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Mimics of ST-segment elevation myocardial infarction (STEMI) are common. We present the case of a STEMI mimic to highlight the importance of a broad differential diagnosis and multidisciplinary care. A 58-year-old woman presented to our hospital with drowsiness, epigastric discomfort and nausea.

BACKGROUND Obstructive sleep apnoea (OSA) occurs frequently in patients with coronary artery disease, with associated intermittent hypoxia a possible stimulus for coronary collateral recruitment through ischaemic preconditioning. We sought to determine whether OSA affects recruitment of coronary collaterals and prognosis of patients presenting with ST elevation myocardial infarction (STEMI). METHODS Patients with a STEMI undergoing percutaneous coronary intervention (PCI) from July 2010 to December 2019 were reviewed. Electronic medical records were accessed to determine documented patient history of OSA. Patients with robust collaterals were defined as Rentrop Grade 2 or 3. RESULTS 1,863 patients were included, of which 143 (7.7%) patients had documented evidence of OSA in their health record. Patients with OSA had a higher body mass index (BMI) (30.2 kg/m2 vs 27 kg/m2, p

Chronic total occlusions (CTO) are found commonly in patients with prior coronary artery bypass grafting (CABG). We sought to determine the effect of CABG on collateral robustness in patients with a CTO. Patients with a CTO diagnosed on coronary angiography between July 2010 and December 2019 were included in this study. Patients were classified as either CTO supplied by a functional graft, CTO supplied by collaterals from a non-grafted donor vessel (non-grafted) or a CTO supplied by collaterals from a grafted donor vessel (grafted). The degree of collateral robustness was determined by the Rentrop classification and collateral connection (CC) grade. Demographic, angiographic and clinical outcomes were recorded. A total of 2088 CTO lesions were identified, of which 878 (42.0%) were supplied by a functional graft, 994 (47.6%) CTOs were supplied by a non-grafted donor vessel and 216 (10.3%) CTOs were supplied by a grafted donor vessel. CTOs supplied by a grafted donor vessel had lower rates of robust collaterals (37.0% vs 83.0%, p

During the COVID-19 pandemic there has been a reduction in hospital admissions for acute myocardial infarction. This manuscript presents the analysis of Google Trends meta-data and shows a marked spike in search volume for chest pain that is strongly correlated with COVID-19 case numbers in the United States. This raises a concern that fear of contracting COVID-19 may be leading patients to self-triage using internet searches. Research Letter. During the COVID-19 pandemic, physicians worldwide have noted reductions in hospital admissions for emergencies including acute myocardial infarction and ischemic stroke.1,2 Several explanations have been proposed including reduced air pollution, changes in diet and lifestyle, or, most worryingly, avoidance of hospitals to reduce the risk of COVID-19 infection.3 There is significant concern that instead of presenting to hospital, fear of COVID-19 has led patients to self-triage using internet searches. Google Trends™ is a free publicly available tool that monitors how often search items are queried over time and provides insights into public health behavior. Recommendations for the documentation of Google Trends™ analyses have previously been published4 and were consulted to facilitate reproducibility of the present study. We quantified searches in the United States (US) for the symptom of interest, chest pain, and the control terms toothache, abdominal pain, knee pain, heart attack and stroke (time period 1st Jan 2017 to 24th May 2020, accessed 28th May 2020, no quotation marks, no combination symbols, all query categories). Data on the number of COVID-19 cases per day in the US was retrieved from USAFacts.org, which collates data from government agencies and is used by the Centers for Disease Control and Prevention. Time-lag correlation analysis was performed using R. To assess the relationship between chest pain searches and COVID-19 caseload, data on search volume was also collected for the states with the highest and lowest numbers of COVID-19 cases. No extramural funding was used to support this work. The number of cases of COVID-19 in the US rose rapidly throughout March 2020 and during the same month the relative search frequency of the symptom chest pain, but not the control terms, nearly doubled compared to the previous three years (Figure 1A). There was a strong correlation between the number of new COVID-19 cases and Google search queries for chest pain (Pearson correlation coefficient 0.79 with 18-day time-lag) (Figure 1B). The search volume for chest pain also spiked in the states with the three highest (New York, New Jersey, Illinois), but not the three lowest (Hawaii, Montana, Alaska), COVID-19 caseloads (Figure 2). In this analysis we describe a strong correlation between the increase in COVID-19 cases and the utilization of Google for medical information. Chest pain is a common presenting symptom of life-threatening medical conditions including coronary artery disease, aortic dissection and pulmonary embolus, but is not a common symptom of COVID-19.5 The analysis presented here suggests that the rise in COVID-19 cases has led patients to seek medical information about their symptoms from the internet at substantially higher rates compared to the previous three years. This does not appear to be due to generally increased search volumes nor seasonal variation (Figure 1). Within the US this was observed in states with a high prevalence of COVID-19 but not states with a low prevalence (Figure 2). This was despite all analyzed states instituting stay-at-home orders, which suggests this phenomenon is not related to lockdown restrictions. This raises a significant concern that in regions where caseloads are high, fear of contracting COVID-19 may be leading patients to self-triage, potentially in lieu of presenting to hospital. The rise in search volume for ‘chest pain’ but not ‘heart attack’ or ‘stroke’ may be explained by several hypotheses, including patients being more likely to search for symptoms rather than diagnoses, or it may reflect the reduced hospitalisations for these conditions during the COVID-19 pandemic and hence fewer patients receiving the diagnostic labels ‘heart attack’ and ‘stroke’. Indeed it was recently reported that the rate of catheter laboratory activation for ST-segment elevation myocardial infarction has decreased by 38% in the US compared to the pre-COVID-19 period,1 and there have been similar reductions in hospital presentations for other life-threatening conditions such as acute aortic dissection.6 This has been accompanied by a concurrent increase in out-of-hospital cardiac arrests7 and, amongst patients that did present to hospital with acute myocardial infarction, increased rates of delayed presentation and complications.8 While COVID-19 has a mortality of approximately 1%,9 acute myocardial infarction in the absence of contemporary treatment has a one-month mortality of up to 50%.10 As lockdown regulations begin to relax worldwide there is a significant risk of a second-wave of COVID-19, and so it is critical to re-emphasize to patients that internet searches are not an alternative to professional medical attention.

OBJECTIVES: Describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. DESIGN: Observational cohort study. SETTING: Twenty-one (21) Australian hospitals. PARTICIPANTS: Consecutive patients aged ≥18 years admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. MAIN OUTCOME MEASURES: Incidence of cardiac complications. RESULTS: Six-hundred-and-forty-four (644) hospitalised patients (62.5±20.1 yo, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (20) (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (3) (0.5%) patients developed high grade atrioventricular (AV) block. Two (2) (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p

Chronic total occlusions (CTO) are found commonly in patients with prior coronary artery bypass grafting (CABG). We sought to determine the effect of CABG on collateral robustness in patients with a CTO. Patients with a CTO diagnosed on coronary angiography between July 2010 and December 2019 were included in this study. Patients were classified as either CTO supplied by a functional graft, CTO supplied by collaterals from a non-grafted donor vessel (non-grafted) or a CTO supplied by collaterals from a grafted donor vessel (grafted). The degree of collateral robustness was determined by the Rentrop classification and collateral connection (CC) grade. Demographic, angiographic and clinical outcomes were recorded. A total of 2088 CTO lesions were identified, of which 878 (42.0%) were supplied by a functional graft, 994 (47.6%) CTOs were supplied by a non-grafted donor vessel and 216 (10.3%) CTOs were supplied by a grafted donor vessel. CTOs supplied by a grafted donor vessel had lower rates of robust collaterals (37.0% vs 83.0%, p 0.0001) with less mature collaterals as determined by the Rentrop grade (p 0.0001) and CC grade (p 0.0001) as compared to CTOs supplied by a non-grafted donor vessel. In patients with a previous CABG, a grafted donor vessel results in less robust coronary collaterals with lower Rentrop and CC grade compared to an ungrafted donor vessel. This may be attributable to changes in coronary blood flow and shear stress, and may be a factor in the lower procedural success rates for CTO intervention in patients with prior CABG.

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

Primary percutaneous coronary intervention (PPCI) has dramatically changed the outcome of patients with ST-elevation myocardial infarction (STEMI). However, despite improvements in interventional technology, registry data show little recent change in the prognosis of patients who survive STEMI, with a significant incidence of cardiogenic shock, heart failure, and cardiac death. Despite a technically successful PPCI procedure, a variable proportion of patients experience suboptimal myocardial reperfusion. Large infarct size and coronary microvascular injury, as the consequence of ischaemia–reperfusion injury and distal embolization of atherothrombotic debris, account for suboptimal long-term prognosis of STEMI patients. In order to address this unmet therapeutic need, a broad-range of device-based treatments has been developed. These device-based therapies can be categorized according to the pathophysiological pathways they target: (i) techniques to prevent distal atherothrombotic embolization, (ii) techniques to prevent or mitigate ischaemia/reperfusion injury, and (iii) techniques to enhance coronary microvascular function/integrity. This review is an overview of these novel technologies with a focus on their pathophysiological background, procedural details, available evidence, and with a critical perspective about their potential future implementation in the clinical care of STEMI patients.

Improvements in systems, technology and pharmacotherapy have significantly changed the prognosis over recent decades in patients presenting with ST-segment elevation myocardial infarction. These clinical achievements have, however, begun to plateau and it is becoming increasingly necessary to consider novel strategies to further improve outcomes. Approximately a third of patients treated by primary percutaneous coronary intervention for ST-segment elevation myocardial infarction will suffer from coronary no-reflow (NR), a condition characterized by poor myocardial perfusion despite patent epicardial arteries. The presence of NR impacts significantly on clinical outcomes including left ventricular dysfunction, heart failure and death, yet conventional management algorithms neither assess the risk of NR nor treat NR. This review will provide a contemporary overview on the pathogenesis, diagnosis and treatment of NR.

Coronary occlusion is a rare but well-described complication of heart valve surgery. The left circumflex coronary artery, especially when it is dominant, is particularly at risk owing to the proximity of the mitral valve annulus. We report three cases of acute coronary complications of different valvular surgical procedures diagnosed and treated in the cardiac catheterization laboratory. Intracoronary optical coherence tomography was used to identify the cause of coronary flow impairment and provided important insights into the mechanism of intraoperative vascular damage.

As transcatheter aortic valve replacement (TAVR) expands to younger and lower-risk severe aortic stenosis patients, appropriate coronary artery disease treatment is key to reducing long-term adverse cardiovascular outcomes. Recently, studies have been exploring the role of coronary-physiology guided revascularization strategies. Our aim was to investigate whether TAVR influences coronary physiology measurements using quantitative meta-analytic methods.We performed a Medline and Embase search for studies evaluating coronary physiology indices before and after TAVR. Double independent screening and extractions of baseline, procedural, angiographic, and echocardiographic data were performed. Risk of bias was assessed using the ACROBAT-NRSI tool. Pooled mean difference estimates of coronary hemodynamic indices before and after TAVR were derived using random-effects models with the inverse variance method (RevMan, Review Manager, version 5.3.5; Nordic Cochrane Centre).Five studies evaluating 250 coronary vessels in 169 severe aortic stenosis patients were quantitatively synthesized. Coronary flow reserve did not change immediately after TAVR in non-diseased vessels (n = 3; mean difference, 0.11; 95% confidence interval [CI], -0.10-0.32; P=.29; I²=0%; P=.68). Importantly, fractional flow reserve also did not vary significantly following TAVR in both non-diseased (n = 3; mean difference, -0.01; 95% CI, -0.04-0.03; P=.75; I²=41; P=.19) and diseased coronaries (n = 3; mean difference, -0.01; 95% CI, -0.03-0.01; P=.49; I²=0%; P=.46). Similarly, instantaneous wave-free ratio remained stable following TAVR (n = 2; mean difference, 0.00; 95% CI, -0.02-0.02; P.99; I²=0; P.99.Pooled coronary physiology measurements before and after TAVR are similar, but data on variation within individual lesions are limited.