of the left main coronary artery (LMCA) by a pulmonary arterial aneurysm (PAA) as a consequence of pulmonary arterial hypertension causing stable angina pectoris is well described. However, acute myocardial infarction is extremely rare, particularly with a full array of electrocardiographic, biochemical, and echocardiographic features, as in this scenario. Case. In this case, a 62-year-old man with a past history of severe fibrotic lung disease was hospitalised with chest pain. The patient had dynamic anterolateral ischaemic changes on electrocardiography and serially elevated high-sensitivity troponin I. Transthoracic echocardiography revealed impaired left ventricular ejection fraction with anterolateral hypokinesis. Coronary angiography with intracoronary imaging revealed external compression of the LMCA. Computer tomography (CT) scans confirmed new PAA, compared to previous scans. The patient was successfully treated by percutaneous coronary stent implantation. Conclusion. Progressive dilatation of the pulmonary artery due to pulmonary arterial hypertension can result in acute MI secondary to external compression of the LMCA. Clinicians should be mindful of acute coronary syndromes in patients with long-standing pulmonary hypertension presenting with chest pain. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to assess the utility of optical coherence tomography (OCT) in patients with exercise-related acute coronary syndrome (ACS) presenting with inconclusive angiographic findings.Background: Regular physical activity reduces the incidence of cardiovascular events. Nevertheless, the risk of ACS or sudden cardiac death (SCD) increases during sport. In adults older than 35 years, exercise-related ACS or SCD is associated with plaque rupture, but not infrequently patients present ambiguous angiographic findings.Methods: Between September 2015 and January 2020, patients admitted for ACS or SCD triggered by physical exertion and with coronary stenosis ≤50% were included in this prospective observational study. OCT was performed on the artery deemed to be responsible of the event.Results: Ten patients were enrolled, predominantly men (80%) of middle age (51 years old, IQR 41-63) with low cardiovascular risk burden. Cycling was the most frequent (50%) exercise-related trigger, 8 patients were regular sport practitioners, and 7 had the clinical event during strenuous exertion. Five patients presented with non-ST-elevation ACS, two with ST-elevation ACS, and three with SCD. Angiographic analysis showed nonsignificant stenosis in all patients (42% stenosis, IQR 36-46). OCT identified the etiology of the event in 9 patients (4 plaque erosion, 3 plaque rupture, 1 eruptive calcific nodule, and 1 coronary dissection). Treatment was adjusted according to OCT findings.Conclusions: OCT is a valuable technique to identify the etiology of exercise-related ACS or SCD in patients with nonobstructive coronary arteries and, as a result, may lead to a more specific treatment. [ABSTRACT FROM AUTHOR]

Introduction. Diabetes mellitus (DM) and smoking are highly prevalent among Middle Eastern patients admitted with acute coronary syndrome (ACS) or who undergo percutaneous coronary intervention (PCI). Methods. This study used the analysis of the data from the first Jordanian PCI registry (JoPCR1) to determine the impact of coexistence of smoking and diabetes mellitus on the coronary artery severity and outcome following percutaneous coronary intervention in Middle Eastern patients. Results. Of 2426 patients enrolled, 1300 (53.6%) and 1055 (43.5%) were diabetics and smokers, respectively. The patients' age was 59.0 ± 10.1 and ranged between 24 and 95 years. Males comprised 79.4% of all patients. The patients were divided into four groups: nondiabetic-nonsmokers (22.2%), diabetic-nonsmokers (34.3%), nondiabetic-smokers (24.2%), and diabetic-smokers (19.2%). Compared with the other three groups, patients in the diabetic-nonsmoker group were older, more likely to be females, and having a higher prevalence of hypertension, dyslipidemia, chronic renal disease, and history of CVD and revascularization. Consequently, the diabetic-nonsmoker patients (but not the diabetic-smokers) had a higher prevalence of multivessel CAD and PCI than the other three groups, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Furthermore, those patients had a higher incidence of ACS as an indication for PCI than the stable coronary disease (73% vs 27%) and the highest CRUSADE bleeding risk score (63.9%) among other groups. The in-hospital events including in-stent thrombosis and emergency CABG events did not significantly differ among groups (p = 0.5 and 0.22). Heart failure and major bleeding events occurred significantly higher among diabetic-nonsmokers compared to other groups. In-hospital deaths occurred significantly more among diabetic-nonsmokers. Moreover, the one-month and one-year follow-up outcome events (the mortality rate, in-stent thrombosis, readmission for ACS, coronary revascularization, and major bleedings) occurred more frequently in the diabetic-nonsmoker group. However, the difference was statistically significant only for major bleeding incidences. Conclusions. In this analysis of a completed prospective Middle Eastern PCI registry, the majority of the diabetic-nonsmoker (and not the diabetic-smokers) patients (73%) presented with ACS. This group was the highest at risk for in-hospital PCI complications as well as the worst in outcomes after one year of follow-up. Those patients were more likely to be older, female, and have the worst cardiovascular baseline features, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Thus, more sufficient education about controlling CVD risk factors should be implemented in the Middle Eastern region. [ABSTRACT FROM AUTHOR]

Objectives: We aim to evaluate long-term outcomes after left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS).Background: PCI of the LMCA has been an acceptable revascularization strategy in stable coronary artery disease. However, limited studies on long-term clinical outcomes of LMCA PCI in ACS patients are available.Methods: A total of 6429 consecutive patients with ACS undergoing PCI in Fuwai Hospital in 2013 were enrolled. Patients are divided into LMCA group and Non-LMCA group according to whether the target lesion was located in LMCA. Prognosis impact on 2-year major adverse cardiovascular and cerebrovascular events (MACCE) is analyzed.Results: 155 (2.4%) patients had target lesion in LMCA, while 6274 (97.6%) patients belong to the non-LMCA group. Compared with non-LMCA patients, LMCA patients have generally more comorbidities and worse baseline conditions. Two-year follow-up reveals that LMCA patients have significantly higher rate of cardiac death (2.6% vs. 0.7%, p = 0.034), myocardial infarction (7.1% vs. 1.8%, p < 0.001), in-stent thrombosis (4.5% vs. 0.8%, p < 0.001), and stroke (7.1% vs. 6.4%, p = 0.025). After adjusting for confounding factors, LMCA remains independently associated with higher 2-year myocardial infarction rate (HR = 2.585, 95% CI = 1.243-5.347, p = 0.011).Conclusion: LMCA-targeted PCI is an independent risk factor for 2-year myocardial infarction in ACS patients. [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) is a known potential complication of thoracic radiation treatment that typically affects the proximal segments of the coronary arteries, requiring coronary artery bypass grafting (CABG). We present a case of acute coronary syndrome occurring in a 57-year-old man with prior thoracic radiation therapy following resection of a chest wall chondrosarcoma. Coronary angiogram demonstrated significant areas of stenosis in the left main coronary artery (LMCA) and ostial left anterior descending (LAD) coronary artery. The patient was also found to have atretic bilateral internal mammary arteries as a consequence of his radiation therapy, rendering them unsuitable as grafts. Percutaneous coronary intervention (PCI) was thus performed with a successful outcome. To our knowledge, this is the first case of radiation-induced CAD of the LMCA with atretic internal mammary arteries treated successfully with PCI. [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) is a known potential complication of thoracic radiation treatment that typically affects the proximal segments of the coronary arteries, requiring coronary artery bypass grafting (CABG). We present a case of acute coronary syndrome occurring in a 57-year-old man with prior thoracic radiation therapy following resection of a chest wall chondrosarcoma. Coronary angiogram demonstrated significant areas of stenosis in the left main coronary artery (LMCA) and ostial left anterior descending (LAD) coronary artery. The patient was also found to have atretic bilateral internal mammary arteries as a consequence of his radiation therapy, rendering them unsuitable as grafts. Percutaneous coronary intervention (PCI) was thus performed with a successful outcome. To our knowledge, this is the first case of radiation-induced CAD of the LMCA with atretic internal mammary arteries treated successfully with PCI. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome (ACS) secondary to a coronary embolism is an unusual occurrence, yet an important consideration given the difficult diagnosis. We report a case of a 69-year-old male with a medical history of paroxysmal atrial fibrillation who presented with chest pain and shortness of breath. A coronary angiogram was significant for three focal transluminal and translucent areas in the ostial, mid, and distal circumflex artery consistent with embolic disease. The patient was subsequently managed medically with anticoagulation. Despite being a relatively rare entity, thromboembolism into the coronary arteries can provoke an acute myocardial infarction, with atrial fibrillation being the most common risk factor. Treatment modalities for ACS secondary to thromboembolism include stent placement, intracoronary thrombolysis, and thrombus aspiration. [ABSTRACT FROM AUTHOR]

Coronary artery fistulas are rare abnormal connections between a coronary artery and a cardiac chamber or a major vessel. Often, they are asymptomatic and the diagnosis is accidental. The case we present is the incidental finding of a fistula displayed with echocardiography during acute coronary syndrome (ACS). A 73-year-old man presented in the emergency room for non-ST-elevation ACS. Echocardiogram showed in a parasternal short axis view an abnormal diastolic flow inside the ventricular inferior wall. Angiography and CT confirmed the diagnosis of coronary fistula from the right coronary into the left ventricular cavity. A literature analysis with discussion about coronary fistulas classification and management was also performed. [ABSTRACT FROM AUTHOR]

Background. Inflammation is involved in the development and progression of coronary artery disease (CAD). The role of the receptor for advanced glycation end products (RAGE) in the development of CAD has been recognized. The expression of sRAGE and S100A12 in patients with coronary artery disease from different studies was inconsistent. We attempted to determine the expression of sRAGE and S100A12 and their relationship in the subjects with different severity levels of CAD. Methods. A total of 259 patients undergoing coronary angiography were enrolled from the Department of Geriatric Cardiology in the First Affiliated Hospital of Nanjing Medical University from January 2014 to December 2016. Groups were divided as follows: normal coronary artery (control group), nonobstructive coronary atherosclerosis (<50% stenosis in all coronary vessels, NOCA group), stable angina (SAP group), and acute coronary syndrome (ACS group). During CAG or PCI, peripheral arterial blood was collected from all the patients. Plasma sRAGE and S100A12 levels were measured by ELISA. We calculated the SYNTAX score of each patient with CAD according to the result of CAG. Results. The levels of sRAGE were significantly elevated in the ACS group compared with those in the control group, the NOCA group, and the SAP group. sRAGE levels were similar among the control group, the NOCA group, and the SAP group. Plasma S100A12 levels were significantly higher in the ACS group than in the control group and the NOCA group. Baseline correlations between plasma levels of sRAGE and plasma S100A12 in the ACS group were significant. Plasma sRAGE concentration was increasing in patients with ACS and was significantly positively correlated with the increasing SYNTAX score. ROC curve analysis revealed that the combination of sRAGE and S100A12 had a good performance in the prediction of high-risk CAD patients. Conclusion. The plasma levels of sRAGE and S100A12 can be increased in patients with ACS. The elevated sRAGE concentration may be independently associated with the severity of CAD and the inflammatory process. sRAGE combined with S100A12 may be used as a predictor of severe coronary heart disease. [ABSTRACT FROM AUTHOR]

Background. Spontaneous coronary artery dissection (SCAD) is an underdiagnosed and rare cause of myocardial infarction (MI). SCAD is defined as the separation of the coronary artery wall by hemorrhage with or without intimal tear. It causes acute coronary syndrome in 1.7% to 4% of cases. Case Summary. We report a case of a patient with acute MI caused by SCAD with marked progression of dissection within 4 days and spontaneous healing in 2 months. Fibromuscular dysplasia (FMD) of the arteries is an associated condition of SCAD that was found in our patient. Conclusion. In young women admitted to the clinic with signs of acute myocardial infarction, SCAD should be suspected. FMD as an associated condition that should be ruled out in every SCAD patient. Conservative treatment of SCAD is the most preferable strategy. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome (ACS) is a life-threatening disease that affects more than half a million people in United States. We currently lack molecular biomarkers to distinguish the unstable angina (UA) and acute myocardial infarction (AMI), which are the two subtypes of ACS. MicroRNAs play significant roles in biological processes and serve as good candidates for biomarkers. In this work, we collected microRNA datasets from the Gene Expression Omnibus database and identified specific microRNAs in different subtypes and universal microRNAs in all subtypes based on our novel network-based bioinformatics approach. These microRNAs were studied for ACS association by pathway enrichment analysis of their target genes. AMI and UA were associated with 27 and 26 microRNAs, respectively, nine of them were detected for both AMI and UA, and five from each subtype had been reported previously. The remaining 22 and 21 microRNAs are novel microRNA biomarkers for AMI and UA, respectively. The findings are then supported by pathway enrichment analysis of the targets of these microRNAs. These novel microRNAs deserve further validation and will be helpful for personalized ACS diagnosis. [ABSTRACT FROM AUTHOR]

Congenital absence of left circumflex artery is a rare occurrence and very few cases have been reported in literature. It is a benign incidental finding; however some patients present with sudden onset chest pain mimicking acute coronary syndrome often resulting in detection of this rare anatomy on coronary angiography. Coronary computed tomography angiography is a relatively new noninvasive imaging modality which can be used to confirm this suspicion and diagnose this unique morphology reliably. [ABSTRACT FROM AUTHOR]

Adiponectin is an adipocyte specific cytokine which, in contrast to other adipokines, has been described to have antiinflammatory, antithrombotic, and anti atherogenic properties. This study evaluates the association between plasma adiponectin levels with acute coronary syndrome (ACS) and angiographic coronary lesion severity in Indian population. Ninety patients included in the study were divided in two groups in 1 : 1 ratio-patients admitted with a diagnosis of ACS and those without ACS. Adiponectin and other risk markers are measured in forty-five consecutive patients in each group undergoing coronary angiography. Patients without ACS were found to have higher adiponectin (16.47 ± 7.88 µg/mL) levels than patients with ACS (9.03 ± 3.13 µg/mL) (P < 0.001). In multiple regression analysis adjusted for all other risk markers, higher adiponectin levels remain positively associated with a lower risk of ACS (P value > 0.002). The greatest increase in risk for ACS was seen at adiponectin levels ≤12.20 µg/mL in study subjects. The adiponectin levels were inversely related to the angiographic severity of coronary artery stenosis increases (P value > 0.02). The study concluded that higher adiponectin levels are independently associated with lower risk of ACS, and patients with severe angiographic coronary artery disease have lower levels of adiponectin. [ABSTRACT FROM AUTHOR]

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention increases the risk of bleeding. We studied the safety and clinical outcomes of switching from DAPT to aspirin monotherapy at 3 months after ZES implantation. We retrospectively evaluated 168 consecutive patients with coronary artery disease who had been implanted with a ZES from June 2009 through March 2010. After excluding 40 patients according to exclusion criteria such as myocardial infarction, 128 patients were divided into a 3-month DAPT group (67 patients, 88 lesions) and a 12-month conventional DAPT group (61 patients, 81 lesions). Coronary angiographic followup and clinical followup were conducted at more than 8 months and at 12 months after ZES implantation, respectively. Minor and major bleeding events, stent thrombosis (ST), and major adverse cardiac events (MACE) (death, myocardial infarction, cerebrovascular accident, target lesion revascularization, and target vessel revascularization) were evaluated. There were no statistically significant differences in the incidences of ST and MACE between the two groups. The incidence of bleeding events was significantly lower in the 3-month group than in the 12-month group (1.5% versus 11.5%, P < 0.05). DAPT can be safely discontinued at 3 months after ZES implantation, which reduces bleeding risk. [ABSTRACT FROM AUTHOR]