Paradoxical sinus deceleration during dobutamine stress echocardiography: case series and review of the literature

Background: Dobutamine stress echocardiography is an established diagnostic modality for assessing myocardial ischaemia in patients with known or suspected coronary artery disease. Dobutamine infusion causes dose-dependent increase in heart rate and contractility. However, in some cases, it induces paradoxical sinus deceleration, whose underlying mechanism and clinical significance are not fully understood. Case summary: We present episodes of paradoxical sinus deceleration observed during dobutamine stress echocardiography in six (four males and two females) patients and described its patterns of occurrence and clinical and echocardiographic characteristics. Discussion: Paradoxical sinus deceleration occurred mostly at maximal dobutamine infusion was accompanied with a decline in blood pressure and resolved spontaneously following cessation of dobutamine infusion. Individuals experiencing paradoxical sinus deceleration had in common abnormal left ventricle geometry but differed with regard to age, sex, and cardiometabolic risk factors.publishedVersio

Right ventricular postsystolic shortening: Resolution after opening a totally occluded right coronary artery

Acute myocardial ischemia induces reduced systolic shortening and causes postsystolic shortening (PSS). Right ventricular (RV) PSS in coronary artery disease has been less studied. We present here the case of a 51-year-old woman admitted with a non-ST segment elevation myocardial infarction and significant PSS in the RV free-wall segments on two-dimensional speckle tracking echocardiography, suggesting ongoing ischemia. A cardiac CT demonstrated occluded proximal right coronary artery with a low-attenuated/soft plaque, confirmed by coronary angiography which was treated by percutaneous coronary intervention. At 3-week follow-up, there was complete resolution of the RV-PSS, with a more synchronized pattern of maximum myocardial shortening at systole.publishedVersio

Thrombus characteristics evaluated by acute optical coherence tomography in ST elevation myocardial Infarction

Aims ST elevation myocardial infarction (STEMI) is caused by an occlusive thrombosis of a coronary artery. We wanted to assess if the thrombus can be characterized according to erythrocyte content and age using intravascular optical coherence tomography (OCT) in a clinical setting. Methods and results We performed manual thrombus aspiration in 66 STEMI patients. OCT was done of the thrombus remnants after aspiration. A light intensity ratio was measured through the thrombus. Forty two of the aspirates had thrombus which could be analyzed histomorphologically for analysis of erythrocyte and platelet content, and to determine the age of thrombus as fresh, lytic or organized. There were 11 red, 21 white and 10 mixed thrombi. Furthermore, 36 aspirates had elements of fresh, 7 of lytic and 8 of organized thrombi. There was no correlation between colour and age. OCT appearance could not predict erythrocyte or platelet content. The light intensity ratios were not significantly different in fresh, lytic or organized thrombi. Conclusion OCT could not differentiate between red and white thrombi, nor determine thrombus age.publishedVersio

Baseline frailty status and outcomes important for shared decision-making in older adults receiving transcatheter aortic valve implantation, a prospective observational study.

AIMS The objective of this study was to examine baseline frailty status (including cognitive deficits) and important clinical outcomes, to inform shared decision-making in older adults receiving transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We conducted a prospective, observational study of 82 TAVI patients, recruited 2013 to 2015, with 2-year follow-up. Mean age was 83 years (standard deviation (SD) 4.7). Eighteen percent of the patients were frail, as assessed with an 8-item frailty scale. Fifteen patients (18%) had a Mini-Mental Status Examination (MMSE) score below 24 points at baseline, indicating cognitive impairment or dementia and five patients had an MMSE below 20 points. Mean New York Heart Association (NYHA) class at baseline and 6 months was 2.5 (SD 0.6) and 1.4 (SD 0.6), (p < 0.001). There was no change in mean Nottingham Extended Activities of Daily Living (NEADL) scale between baseline and 6 months, 54.2 (SD 11.5) and 54.5 (SD 10.3) points, respectively, mean difference 0.3 (p = 0.7). At 2 years, six patients (7%) had died, four (5%, n = 79) lived in a nursing home, four (5%) suffered from disabling stroke, and six (7%) contracted infective endocarditis. CONCLUSIONS TAVI patients had improvement in symptoms and maintenance of activity of daily living at 6 months. They had low mortality and most patients lived in their own home 2 years after TAVI. Complications like death, stroke, and endocarditis occurred. Some patients had cognitive impairment before the procedure which might influence decision-making. Our findings may be used to develop pre-TAVI decision aids

Studies on homocysteine-lowering B-vitamin therapy in patients with coronary artery diseas : sub-studies from the Western Norway B-vitamin intervention trial (WENBIT)

Background: A high plasma level of total homocysteine (tHcy) is a risk factor for cardiovascular disease, and is related to important components of atherosclerosis such as inflammation and endothelial dysfunction. Objectives: To test the effect of homocysteine-lowering B-vitamin therapy on 1) tHcy, and metabolites and determinants of tHcy, 2) inflammatory markers associated with atherosclerosis and 3) coronary endothelial and vascular function. Design: Single centre, double-blind clinical interventional study, randomised in a 2x2 factorial design into daily oral treatment with A) folic acid (0.8 mg)/vitamin B12 (0.4 mg)/vitamin B6 (40 mg), B) folic acid/vitamin B12, C) vitamin B6 alone or D) placebo. For the first two weeks, groups A and B received additional folic acid 5 mg/day. Subjects and methods. Two sub-groups of patients participating in the Western Norway Bvitamin Intervention Trial (WENBIT); Patient group 1: Ninety patients (21 female, aged 38- 80 years) with suspected coronary artery disease (CAD). Blood samples were collected at baseline, after 3 days, 2 weeks, 1, 3, 6 months and one year of B-vitamin intervention. An oral methionine loading test (0.1 g/kg body weight) was done at baseline and after 3 months. Patient group 2: Forty patients (8 female, aged 39-74 years) with CAD. They were examined at baseline, and after 9 and 24 months, coronary blood flow (CBF) was assessed by coronary angiography and Doppler flow-wire measurements during intra-coronary infusion of saline (basal), incremental (0.72 μg/min, 7.2 μg/min and 36.0 μg/min) doses of acetylcholine, 2.4 mg/min adenosine and nitroglycerin. Results: In patient group 1, we documented a reduction of 31% on plasma tHcy and a pronounced reduction of post methionine load (PML) tHcy by folic acid/vitamin B12. Vitamin B6 reduced cystathionine and particularly PML cystathionine. There was a strong inverse relation between PML betaine and PML increase in tHcy, a relation that was abolished by folic acid/vitamin B12 treatment for 3 months. Treatment with folic acid/vitamin B12 or vitamin B6 for 6 months had no effects on levels of neopterin, sCD40L, IL 6 or CRP. During the two years of follow-up of patient group 2, basal CBF and adenosine-stimulated CBF increased among patients treated with folic acid /B12 as opposed to those not receiving folic acid /B12. Conclusions: The doses of folic acid/B12 applied in WENBIT give adequate tHcy lowering effect. Cystathionine may be a useful marker for assessment of the vitamin B6 effect. Plasma betaine is a strong determinant of the PML increase in tHcy in patients not supplemented with B-vitamins which emphasizes the complementary relationship between betaine and folate metabolism. Although we observed improved coronary vascular function after treatment with folic acid/vitamin B12, failure to reverse inflammatory processes associated with atherosclerosis may partly explain the negative results of previous B-vitamin intervention trials among patients with established CVD

Acute Myocardial Infarction Due to Microvascular Obstruction in a Young Woman Who Recently Recovered from COVID-19 Infection

Although cardiovascular complications are common in hospitalized COVID-19 patients, those with milder cases who recovered at home are less studied. Here, we report the case of a young woman who recently recovered from COVID-19 at home. A week after recovery, she was admitted to our institution with acute chest pain, signs of ischemia on the electrocardiogram and elevated cardiac troponins. Coronary angiography showed normal epicardial coronary arteries, but the cardiac magnetic resonance showed transmural late gadolinium enhancement (LGE) in the mid-ventricular level of the lateral wall. The findings were strongly suggestive of a minor transmural myocardial infarction. This case report highlights the role of multimodality imaging in detecting cardiac injury in COVID-19 patients as well as the fact that mild COVID-19 cases who recovered at home are also exposed to thromboembolic events during the convalescent period

The Association between Progression of Atherosclerosis and the Methylated Amino Acids Asymmetric Dimethylarginine and Trimethyllysine

Objective: We previously showed that treatment with folic acid (FA)/B12 was associated with more rapid progression of coronary artery disease (CAD). High doses of FA may induce methylation by increasing the availability of S-adenosylmethionine (SAM). Asymmetric dimethylarginine (ADMA) and trimethyllysine (TML) are both produced through proteolytic release following post-translational SAM–dependent methylation of precursor amino acid. ADMA has previously been associated with CAD. We investigated if plasma levels of ADMA and TML were associated with progression of CAD as measured by quantitative coronary angiography (QCA). Methods: 183 patients from the Western Norway B Vitamin Intervention Trial (WENBIT) undergoing percutaneous coronary intervention (PCI) were randomized to daily treatment with 0.8 mg FA/0.4 mg B12 with and without 40 mg B6, B6 alone or placebo. Coronary angiograms and plasma samples of ADMA and TML were obtained at both baseline and follow-up (median 10.5 months). The primary end-point was progression of CAD as measured by diameter stenosis (DS) evaluated by linear quantile mixed models. Results: A total of 309 coronary lesions not treated with PCI were identified. At follow-up median (95% CI) DS increased by 18.35 (5.22–31.49) percentage points per mmol/L ADMA increase (p-value 0.006) and 2.47 (0.37–4.58) percentage points per mmol/L TML increase (p-value 0.021) in multivariate modeling. Treatment with FA/B12 (6B6) was not associated with ADMA or TML levels. Conclusion: In patients with established CAD, baseline ADMA and TML was associated with angiographic progression of CAD. However, neither ADMA nor TML levels were altered by treatment with FA/B12 (6B6)

Thrombus characteristics evaluated by acute optical coherence tomography in ST elevation myocardial Infarction

Aims ST elevation myocardial infarction (STEMI) is caused by an occlusive thrombosis of a coronary artery. We wanted to assess if the thrombus can be characterized according to erythrocyte content and age using intravascular optical coherence tomography (OCT) in a clinical setting. Methods and results We performed manual thrombus aspiration in 66 STEMI patients. OCT was done of the thrombus remnants after aspiration. A light intensity ratio was measured through the thrombus. Forty two of the aspirates had thrombus which could be analyzed histomorphologically for analysis of erythrocyte and platelet content, and to determine the age of thrombus as fresh, lytic or organized. There were 11 red, 21 white and 10 mixed thrombi. Furthermore, 36 aspirates had elements of fresh, 7 of lytic and 8 of organized thrombi. There was no correlation between colour and age. OCT appearance could not predict erythrocyte or platelet content. The light intensity ratios were not significantly different in fresh, lytic or organized thrombi. Conclusion OCT could not differentiate between red and white thrombi, nor determine thrombus age