Coronary Artery Perforation and Regrowth of a Side Branch Occluded by a Polytetrafluoroethylene-Covered Stent Implantation

Stenting of the right coronary artery stenosis caused coronary perforation and profound dye (blood) extravasation in a 69-year-old female patient. Instantaneous balloon inflation followed by implantation of a polytetrafluoroethylene- (PTFE-)covered stent sealed the coronary perforation, restored the blood flow, and perceivably caused acute occlusion of a large side branch (SB). The immediate in situ balloon inflation prevented the development of cardiac tamponade. Surprisingly, followup coronary angiography 4 and 11 months later showed spontaneous recanalization of the SB occluded by PTFE-covered stent. The SB was filled through a channel beginning at the end of the covered stent streaming retrogradely beneath it toward the SB ostium. Up to the best of our knowledge, this is the first described case of late spontaneous recanalization of as SB occluded by a PTFE-covered stent

Impaired glucose tolerance in ischemic heart disease

Background: Diabetes mellitus (DM) and impaired glucose tolerance test (IGT) are well known risk factors for cardiovascular disease (CVD). Individuals with IGT, a prediabetic state, are asymptomatic during many years and they often remain undiagnosed until they have developed overt diabetes or cardiovascular complications. Patients and methods: A total 123 patients, aged 31-80 years with a previous acute myocardial infarction (MI) but without a known DM were examined. A standard oral glucose test (OGTT) was performed. Calculated intimamedia (clMa) of the brachial and common carotid arteries, flow-mediated dilation (FMD) of the brachial artery, left ventricular dimensions and systolic function were examined. Left ventricular diastolic function was evaluated by tissue velocity echocardiography. Microalbuminuria (MA) was defined as excretion of 20-200 mug albumin/min. Results: The prevalence of DM and IGT in patients discharged from the CCU after MI without known DM diagnosis was high (38%). A fasting plasma glucose (PG) alone failed to identify more than 80% of the patients with abnormal glucose metabolism in this study. A multiple stepwise regression analysis revealed an independent and significant association between 2h PG and CRP (P <0.05). In the whole group calculated intimamedia area was associated with 2h PG after the glucose load (P <0.05). Both cIMa of the common carotid artery and the cIMa of the brachial artery were independently and significantly associated with left ventricular septum thickness. Microalbuminuria (MA) was present in 11% of patients. Patients with MA had significantly higher levels of 2h PG, lower displacement of the atrioventricular (AV) plane by M-mode echocardiography, thicker LV septum wall and a higher prevalence of impaired glucose tolerance compared with those with normoalbuminuria (p<0.05). Urinary albumin excretion (UAE) was significantly and positively associated with cIMa in both brachial and common carotid arteries, age and interventricular septum thickness. 2-h PG was significantly and negatively associated with diastolic TDI parameters such as early diastolic filling velocity (E-v), ratio of the early to late diastolic filling velocity (E'/A') and positively associated with Tei index (p<0.05). Left ventricular ejection time and Teiindex were significantly higher, E'/A' and E-v were significantly lower in patients with disturbed glucose metabolism compared with patients with normal glucose tolerance (p<0.01). These differences also remained significant when patients with DM were excluded from analysis. Conclusions: The prevalence of abnormal glucose tolerance was high in patients discharged after MI without known DM. Glucose intolerance was associated with inflammation, surrogate variables for atherosclerosis, microalbuminuria and LV diastolic dysfunction. In this population FMD was probably not a reliable marker, since FMD is a functional parameter of the arterial system, particularly well suited for the study of the earlier stages of atherosclerosis in children and young adults without stiff arteries

2-h postchallenge plasma glucose predicts cardiovascular events in patients with myocardial infarction without known diabetes mellitus

Background and purpose The incidence of cardiovascular events remains high in patients with myocardial infarction (MI) despite advances in current therapies. New and better methods for identifying patients at high risk of recurrent cardiovascular (CV) events are needed. This study aimed to analyze the predictive value of an oral glucose tolerance test (OGTT) in patients with acute myocardial infarction without known diabetes mellitus (DM). Methods The prospective cohort study consisted of 123 men and women aged between 31–80 years who had suffered a previous MI 3–12 months before the examinations. The exclusion criteria were known diabetes mellitus. Patients were followed up over 6.03 ± 1.36 years for CV death, recurrent MI, stroke and unstable angina pectoris. A standard OGTT was performed at baseline. Results 2-h plasma glucose (HR, 1.27, 95% CI, 1.00 to 1.62; P < 0.05) and smoking (HR, 3.56, 95% CI, 1.02 to 12.38; P < 0.05) proved to be independent predictors of CV events in multivariate statistical analysis after adjustments for age, sex, total cholesterol, and other baseline characteristics. Conclusions In this study population, with previous MI and without known DM, 2-h PG and smoking were significant predictors of CV death, recurrent MI, stroke and unstable angina pectoris, independent of baseline characteristics and medical treatment

Rationale and design of BROKEN-SWEDEHEART: a registry-based, randomized, parallel, open-label multicenter trial to test pharmacological treatments for broken heart (takotsubo) syndrome

Background Takotsubo syndrome (TS) is a life-threatening acute heart failure syndrome without any evidence-based treatment options. No treatment for TS has been examined in a randomized trial.Study design and objectives BROKEN-SWEDEHEART is a multicenter, randomized, open-label, registry-based 2 x 2 factorial clinical trial in patients with TS designed to test whether treatment with adenosine and dipyridamole accelerates cardiac recovery and improves clinical outcomes compared to standard care (study 1); and apixaban reduces the risk of thromboembolic events compared to no treatment with antithrombotic drugs (study 2). The trial will enroll 1,000 patients. Study 1 (adenosine hypothesis) will evaluate 2 coprimary end points: (1) wall motion score index at 48 to 96 hours (evaluated in the first 200 patients); and (2) the composite of death, cardiac arrest, need for mechanical assist device or heart failure hospitalization within 30 days or left ventricular ejection fraction &amp;lt;50% at 48 to 96 hours (evaluated in 1,000 patients). The primary end point in study 2 (apixaban hypothesis) is the composite of death or thromboembolic events within 30 days or the presence of intraventricular thrombus on echocardiography at 48 to 96 hours. Conclusions BROKEN-SWEDEHEART will be the first prospective randomized multicenter trial in patients with TS. It is designed as 2 parallel studies to evaluate whether adenosine accelerates cardiac recovery and improves cardiac function in the acute phase and the efficacy of anticoagulation therapy for preventing thromboembolic complications in TS. If either of its component studies is successful, the trial will provide the first evidence-based treatment recommendation in TS.Clinical trials identifier : The trial has been approved by the Swedish Medicinal Product Agency and the Swedish Ethical Board and is registered at ClinicalTrials.gov (NCT04666454). (Am Heart J 2023;257:33-40.)Funding Agencies|Swedish Research Council [2019-00475]; Swedish Heart and Lung Foundation [20200826]; ALF Goteborg [ALFGBG-920961]</p

Coronary Plaque Burden, as Determined by Cardiac Computed Tomography, in Patients with Myocardial Infarction and Angiographically Normal Coronary Arteries Compared to Healthy Volunteers: A Prospective Multicenter Observational Study

<div><p>Objectives</p><p>Patients presenting with acute myocardial infarction and angiographically normal coronary arteries (MINCA) represent a diagnostic and a therapeutic challenge. Cardiac computed tomography (CT) allows detection of coronary artery disease (CAD) even in the absence of significant stenosis. We aimed to investigate whether patients suffering from MINCA had a greater coronary plaque burden, as determined by cardiac CT, than a matched group of healthy volunteers.</p><p>Methods</p><p>Consecutive patients, aged 45 to 70, with MINCA were enrolled in the Stockholm metropolitan area. Patients with myocarditis were excluded using cardiovascular magnetic resonance imaging. Remaining patients underwent cardiac CT, as did a reference group of healthy volunteers matched by age and gender, with no known cardiovascular disease. Plaque burden was evaluated semi-quantitatively on a per patient and a per segment level.</p><p>Results</p><p>Despite a higher prevalence of smoking and hypertension, patients with MINCA did not have more CAD than healthy volunteers. Among 57 MINCA patients and 58 volunteers no signs of CAD were found in 24 (42%) and 25 (43%) respectively. On a <i>per segment</i> level, MINCA patients had less segments with stenosis ≥20% (2% vs. 5%, p<0.01), as well as a smaller proportion of large (2% vs. 4%, p<0.05) and mixed type plaques (1% vs. 4%, p<0.01). The median coronary calcium score did not differ between MINCA patients and healthy volunteers (6 vs. 8, <i>ns</i>).</p><p>Conclusions</p><p>MINCA patients with no or minimal angiographic stenosis do not have more coronary atherosclerosis than healthy volunteers, and a large proportion of these patients do not have any signs of CAD, as determined by cardiac CT. The MINCA patient group is probably heterogeneous, with a variety of different underlying mechanisms. Non-obstructive CAD is most likely not the most prevalent cause of myocardial infarction in this patient group.</p></div

Baseline characteristics.

<p>Abbreviations: MINCA, myocardial infarction with angiographically normal coronary arteries; CAD, coronary artery disease; BMI, body mass index; SD, standard deviation. Data are presented as mean ± SD or absolute value (percentage).</p><p>*P<0.05,</p>†<p>P<0.01, using Fisher’s exact test.</p

The right coronary artery in a patient presenting with acute myocardial infarction.

<p>Cardiac computed tomography (A) shows a large atherosclerotic plaque and more distally a small plaque, both with <20% stenosis. Coronary angiography (B) shows only minimal signs of atherosclerosis.</p

Different plaque types, as seen by cardiac computed tomography.

<p>A non-calcified plaque is shown in longitudinal and cross section (A and B). The degree of stenosis was 20–50%. A large mixed plaque is shown in longitudinal section (C) and in cross section at the level of non calcified (D) and calcified (E) components. A large calcified plaque is shown to the right. (F and G). The mixed and calcified plaques (C to G) were both eccentric in location and the degree of stenosis was <20%.</p

Cardiac CT plaque burden per segment.

<p>Abbreviations: Cardiac CT, cardiac computed tomography; MINCA, myocardial infarction with angiographically normal coronary arteries; CAD, coronary artery disease; Values are presented as absolute value (percentage).</p><p>*P-values apply to the comparison of the four categories in the two columns to the left of the value, using the chi-square test.</p

Cardiac CT plaque burden per patient.

<p>Abbreviations: Cardiac CT, cardiac computed tomography; MINCA, myocardial infarction with angiographically normal coronary arteries; CAD, coronary artery disease; <i>ns</i>, non significant. Values are presented as absolute value (percentage) or median (range).</p><p>*refers to the maximum diameter stenosis;</p>†<p>refers to obstructive and non-obstructive CAD.</p