Coronary Artery Ectasia Predicts Future Cardiac Events in Patients With Acute Myocardial Infarction

Percutaneous intervention of a giant native coronary artery aneurysm using self-expanding stents

In the absence of standardized management guidelines, coronary artery aneurysms (CAAs) present therapeutic challenges. Percutaneous coronary intervention (PCI) is rarely explored, especially in giant aneurysms with persistent angina, where surgery might be presumed as a preferred option. We describe the technical aspects and feasibility of PCI using Gore Viabahn expanded polytetrafluoroethylene (ePTFE)-covered nitinol self-expanding stents in a 66-year-old woman with a complex medical history and an enlarging, symptomatic right coronary artery aneurysm. The case was complicated by endoleak after the first stent, but intravascular ultrasound guidance enabled the precise deployment of additional stents, resulting in the successful exclusion of the aneurysm. This case demonstrates steps to successful CAA PCI with Gore Viabahn ePTFE-covered nitinol self-expanding stents and emphasizes that in unsuitable surgical candidates, PCI might be a potential alternative for symptomatic CAAs.

Coronary Artery Aneurysms and Acute Coronary Syndrome: An Interventionalist's Dilemma

We report three cases of coronary artery aneurysm (CAA) in adults who presented with acute coronary syndrome. Two of these patients did not have traditional coronary artery disease risk factors. Management of CAA poses a significant challenge to interventionalists. We discuss the etiologic mechanisms, risk factors, pathophysiology, and diagnosis using angiography, intravascular ultrasound, and coronary computed tomography. We also highlight management options, including medical therapy and catheter-based interventions such as stenting, coil embolization, stent-assisted coil embolization, and surgical exclusion.

Prognostic role of coronary artery ectasia in patients with nonobstructive coronary artery disease

AIMS

Coronary artery ectasia (CAE) has been linked to the occurrence of adverse events in patients with ischemia/angina and no obstructive coronary arteries (INOCA/ANOCA), while the relationship between CAE and myocardial infarction with nonobstructive coronary arteries (MINOCA) has been poorly investigated. In our study we aimed at assessing differences in clinical, angiographic and prognostic features among patients with CAE and MINOCA vs. INOCA/ANOCA presentation.

METHODS

Patients with angiographic evidence of CAE were enrolled at the University Hospital of Parma and divided into MINOCA vs. INOCA/ANOCA presentation. Clinical and quantitative angiographic information was recorded and the incidence of major adverse cardiovascular events (MACE) was assessed at follow-up.

RESULTS

We enrolled a total of 97 patients: 49 (50.5%) with MINOCA and 48 (49.5%) with INOCA/ANOCA presentation. The presentation with MINOCA was associated with a higher frequency of inflammatory diseases ( P  = 0.041), multivessel CAE ( P  = 0.030) and thrombolysis in myocardial infarction (TIMI) flow < 3 ( P  = 0.013). At a median follow-up of 38 months, patients with MINOCA had a significantly higher incidence of MACE compared with those with INOCA/ANOCA [8 (16.3%) vs. 2 (4.2%), P  = 0.045], mainly driven by a higher rate of nonfatal MI [5 (10.2%) vs. 0 (0.0%), P  = 0.023]. At multivariate Cox regression analysis, the presentation with MINOCA ( P  = 0.039) and the presence of TIMI flow <3 ( P  = 0.037) were independent predictors of MACE at follow-up.

CONCLUSION

Among a cohort of patients with CAE and nonobstructive coronary artery disease, the presentation with MINOCA predicted a worse outcome.

Progressive Dilation of Coronary Artery Ectasia Causing Recurrent Myocardial Infarction

We present a case of recurrent myocardial infarction with coronary artery ectasia that had progressive dilation. Both implanting drug-eluting stent and antithrombotic therapy with warfarin plus P2Y12 inhibitor were feasible. The careful follow-up including morphologic evaluation may be needed for this specific lesion. (Level of Difficulty: Intermediate.).

Chronic exposure to high altitude and the presence of coronary ectasia in patients with ST elevation myocardial infarction

Objective

To evaluate the association between chronic exposure to high altitude and the presence of coronary ectasia (CE) in patients with ST-segment elevation myocardial infarction (STEMI) treated in a highly specialized cardiovascular reference hospital in Peru.

Materials and methods

Retrospective matched case-control study. The cases were patients with CE and controls without CE. The relationship between CE and chronic exposure to high altitude was evaluated considering intervening variables such as arterial hypertension, diabetes mellitus, dyslipidemia, smoking, and hematocrit values. Patients with chronic inflammatory pathologies, chronic obstructive pulmonary disease, and previous revascularization were excluded. Multivariate logistic regression was applied to obtain the OR value and their respective confidence intervals.

Results

Eighteen cases and 18 controls were studied, most of them were men with an average age of 65 years. Thirty-six percent of the population came from high altitude; in this group 76.9% had coronary ectasia of the infarct-related artery. The mean hematocrit value was slightly higher in the high-altitude native (46 ± 7% versus 42 ± 5%, p=0.094). Multivariate conditional logistic regression did not find a significant relationship between exposure to high altitude and the risk of presenting CE (OR:6.03, IC95%: 0.30-118, p=0.236).

Conclusions

In patients with STEMI, we found no association between chronic exposure to high altitude and coronary ectasia.

A Case of Father-Son Juvenile Acute Myocardial Infarction

Coronary artery ectasia (CAE) is a cause of juvenile myocardial infarction. The causes of CAE include arteriosclerosis, vasculitis such as Kawasaki disease, and genetic contribution. There are few reports about familial aggregation of CAE-related juvenile myocardial infarction. We report an unusual case of father-son juvenile myocardial infarction owing to CAE. (Level of Difficulty: Beginner.).

Characteristics of coronary artery ectasia and accompanying plaques: an optical coherence tomography study

Coronary artery ectasia (CAE) in adults is often caused by atherosclerotic plaques. CAE can affect atherosclerotic plaques through hemodynamic changes. However, no study has evaluated the characteristics of CAE with atherosclerotic plaques. Therefore, we aimed to disclose the characteristics of atherosclerotic plaques in patients with CAE using optical coherence tomography (OCT). We evaluated patients with CAE, confirmed by coronary angiography, who underwent pre-intervention OCT between April 2015 and April 2021. Each millimeter of the OCT images was analyzed to assess the characteristics of CAEs, plaque phenotypes, and plaque vulnerability. A total of 286 patients (344 coronary vessels) met our criteria, 82.87% of whom were men. Right coronary artery lesions were the most common, comprising 44.48% (n = 153) of the total. We found 329 CAE vessels with plaques, accounting for 95.64% of the coronary vessels. After grouping CAEs and plaques by their relative positions, we found that the length of plaques within CAE lesions was longer than that of plaques in other sites (P < 0.001). Plaques within CAE lesions had greater maximum lipid angles and lipid indexes (P = 0.007, P = 0.004, respectively) than those on other sites. This study revealed the most common vascular and morphological characteristics of CAE. While the accompanying plaques were not affected by the location or morphology of the CAE vessels, they were affected by their position relative to the CAE lesion.

Circulating miRNA-451a and miRNA-328-3p as Potential Markers of Coronary Artery Aneurysmal Disease

MicroRNAs (miRNAs) are currently investigated as crucial regulatory factors which may serve as a potential therapeutic target. Reports on the role of miRNA in patients with coronary artery aneurysmal disease (CAAD) are limited. The present analysis aims to confirm the differences in the expression of previously preselected miRNAs in larger study groups and evaluate their usefulness as potential markers of CAAD. The study cohort included 35 consecutive patients with CAAD (Group 1), and two groups of 35 patients matched Group 1 regarding sex and age from the overall cohort of 250 patients (Group 2 and Group 3). Group 2 included patients with angiographically documented coronary artery disease (CAD), while Group 3 enrolled patients with normal coronary arteries (NCA) assessed during coronary angiography. We applied the RT-qPCR method using the custom plates for the RT-qPCR array. We confirmed that the level of five preselected circulating miRNAs was different in patients with CAAD compared to Group 2 and Group 3. We found that miR-451a and miR-328 significantly improved the CAAD prediction. In conclusion, miR-451a is a significant marker of CAAD compared to patients with CAD. In turn, miR-328-3p is a significant marker of CAAD compared to patients with NCA.

Coronary artery aneurysms: Comprehensive review and a case report of a left main coronary artery aneurysm

Coronary artery aneurysms (CAAs) are rare anatomical disorders of the coronary arteries. Atherosclerosis and Kawasaki disease are the principal causes of CCAs, while other causes including genetic factors, inflammatory arterial diseases, connective tissue disorders, endothelial damage after cocaine use, iatrogenic complications after interventions and infections, are also common among patients with CAAs. Although there is a variety of non-invasive methods including echocardiography, computed tomography, and magnetic resonance imaging, coronary angiography remains the gold standard diagnostic method. There is still no consensus about the most appropriate therapeutic strategy. Medical therapy including antiplatelets, anticoagulants, statins and ACEs are preferred either in patients with atherosclerosis, inflammatory status and stable CAAs, while percutaneous or surgery interventions are usually applied in patients with acute coronary syndrome due to a CAA culprit, obstructive coronary artery disease or large saccular aneurysms at a high risk of rupturing.

Next-generation sequencing of prolidase gene identifies novel and common variants associated with low prolidase in coronary artery ectasia

BACKGROUND

Decreased collagen biosynthesis and increased collagenolysis can cause ectasia progression in the arterial walls. Prolidase is a key enzyme in collagen synthesis; a decrease in prolidase activity or level may decrease collagen biosynthesis, which may contribute to ectasia formation. Considering that, the variations in PEPD gene encoding prolidase enzyme were evaluated by analyzing next-generation sequencing (NGS) for the first time together with known risk factors in coronary artery ectasia (CAE) patients.

METHODS

Molecular analysis of the PEPD gene was performed on genomic DNA by NGS in 76 CAE patients and 76 controls. The serum levels of prolidase were measured by the sandwich-ELISA technique.

RESULTS

Serum prolidase levels were significantly lower in CAE group compared to control group, and it was significantly lower in males than females in both groups (p < 0.001). On the other hand, elevated prolidase levels were observed in CAE patients in the presence of diabetes (p < 0.001), hypertension (p < 0.05) and hyperlipidemia (p < 0.05). Logistic regression analysis demonstrated that the low prolidase level (p < 0.001), hypertension (p < 0.02) and hyperlipidemia (p < 0.012) were significantly associated with increased CAE risk. We identified four missense mutations in the PEPD gene, namely G296S, T266A, P365L and S134C (novel) that could be associated with CAE. The pathogenicity of these mutations was predicted to be "damaging" for G296S, S134C and P365L, but "benign" for T266A. We also identified a novel 5'UTR variation (Chr19:34012748 G>A) in one patient who had a low prolidase level. In addition, rs17570 and rs1061338 common variations of the PEPD gene were associated with low prolidase levels in CAE patients, while rs17569 variation was associated with high prolidase levels in both CAE and controls (p < 0.05).

CONCLUSIONS

Our findings indicate that the low serum prolidase levels observed in CAE patients is significantly associated with PEPD gene variations. It was concluded that low serum prolidase level and associated PEPD mutations may be potential biomarkers for the diagnosis of CAE.

Long-term Outcomes of Acute Myocardial Infarction in Pre-existing Coronary Artery Ectasia: A Systematic Review and Meta-Analysis

Coronary artery ectasia is associated with an increased risk of acute myocardial infarction. This meta-analysis evaluates outcomes following acute myocardial infarction in patients with pre-existing coronary artery ectasia. A search strategy was designed to utilize PubMed/Medline, EMBASE, and Google scholar for studies including the outcomes of acute myocardial infarction in patients with coronary artery ectasia from inception to February 10, 2022. We reported effect sizes as odds ratio (OR) with a 95% confidence interval (CI). We used I2 statistics to estimate the extent of unexplained statistical heterogeneity. There were 7 studies comprising 13,499 patients in the final analysis. There was no significant difference between patients with coronary ectasia and patients without coronary ectasia in terms of all-cause mortality (OR 0.95; 95% CI 0.58 to 1.56; P = 0.79; I2 = 0%), major adverse cardiovascular events (MACE; OR 4.04; 95% CI 0.34 to 47.57; P = 0.17; I2 = 95%), myocardial re-infarction (OR 2.13; 95% CI 0.83 to 5.47; P = 0.08; I2 = 59%), target vessel revascularization (OR 1.31; 95% CI 0.69 to 2.48; P = 0.21; I2 = 0%), or requiring mechanical supportive devices (OR 1.32; 95% CI 0.22 to 7.83; P = 0.57; I2 = 56%). Acute myocardial infarction in the presence of coronary artery ectasia is not associated with an increased risk of death, MACE, myocardial infarction, or the need for mechanical circulatory support.

Giant Aneurysm of Left Main Coronary Artery in a Patient With Prior Operation for 4-Valve Endocarditis

Left main coronary artery aneurysm is an unusual complication of infective endocarditis. Although this type of aneurysm is often asymptomatic, rupture and thrombus formation that result in myocardial infarction are known complications; therefore, prompt recognition and surgical intervention are warranted. This report describes a patient who presented with a giant left main coronary artery aneurysm 3.5 years after being treated for 4-valve endocarditis. The management and technical aspects of this challenging case are discussed here.

Systemic Immune Inflammation Index is a Novel Marker in Predicting the Presence and Severity of Isolated Coronary Artery Ectasia

BACKGROUND

The underlying pathology of isolated coronary artery ectasia (CE) has not been fully elucidated.

OBJECTIVE

We aimed to examine the relationship between the systemic immune inflammation index (Sıı), which corresponds to the multiplying of the neutrophil-to-lymphocyte ratio (NLR) and the platelet counts, and isolated CE.

METHOD

The retrospective study population included 200 patients with isolated CE, 200 consecutive with obstructive coronary artery disease, and 200 consecutive with a normal coronary artery angiogram. A 2-sided p-value of <0.05 was considered significant.

RESULTS

Sıı, NLR, platelet-to-lymphocyte ratio (PLR), and monocyte-to-high density lipoprotein cholesterol ratio (MHR) were significantly higher in the CE group compared with the other groups (all p<0.001). In multivariate analysis, Sıı (p<0.001, OR = 1.005, 95% CI =1.004-1.005) was found to be an independent predictor of isolated CE. In Receiver Operating Characteristic curve analysis, Sıı had a higher Area Under the Curve than NLR, PLR, and MHR. Sıı value of >517.35 has 79% sensitivity, 76% specificity for the prediction of the CE [AUC: 0.832, (p<0.001)]. Sıı had a significant correlation with the number of ectatic coronary arteries and Markis classification (r:0.214 p=0.002; r:-0.195, p=0.006, respectively).

CONCLUSION

To the best of our knowledge, this is the first study that Sıı was significantly associated with isolated CE presence and anatomical severity.

Prevalence, Predictors, and Impact of Coronary Artery Ectasia in Patients With Atherosclerotic Heart Disease

The clinical relevance of coronary artery ectasia (CAE) is poorly understood. We investigated the prevalence, potential predictors, and prognostic significance of CAE in patients with atherosclerotic coronary artery disease. Consecutive patients undergoing percutaneous coronary intervention (PCI) from January 2016 to December 2018 were included and followed up for 1 year. CAE was diagnosed as an abnormal dilation >1.5-fold the diameter of adjacent normal segments on angiography. A total of 590 patients with CAE were identified from 36 790 patients undergoing PCI (overall rate of CAE: 1.6%). In multivariate analysis, variables including body mass index >30 kg/m2 (risk ratio, RR: 2.413, P = .018), ever-smoking (RR: 1.669, P < .001), hypertension (RR: 1.221, P = .025), acute myocardial infarction at admission (RR: 1.343, P = .004), no diabetes (RR: .810, P = .023), previous myocardial infarction (RR: 1.545, P < .001), no left main disease (RR: .632, P = .008) and multiple-vessel disease (RR: 1.326, P = .001), increased C-reactive protein (RR: 1.006, P = .012) were predictors of CAE. The incidence of adverse cardiovascular outcomes did not differ significantly between patients with or without CAE (P = .203). CAE is not uncommon among patients undergoing PCI in this cohort study. The presence of CAE vs its absence had no significant impact on 1-year clinical outcomes after PCI.

Coronary Artery Aneurysms as a Cause of Acute Coronary Syndrome Presentation - A Focused Review

Coronary artery aneurysms (CAA) are defined as a dilation of a coronary vessel greater than 1.5 times the diameter of a local reference vessel. While CAAs tend to be incidental findings on imaging, they result in complications, such as thrombosis, embolization, ischemia, arrhythmias, and heart failure. Among symptomatic cases, chest pain has been the most common manifestation of CAAs. This necessitates an understanding of CAAs as a cause of acute coronary syndrome (ACS) presentation. However, due to the unclear pathophysiology of CAAs and their variable presentation complicated by similar ACS conditions, there is no clear strategy for CAA management. In this article, we will discuss the contribution of CAAs to ACS presentations and review the current management options for CAAs.

Multi-vessel giant coronary artery aneurysms: An unusual cause of chest pain

We describe an unusual case of multi-vessel giant coronary artery aneurysms complicated by acute coronary syndrome despite escalation of therapy. A 65-year-old man with hypertension and hypercholesterolemia presented to clinic with atypical chest pain over 4 months. Outpatient computed tomography coronary angiography (CTCA) demonstrated giant coronary aneurysms involving all 3 major coronary arteries. Outpatient coronary angiogram findings were in concordance with the CTCA with no definite obstructive coronary disease. Myocardial perfusion imaging was normal. He was commenced on dual antiplatelet therapy (DAPT). At 6 months, he presented with chest pain and non-ST-elevation myocardial infarction. Repeat coronary angiogram demonstrated occluded first septal LAD branch which previously had aneurysmal dilatation. DAPT was changed to long-term oral anticoagulation. He remains well at 18 months. This case highlights the importance of multi-modality imaging in the diagnosis and workup of coronary artery aneurysms and challenges in management; an individualized approach is required.

Recurrent ST-Elevation Myocardial Infarction (STEMI) in Coronary Artery Aneurysm Secondary to Atherosclerosis

We describe a rare case of coronary artery aneurysm (CAA) with recurrent ST-elevation myocardial infarction (STEMI) despite being on standard dual antiplatelet therapy (DAPT). A 47-year-old male presented with chest pain and was found to have inferior wall STEMI along with diffuse right coronary artery (RCA) ectasia and proximal RCA aneurysm, thrombotic occlusion, and dissection. He was managed with extensive thrombectomy, angioplasty, prolonged Heparinization, and DAPT. The patient went on to have a similar presentation nine months later with a recurrent inferior wall STEMI with proximal RCA aneurysm and thrombotic occlusion managed with thrombectomy and bare metal stent placement. He was placed on long-term anticoagulation and DAPT with no further recurrence of MI reported on follow-up.

Etiology, clinical presentation, and management of left main coronary artery aneurysms

BACKGROUND AND AIM OF THE STUDY

The widespread use of noninvasive/invasive coronary imaging increased the probability of recognition of coronary aneurysms. Left main coronary aneurysms (LMCA), though rare, are potentially life-threatening but in the absence of controlled studies, guidelines do not provide any specific recommendation for their management. We, therefore, aimed to investigate the epidemiology, clinical presentation, therapeutic strategies, and prognostic implication of LMCA.

METHODS

A systematic review of the literature was performed to retrieve all the reported cases of LMCA as of December 2021, which were summarized and classified according to their etiology, clinical presentation, and therapeutic management.

RESULTS

Out of 1997 works retrieved, 180 studies were analyzed, describing 209 LMCA cases (aged 51 ± 19 years, 68% males). Atherosclerosis was the most common etiology (40%), followed by inflammatory (12%), congenital (9%), or degenerative (6%) conditions. Stable angina (43%) and acute coronary syndromes (32%) were more often the first clinical manifestations, while 29 (14%) LMCA were incidental findings. Most cases were treated surgically (53%), while percutaneous intervention was rarely adopted (7%). Data about antithrombotic therapies were scarce and heterogeneous. Finally, when longitudinal data were reported (n = 81), LMCA resulted associated with a severe prognosis, with a 15% mortality over an 8-month median follow-up.

CONCLUSIONS

LMCA are most frequently, but not exclusively, caused by advanced atherosclerosis. Irrespective of their etiology and clinical presentation, LMCA may be associated with high short-term mortality. In absence of controlled studies, a careful evaluation of each case is warranted to optimize therapeutic strategies.

13N-Ammonia myocardial blood flow quantitation in patient with aneurismal coronary artery disease

Aneurysmal coronary artery disease includes coronary artery aneurysms and ectasia; this condition has been associated with poor long-term outcomes. Few studies have explored myocardial blood flow 13N-ammonia PET/CT MPI added value. We present a 45-year-old man who came to the emergency department with chest pain. After a physical examination and laboratory studies, he was diagnosed with very high-risk unstable angina and referred to the catheterization laboratory. Coronary angiography showed the culprit lesion in the LCx and was treated by angioplasty and stent. LAD was found with coronary artery ectasia (TIMI 2 flow grade) and the RCA with aneurysmal disease in the proximal and middle segments (TIMI 3 flow grade). Medical treatment was decided for these findings and the patient was discharged. Two weeks later, we performed a 13N-ammonia PET/CT MPI founding apical, inferior, and inferoseptal severe ischemia, and reduced hyperemic coronary blood flow and coronary flow reserve in the RCA territory. Flow was normal in the LAD territory. Although coronary angiography remains the gold standard for evaluating these coronary abnormalities, it does not show the physiological compromise. Therefore 13N-ammonia PET/CT MPI should be performed as a complementary noninvasive imaging approach.

Dual Antiplatelet Therapy Versus Antiplatelet Monotherapy Plus Oral Anticoagulation in Patients with Acute Coronary Syndrome and Coronary Artery Ectasia: Design and Rationale of OVER-TIME Randomized Clinical Trial

INTRODUCTION

The optimal anti-thrombotic therapy to prevent recurrent ischemic events in patients with acute coronary syndrome and coronary artery ectasia (CAE) remains unclear.

AIM

To assess the efficacy and safety of antiplatelet plus anticoagulant therapy versus dual antiplatelet therapy in patients with acute coronary syndromes and coronary artery ectasia.

METHODS

OVER-TIME is an investigator initiated, exploratory, open label, single center, randomized clinical trial comparing dual antiplatelet therapy (acetyl-salicylic acid plus a P2Y12 inhibitor) with the combination of an antiplatelet monotherapy (a P2Y12 inhibitor) plus a low dose anticoagulant (rivaroxaban, 15mg oral dose) for the prevention of recurrent ischemic events among patients with CAE. We aim to enroll approximately 60 patients with CAE and acute coronary syndromes. After recruitment, patients are randomized to (a) standard of care (dual antiplatelet regimen) or (b) the combination of antiplatelet monotherapy and low dose anticoagulant. Patients will be followed for at least 12 months. The OVER-TIME study aims to assess the efficacy of the regimen in prevention of major cardiovascular events and its security in bleeding events in acute coronary syndromes among patients with CAE. Expected results and conclusions: OVER-TIME is the first randomized controlled trial to assess different antithrombotic strategies in patients with CAE and acute coronary syndrome, and its results will offer preliminary data for the prevention of major cardiovascular events and bleeding events in this group of patients.

TRIAL REGISTRATION NUMBER

NCT05233124 (ClinicalTrials.gov), date of registration: February 10, 2022.

Coronary Artery Ectasia: Review of the Non-Atherosclerotic Molecular and Pathophysiologic Concepts

Coronary artery ectasia (CAE) is frequently encountered in clinical practice, conjointly with atherosclerotic CAD (CAD). Given the overlapping cardiovascular risk factors for patients with concomitant CAE and atherosclerotic CAD, a common underlying pathophysiology is often postulated. However, coronary artery ectasia may arise independently, as isolated (pure) CAE, thereby raising suspicions of an alternative mechanism. Herein, we review the existing evidence for the pathophysiology of CAE in order to help direct management strategies towards enhanced detection and treatment.

Antithrombotic treatment strategy for patients with coronary artery ectasia and acute myocardial infarction: A case report

BACKGROUND

There is no consensus on the antithrombotic treatment strategy for patients with coronary artery ectasia (CAE).

CASE SUMMARY

This case reports the dynamic observation of a patient for 48 mo after a diagnosis of CAE with acute myocardial infarction (AMI). The first antithrombotic agents used were aspirin (100 mg/d) and clopidogrel (75 mg/d). During the sixth month of observation, a second AMI occurred involving the same culprit vessel; therefore, antithrombotic agents were changed to aspirin (100 mg/d) and ticagrelor (90 mg twice per day). Twelve months after the second AMI, an attempt to reduce the dosage ticagrelor failed; therefore the original dose was continued. The CAE was relatively stable during the following 4 years.

CONCLUSION

This case indicates that a combination of aspirin and ticagrelor may be more effective for CAE patients with AMI than aspirin and clopidogrel.

Circulating microRNAs in patients with aneurysmal dilatation of coronary arteries

To understand the mechanism underlying coronary artery abnormal dilatation (CAAD), the present study identified and compared the expression of circulating microRNAs (miRNAs) in three groups of patients. Group 1 included 20 patients with CAAD, Group 2 included 20 patients with angiographically confirmed coronary artery disease (CAD), and Group 3 included 20 patients with normal coronary arteries (control). miRNAs were isolated from plasma samples and were profiled using PCR arrays and miRCURY LNA Serum/Plasma Focus PCR Panels. The present study demonstrated that the plasma miRNA levels were significantly different in Group 1 compared with in Group 2 and Group 3 (fold change >2 and P<0.05). The comparison of Group 1 with Group 3 identified 21 significantly upregulated and two downregulated miRNAs in patients with CAAD compared with in the control group. Moreover, six upregulated and two downregulated miRNAs were identified in patients with CAD compared with in the controls. The third comparison revealed four upregulated and three downregulated miRNAs in Group 1, when compared with patients with CAD. In conclusion, the present study identified a specific signature of plasma miRNAs, which were upregulated and downregulated in patients with CAAD compared with in patients with CAD and control individuals.

Safety of conservative management for non-stenotic culprit lesions in STEMI patients treated with a two-step reperfusion strategy: a SUPER-MIMI sub-study

BACKGROUND

In the observational SUPER-MIMI study, a minimalist immediate mechanical intervention (MIMI) technique-which involves restoring blood flow in the acute phase and postponing stenting-was shown to be safe and effective among patients with a high thrombotic burden after ST-segment elevation myocardial infarction (STEMI). We aim to assess whether a non-stenting strategy after a SUPER-MIMI strategy was safe at 4-year follow-up in patients enrolled in the SUPER-MIMI study who were not stented.

METHODS

This prospective cohort study assessed the long-term outcomes of a subgroup of patients included in the SUPER-MIMI study.

RESULTS

Among the 155 patients enrolled in the SUPER-MIMI study, 57 patients (36.8%) benefited from a conservative management (without stenting or balloon angioplasty) and were included in the current substudy. The mean duration of follow-up was 4.1±1.0 years. Four patients (7.0%) presented definite culprit lesion re-thrombosis, all of which occurred in the right coronary artery. The re-thrombosis rate appeared to be higher among patients with larger vessels: 2.9%, 8.3%, and 28.6% in arteries with diameters of 3-<4, 4-<5, and ≥5 mm, respectively. The overall rate of target lesion revascularization was 10.5%. There was one cardiac death and three rehospitalizations for heart failure. Overall, 82.5% of patients remained event free at a mean of 4.1±1.0 years.

CONCLUSIONS

Conservative management of non-stenotic culprit lesions after a SUPER-MIMI strategy was associated with a high rate of re-thrombosis, particularly in patients with large coronary arteries.

Association of ectatic non-infarct-related artery with 1-month stent thrombosis in patients with ST elevation myocardial infarction

BACKGROUND

Ectatic infarct-related artery (IRA) has been shown to be associated with higher thrombus burden, no-reflow, stent thrombosis (ST) and major adverse cardiovascular events in patients with ST-elevation myocardial infarction (STEMI). The effect of ectatic non-IRA on ST without ectatic IRA is not known. We aimed to assess the effect of ectatic non-IRA presence on ST within 1 month after primary percutaneous intervention (pPCI) in patients with STEMI.

METHODS

A total of 1541 patients with a diagnosis of STEMI and underwent pPCI between 2015 and 2020 were retrospectively included in the study. Patients with and without 1 month ST were compared. Penalised logistic regression method was used to assess the association between ST and candidate predictors due to the risk of overfitting.

RESULTS

Median age of the study group was 56.5 (48.7 to 67.2) years. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score, ectatic non-IRA presence and use of tirofiban were significantly higher in the ST group (18.2±9.9 vs 15.1±9.9, p=0.03; 25% vs 7.2%, p<0.001; 54.2% vs 30.5%, p<0.001; respectively). Significantly higher thrombus aspiration (14.3% vs 6.7%, p=0.03) and lower stent implantation (67.7% vs 84%, p<0.001) rates were observed in ectatic IRA group compared with ectatic non-IRA group. In multivariable analysis, ectatic non-IRA presence was independently associated with 1-month ST (OR 4.01, 95% CI 1.86 to 8.63, p=0.01).

CONCLUSION

Ectatic non-IRA presence without ectatic IRA in patients with STEMI increases the risk of ST within the first month of pPCI.

A rare case of asymptomatic right coronary artery ectasia associated with giant aneurysm

A rare case of giant coronary artery ectasia associated with coronary artery aneurysm was recognized. A 69-year-old woman presented with an ischemic electrocardiogram changes during a medical check-up. Coronary computed tomography angiography showed right coronary artery (RCA) ectasia associated with a giant aneurysm originating from the distal RCA. She was asymptomatic and exhibited no risk factors, including Kawasaki disease, hypertension, diabetes mellitus or family history. The patient underwent surgery for giant coronary aneurysms to prevent rupture. The aneurysm was on the peripheral side of the right coronary artery; hence, coronary artery bypass was not performed. The patient’s postoperative course was uneventful. Histopathological examination of the aneurysm revealed degeneration due to atherosclerosis. She was prescribed warfarin and aspirin for thrombus prevention.

Comparison of systemic immune-inflammation index levels in patients with isolated coronary artery ectasia versus patients with obstructive coronary artery disease and normal coronary angiogram

Coronary artery ectasia (CAE) is associated with increased risk of mortality, equivalent to that of patients with obstructive coronary artery disease (CAD). Considering the role of inflammation in the pathogenesis of CAE, we aimed to investigate whether there is an association between systemic immune-inflammation index (SII) and isolated CAE. The study population included 510 patients of which 170 patients with isolated CAE, 170 patients with obstructive CAD and 170 patients with normal coronary angiograms (NCA). The severity of CAE was determined according to the Markis classification. Patients with isolated CAE had significantly higher SII values compared to those with obstructive CAD and NCA [median 550 IQR (404-821), median 526 IQR (383-661), and median 433 IQR (330-555), respectively, p < .001]. In multivariate analysis, SII (OR 1.032, 95% CI 1.020-1.044, p = .003), male gender (OR 2.083, p = .008), eGFR (OR 0.979, p = .016), and CRP (OR 1.105, p = .005) were independent factors of isolated CAE. Moreover, in the Spearman correlation analysis, there was a moderate but significant positive correlation between SII and CRP (r = 0.379, p < .001). In conclusion, higher SII levels were independently associated with the presence of isolated CAE. This result suggests that a more severe inflammatory process may play a role in the development of this variant of CAD.

Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma

Coronary artery ectasia (CAE) is defined as a diffuse or focal dilation of an epicardial coronary artery, which diameter exceeds by at least 1. 5 times the normal adjacent segment. The term ectasia refers to a diffuse dilation, involving more than 50% of the length of the vessel, while the term aneurysm defines a focal vessel dilation. CAE is a relatively uncommon angiographic finding and its prevalence ranges between 0.3 and 5% of patients undergoing coronary angiography. Although its pathophysiology is still unclear, atherosclerosis seems to be the underlying mechanism in most cases. The prognostic role of CAE is also controversial, but previous studies reported a high risk of cardiovascular events and mortality in these patients after percutaneous coronary intervention. Despite the availability of different options for the interventional management of patients with CAE, including covered stent implantation and stent-assisted coil embolization, there is no one standard approach, as therapy is tailored to the individual patient. The abnormal coronary dilation, often associated with high thrombus burden in the setting of acute coronary syndromes, makes the interventional treatment of CAE patients challenging and often complicated by distal thrombus embolization and stent malapposition. Moreover, the optimal antithrombotic therapy is debated and includes dual antiplatelet therapy, anticoagulation, or a combination of them. In this review we aimed to provide an overview of the pathophysiology, classification, clinical presentation, natural history, and management of patients with CAE, with a focus on the challenges for both clinical and interventional cardiologists in daily clinical practice.

High frequency of coronary artery ectasia in obstructive sleep apnea

STUDY OBJECTIVES

Patients with obstructive sleep apnea (OSA) have a greater risk of developing coronary artery disease. However, the frequency of specific coronary artery vascular phenotypes, such as coronary artery ectasia (CAE), which has a frequency of 5% in the general population, has not been studied in patients with OSA. This study aimed to estimate CAE frequency in patients with OSA who underwent coronary angiography.

METHODS

A retrospective cross-sectional study was performed. The results of each polysomnography were reviewed, classifying OSA severity according to the apnea-hypopnea index. Each coronary angiography was reviewed. CAE was defined and classified according to the scales described in the literature. Two groups of patients were classified and compared (OSA/CAE group vs OSA/non-CAE group).

RESULTS

We identified the frequency of CAE in 185 patients with OSA who underwent coronary angiography. The frequency of CAE was 18.4% in these patients. ST-elevation myocardial infarction as the indication for coronary angiography was significantly greater in the OSA/CAE group than the OSA/non-CAE group (26.5% vs 9.9%; P = .02); 62% of the patients having severe OSA (apnea-hypopnea index ≥ 30 events/h). These patients in the OSA/CAE group had a significantly higher median apnea-hypopnea index than in the OSA/non-CAE group (72.5 events/h vs 53.5 events/h, respectively; P = .039). The CAE severity was not directly related to the OSA severity.

CONCLUSIONS

The frequency of CAE in patients with OSA is higher than that reported for the general population. The severity of OSA is related to the presence of CAE but not to its severity.

CITATION

del Portillo JH, Hernandez BM, Bazurto MA, Echeverri D, Cabrales J. High frequency of coronary artery ectasia in obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):433-438.

Coronary artery aneurysms of unknown origin in a 14-year-old girl

The case of a 14-year-old girl with acute myocardial infarction due to coronary artery aneurysms (CAAs) of unknown origin, which resembled coronary artery lesions caused by Kawasaki disease, is reported. She was transferred to our hospital due to chest pain with ST-T elevation. She had no history of Kawasaki disease. On the first admission, she was misdiagnosed with acute myocarditis. Then, 54 days later, she experienced chest pain with exertional dyspnea. Her electrocardiogram showed negative T waves in the chest leads. A CAA of the left coronary artery was suspected on two-dimensional echocardiography. Coronary angiograms showed 90% stenosis and multiple CAAs of the left anterior descending artery and the bifurcation of the left coronary artery. Both the right coronary artery and left circumflex artery were occluded. A left ventriculogram showed dyskinesis and an aneurysm at the apex. She underwent triple-vessel coronary artery bypass grafting, and her symptoms improved. In addition, an intracranial aneurysm was also found on cerebral angiography. There were no specific laboratory findings other than SS-A antibodies. It was suspected that the weakness of the vessels was related to the disease. It may have been a different disease that was never previously detected, but her CAAs were Kawasaki-like CAAs. <Learning objective: A timely precise diagnosis of acute myocardial infarction is unlikely to be made in children because they are rare. The present patient was initially misdiagnosed as having acute myocarditis, because the coronary arteries could not be detected by two-dimensional echocardiography. Either computed tomographic angiography or magnetic resonance angiography is recommended in patients with ST-T abnormalities on the electrocardiogram if it is difficult to identify the coronary arteries. In this case, the patient had a rare coronary artery disease in which the cause of the coronary artery aneurysms was unknown.

Effect of type 2 diabetes on coronary artery ectasia: smaller lesion diameter and shorter lesion length but similar adverse cardiovascular events

Background

Coronary artery ectasia (CAE) is a rare finding in coronary angiography and associated with poor clinical outcomes. Unlike atherosclerosis, diabetes mellitus (DM) is not commonly associated with CAE. This study aims to investigate the effect of type 2 diabetes mellitus (DM2) on coronary artery ectasia, especially the differences in angiographic characteristics and clinical outcomes.

Methods

Patients with angiographically confirmed CAE from 2009 to 2015 were included. Quantitative coronary angiography (QCA) was performed to measure the diameter and length of the dilated lesion. The primary endpoint was the maximum diameter and maximum length of the dilated lesion at baseline coronary angiography. The secondary endpoint was 5-year major adverse cardiovascular events (MACE), which was a component of cardiovascular death and nonfatal myocardial infarction (MI). Propensity score weighting (PSW) and propensity score matching (PSM) were used to balance covariates. Kaplan–Meier method and Cox regression were performed to assess the clinical outcomes.

Results

A total of 1128 patients were included and 258 were combined with DM2. In the DM2 group, the maximum diameter of dilated lesion was significantly lower (5.26 mm vs. 5.47 mm, P  = 0.004) and the maximum length of the dilated lesion was significantly shorter (25.20 mm vs. 31.34 mm, P  = 0.002). This reduction in dilated lesion diameter (5.26 mm vs. 5.41 mm, P  = 0.050 in PSW; 5.26 mm vs. 5.46 mm, P  = 0.007 in PSM, respectively) and length (25.17 mm vs. 30.17 mm, P  = 0.010 in PSW; 25.20 mm vs. 30.81 mm, P  = 0.012 in PSM, respectively) was consistently observed in the propensity score analysis. A total of 27 cardiovascular deaths and 41 myocardial infarctions occurred at 5-year follow-up. Compared with non-DM group, there were similar risks of MACE (6.02% vs. 6.27%; HR 0.96, 95% CI 0.54–1.71, P  = 0.894), cardiovascular death (2.05% vs. 2.61%; HR 0.78, 95% CI 0.29–2.05, P  = 0.605) and MI (4.07% vs. 3.72%; HR 1.11, 95% CI 0.54–2.26, P  = 0.782) in patients with DM2. Consistent result was observed in multivariable regression.

Conclusions

Compared to non-DM patients, patients with CAE and type 2 diabetes were associated with a smaller diameter and shorter length of dilated vessels, suggesting the important effect of DM2 on the pathophysiological process of CAE. Similar risks of MACE were found during 5-year follow up among diabetic and non-DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01444-5.

The Impact of C-Peptide and Diabetes Mellitus on Coronary Ectasia and Effect of Coronary Ectasia and C-Peptide on Long-Term Outcomes: A Retrospective Cohort Study

BACKGROUND

Coronary artery ectasia (CAE) is an entity frequently associated with atherosclerotic coronary artery disease (CAD) in clinical practice. Although it has common risk factors with atherosclerotic CAD in its development, the pathophysiology of CAE is not fully known and it is not seen in every CAD suggesting that different determinants may play a pivotal role in the development of CAD. This study aimed to reveal the impact of C-peptide and diabetes mellitus (DM) on CAE and the effect of C-peptide and coronary ectasia on long-term outcomes in patients who underwent coronary angiography.

METHODS

A total of 6611 patients who underwent coronary angiography were followed up retrospectively, and their major adverse cardiovascular event (MACE) status of an average of sixty months was recorded. According to their angiographic features, the patients were divided into two groups those with and without CAE. MACE development was accepted as the primary endpoint.

RESULTS

A total of 552 patients had CAE and MACE developed in 573 patients. Patients with CAE and higher C-peptide levels (Q4 + Q3) showed higher rates of MACE as compared to those without CAE and lower C-peptide levels (Q1 + Q2) (20.8% vs 7.6%; 70.1% vs 29.1%; p < 0.001, for both of them). In multivariate regression analysis, high C-peptide levels were determined as an independent risk factor for CAE (OR 2.417; 95% CI 2.212-2.641; p < 0.001). The Kaplan-Meier cumulative survival curves showed that the risks for MACE increased as the C-peptide levels increased. The Cox regression analysis for 5-years MACE related to the plasma C-peptide levels and presence of CAE, C-peptide, and CAE were found to be independent predictors of MACE (HR = 1.255, 95% CI: 1.164-1.336, p < 0.001 and HR = 1.012, 95% CI: 1.002-1.023, p=0.026, respectively).

CONCLUSION

Our study revealed that a high C-peptide level is an independent risk factor for CAE and that CAE and C-peptide are independent predictors for the development of MACE.

Plasma Big Endothelin-1 Level Predicted 5-Year Major Adverse Cardiovascular Events in Patients With Coronary Artery Ectasia

Background: Coronary artery ectasia (CAE) is found in about 1% of coronary angiography and is associated with poor clinical outcomes. The prognostic value of plasma big Endothelin-1 (ET-1) in CAE remains unknown. Methods: Patients with angiographically confirmed CAE from 2009 to 2015, who had big ET-1 data available were included. The primary outcome was 5-year major adverse cardiovascular events (MACE), defined as a component of cardiovascular death and non-fatal myocardial infarction (MI). Patients were divided into high or low big ET-1 groups using a cut-off value of 0.58 pmol/L, according to the receiver operating characteristic curve. Kaplan-Meier method, propensity score method, and Cox regression were used to assess the clinical outcomes in the 2 groups. Results: A total of 992 patients were included, with 260 in the high big ET-1 group and 732 in the low big ET-1 group. At 5-year follow-up, 57 MACEs were observed. Kaplan-Meier analysis and univariable Cox regression showed that patients with high big ET-1 levels were at increased risk of MACE (9.87 vs. 4.50%; HR 2.23, 95% CI 1.32-3.78, P = 0.003), cardiovascular death (4.01 vs. 1.69%; HR 2.37, 95% CI 1.02-5.48, P = 0.044), and non-fatal MI (6.09 vs. 2.84%; HR 2.17, 95% CI 1.11-4.24, P = 0.023). A higher risk of MACE in the high big ET-1 group was consistent in the propensity score matched cohort and propensity score weighted analysis. In multivariable analysis, a high plasma big ET-1 level was still an independent predictor of MACE (HR 1.82, 95% CI 1.02-3.25, P = 0.043). A combination of high plasma big ET-1 concentrate and diffuse dilation, when used to predict 5-year MACE risk, yielded a C-statistic of 0.67 (95% CI 0.59-0.74). Conclusion: Among patients with CAE, high plasma big ET-1 level was associated with increased risk of MACE, a finding that could improve risk stratification.

Development and Validation of a Nomogram for Predicting the Risk of Adverse Cardiovascular Events in Patients with Coronary Artery Ectasia

Coronary artery ectasia (CAE) is a rare finding and is associated with poor clinical outcomes. However, prognostic factors are not well studied and no prognostication tool is available. In a derivation set comprising 729 consecutive CAE patients between January 2009 and June 2014, a nomogram was developed using Cox regression. Total of 399 patients from July 2014 to December 2015 formed the validation set. The primary outcome was 5-year major adverse cardiovascular events (MACE), a component of cardiovascular death and nonfatal myocardial infarction. Besides the clinical factors, we used quantitative coronary angiography (QCA) and defined QCA classification of four types, according to max diameter (< or ≥5 mm) and max length ratio (ratio of lesion length to vessel length, < or ≥1/3) of the dilated lesion. A total of 27 cardiovascular deaths and 41 nonfatal myocardial infarctions occurred at 5-year follow-up. The nomogram effectively predicted 5-year MACE risk using predictors including age, prior PCI, high sensitivity C-reactive protein, N-terminal pro-brain natriuretic peptide, and QCA classification (area under curve [AUC] 0.75, 95% CI 0.68–0.82 in the derivation set; AUC 0.71, 95% CI 0.56–0.86 in the validation set). Patients were classified as high-risk if prognostic scores were ≥155 and the Kaplan–Meier curves were well separated (log-rank p < 0.001 in both sets). Calibration curve and Hosmer–Lemeshow test indicated similarity between predicted and actual 5-year MACE survival (p = 0.90 in the derivation and p = 0.47 in the validation set). This study developed and validated a simple-to-use method for assessing 5-year MACE risk in patients with CAE.

Metabolomic Characterization of Fatty Acids in Patients With Coronary Artery Ectasias

Background: We used a targeted metabolomics approach to identify fatty acid (FA) metabolites that distinguished patients with coronary artery ectasia (CAE) from healthy Controls and patients with coronary artery disease (CAD). Materials and methods: Two hundred fifty-two human subjects were enrolled in our study, such as patients with CAE, patients with CAD, and Controls. All the subjects were diagnosed by coronary angiography. Plasma metabolomic profiles of FAs were determined by an ultra-high-performance liquid chromatography coupled to triple quadrupole mass spectrometric (UPLC-QqQ-MS/MS). Results: Ninety-nine plasma metabolites were profiled in the discovery sets (n = 72), such as 35 metabolites of arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), 10 FAs, and 54 phospholipids. Among these metabolites, 36 metabolites of AA, EPA, and DHA showed the largest difference between CAE and Controls or CAD. 12-hydroxyeicosatetraenoic acid (12-HETE), 17(S)-hydroxydocosahexaenoic acid (17-HDoHE), EPA, AA, and 5-HETE were defined as a biomarker panel in peripheral blood to distinguish CAE from CAD and Controls in a discovery set (n = 72) and a validation set (n = 180). This biomarker panel had a better diagnostic performance than metabolite alone in differentiating CAE from Controls and CAD. The areas under the ROC curve of the biomarker panel were 0.991 and 0.836 for CAE versus Controls and 1.00 and 0.904 for CAE versus CAD in the discovery and validation sets, respectively. Conclusions: Our findings revealed that the metabolic profiles of FAs in the plasma from patients with CAE can be distinguished from those of Controls and CAD. Differences in FAs metabolites may help to interpret pathological mechanisms of CAE.

Characteristics and outcomes of patients with coronary artery ectasia presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The clinical significance of coronary artery ectasia (CAE) is not yet fully understood. We aimed to examine differences in clinical and procedural characteristics, clinical management, and outcomes in patients with CAE undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI).

METHODS

This was a retrospective analysis of consecutive patients presenting with STEMI with a culprit native coronary artery from July 2015 to June 2019. Patients were divided into CAE and Non-CAE groups as detected on coronary angiography during PPCI. Comparison between groups was made for baseline clinical and procedural characteristics, as well as complications, pharmacological treatment, and follow-up outcomes.

RESULTS

36/1780 (2.0%) patients were found to have CAE. Patients with CAE had a median age of 57.1 ± 11.7 years and were more likely to be male 33/36 (91.7%). Diabetes was less commonly seen in the CAE group (11.1% vs 31.4%, p = 0.010), and there were no differences in the proportion of patients with hypertension and hyperlipidemia. Patients with CAE had more involvement of right coronary artery (RCA) culprit vessel (63.9% vs. 38.4%, p = 0.026), less coronary stenting (25.0% vs 87.2%, p < 0.001) and post-PPCI TIMI 3 flow (69.4% vs 95.5%, P < 0.001), and were more likely to be discharged with oral anticoagulants (36.1% vs 7.6%, p < 0.001). At 3-year follow-up, all-cause mortality rates were higher in the non-CAE group (0.0% vs 11.5%, p < 0.028), suggesting that CAE was not associated with unfavorable long-term outcome. On multivariate analysis, CAE was not an independent predictor of MACE.

CONCLUSION

Despite lower rates of post-PPCI TIMI 3 flow, CAE was not associated with unfavorable long-term outcome.

Sino-tubular junction to sinuses of Valsalva ratio: An echocardiographic parameter to predict coronary artery ectasia in patients with aortic enlargement

BACKGROUND

Coronary artery ectasia (CAE) is associated with ascending aortic (AA) ectasia. The purpose of this study is to evaluate the diagnostic performance of different echocardiographic parameters (EP) in predicting the presence of CAE.

METHODS

Four hundred-eighteen patients with AA ectasia candidate to coronary angiography were identified and divided in two groups in respect of the presence of CAE. Receiver-operating characteristic curves areas (AUC) were used to assess the discrimination power of the following EP: aortic annulus diameter, sinuses of Valsalva (SV) diameter, sino-tubular junction (STJ) diameter, AA diameter, STJ to SV ratio (STJ-to-SV) and STJ to AA ratio (STJ-to-AA). All these parameters were indexed by body surface area. The relationship between the best EP and the presence of CAE was investigated by means of multivariable logistic regression.

RESULTS

The rate of CAE in the study population was 32%. On univariable logistic regression, aortic annulus, STJ, STJ-to-SV and STJ-to-AA were associated with the presence of CAE after Bonferroni correction. STJ-to-SV emerged as the parameter with the best discrimination power (AUC = 0.81) compared to STJ (AUC = 0.69), STJ-to-AA (AUC = 0.68), aortic annulus (AUC = 0.59), AA (AUC = 0.56) and SV (AUC = 0.55); (p for comparison <0.01). An 89.6% value for STJ-to-SV ratio emerged as the best cut-off to diagnose CAE with a sensitivity = 75%, specificity = 82%, positive predictive value = 66% and negative predictive value = 88%. On multivariable analysis, STJ-to-SV was still associated with the presence of CAE (OR = 1.15;95%CI:1.11-1.19;p < 0.01).

CONCLUSION

In patients with dilated aorta, STJ-to-SV sampled by transthoracic echocardiography shows a good diagnostic performance in predicting the presence of CAE.

Association of Opium Addiction with Coronary Artery Ectasia and Coronary Artery Disease

Background

Coronary artery ectasia (CAE) is a rare cardiovascular disorder with unknown mechanisms and related risk factors. The roles played by homocysteine in induction of cardiovascular diseases (CVDs) have also been documented previously. This project was designed to assess the relationship between opium and CAE and coronary artery disease (CAD).

Methods

This cross-sectional study was performed on 46 patients with CAE, 30 patients with CAD, and 42 cases without CAE and CAD (controls). Demographic data and information regarding opium consuming and also smoking were collected using a standard checklist. Serum levels of homocysteine, creatinine (Cr), urea, fasting blood glucose (FBG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride (TG), and cholesterol were determined.

Findings

Statistical analysis revealed that opium consumers were significantly higher in patients with CAD and CAE when compared to healthy controls. Opium increased serum levels of Cr in the normal controls, and decreased HDL in the patients with CAD. Homocysteine serum levels were not significantly different between the groups.

Conclusion

The results of study showed that opium addiction was associated with increased risk of CAE and CAD, independent of homocysteine serum levels.

Pharmacologic Management of Coronary Artery Ectasia

Coronary artery ectasia (CAE) is a rare form of aneurysmal coronary heart disease. It is defined as a dilatation of the coronary artery by more than one-third of its length and with a diameter 1.5 times of a normal coronary artery adjacent to it. This condition increases the risk of angina pectoris and acute coronary syndrome. Hence, we discuss the pharmacologic options for primary and secondary prevention of CAE complications. Antiplatelets such as aspirin are considered the mainstay of treatment in patients with CAE. Anticoagulants such as warfarin are warranted on a case-by-case basis to prevent thrombus formation depending on the presence of concomitant obstructive coronary artery disease and the patient’s risk of bleeding. Since atherosclerosis is the most common cause of CAE, statins are indicated in all patients for primary prevention. Angiotensin-converting enzyme (ACE) inhibitors may be indicated, especially in hypertensive patients, due to their anti-inflammatory properties. Beta-blockers may be indicated due to their antihypertensive and anti-ischemic effects. Calcium (Ca) channel blockers may be needed to prevent coronary vasospasm. Nitrates are generally contraindicated as they may lead to worsening of symptoms. Other antianginal medications such as trimetazidine can improve exercise tolerance with no reported adverse events in these patients.

Prevalence and Long-term Outcomes of Patients with Coronary Artery Ectasia Presenting with Acute Myocardial Infarction

Coronary artery ectasia (CAE) is described in 5% of patients undergoing coronary angiography. Previous studies have shown controversial results regarding the prognostic impact of CAE. The prevalence and prognostic value of CAE in patients with acute myocardial infarction (AMI) remain unknown. In 4788 patients presenting with AMI referred for coronary angiography the presence of CAE (defined as dilation of a coronary segment with a diameter ≥1.5 times of the adjacent normal segment) was confirmed in 174 (3.6%) patients (age 62 ± 12 years; 81% male), and was present in the culprit vessel in 79.9%. Multivessel CAE was frequent (67%). CAE patients were more frequently male, had high thrombus burden and were treated more often with thrombectomy and less often was stent implantation. Markis I was the most frequent angiographic phenotype (43%). During a median follow-up of 4 years (1-7), 1243 patients (26%) experienced a major adverse cardiovascular event (MACE): 282 (6%) died from a cardiac cause, 358 (8%) had a myocardial infarction, 945 (20%) underwent coronary revascularization and 58 (1%) presented with a stroke. Patients with CAE showed higher rates of MACE as compared to those without CAE (36.8% versus 25.6%; p <0.001). On multivariable analysis, CAE was associated with MACE (HR 1.597; 95% CI 1.238-2.060; p <0.001) after adjusting for risk factors, type of AMI and number of narrowed coronary arteries. In conclusion, the prevalence of CAE in patients presenting with AMI is relatively low but was independently associated with an increased risk of MACE at follow-up.

Coronary artery aneurysm: A review

Coronary artery aneurysm (CAA) is a clinical entity defined by a focal enlargement of the coronary artery exceeding the 1.5-fold diameter of the adjacent normal segment. Atherosclerosis is the main cause in adults and Kawasaki disease in children. CAA is a silent progressive disorder incidentally detected by coronary angiography, but it may end with fatal complications such as rupture, compression of adjacent cardiopulmonary structures, thrombus formation and distal embolization. The pathophysiological mechanisms are not well understood. Atherosclerosis, proteolytic imbalance and inflammatory reaction are involved in aneurysmal formation. Data from previously published studies are scarce and controversial, thereby the management of CAA is individualized depending on clinical presentation, CAA characteristics, patient profile and physician experience. Multiple therapeutic approaches including medical treatment, covered stent angioplasty, coil insertion and surgery were described. Herein, we provide an up-to-date systematic review on the pathophysiology, complications and management of CAA.

Coronary Artery Anomalies

Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin or course of any of the 3 main epicardial coronary arteries. Although CAAs have been identified as a common underlying condition in young athletes with sudden cardiac death, the widespread use of invasive and noninvasive coronary imaging has led to increased recognition of CAAs among adults. CAAS are often discovered as an incidental finding during the diagnostic workup for ischemic heart disease. The clinical correlates and prognostic implication of CAAs remain poorly understood in this context, and guideline-recommended therapeutic choices are supported by a low level of scientific evidence. Several studies have examined whether assessment of CAA-related myocardial ischemia can improve risk stratification in these patients, suggesting that multimodality imaging and functional tests may be key in the management of CAAs. The aim of this review is to outline definitions, classification, and epidemiology of the most relevant CAAs, highlighting recent advances and the potential impact of multimodality evaluation, and to discuss current therapeutic opportunities.

Clinical outcome of patients with ST-elevation myocardial infarction and angiographic evidence of coronary artery ectasia

OBJECTIVES

The aim of this study was to describe the prevalence of coronary artery ectasia (CAE) in patients with ST-elevation myocardial infarction (STEMI) and to compare the long-term outcome of subjects with and without CAE undergoing emergent coronary angiography.

BACKGROUND

The prognostic impact of CAE in STEMI patients has been poorly investigated.

METHODS

This retrospective, single-center, study included consecutive patients with STEMI undergoing emergent coronary angiography from January 2012 to December 2017. The primary endpoint was the assessment of recurrent myocardial infarction (MI) in patients with versus those without CAE at the longest available follow-up. The propensity score weighting technique was employed to account for potential selection bias between groups.

RESULTS

From 1,674 patients with STEMI, 154 (9.2%) had an angiographic evidence of CAE; 380 patients were included in the no CAE group. CAE patients were more often males and smokers, and showed a lower prevalence of diabetes than no CAE patients. After percutaneous coronary intervention, the corrected thrombolysis in MI frame count (p < .001) and the myocardial blush grade (p < .001) were significantly lower in CAE than in no CAE patients. The mean follow-up was 1,218.3 ± 574.8 days. The adjusted risk for the primary outcome resulted significantly higher in patients with CAE compared to those without (adjusted HR: 1.84; p = .017). No differences in terms of all-cause and cardiac death were found between groups.

CONCLUSIONS

In this study, STEMI patients with CAE had a distinct clinical and angiographic profile, and showed a significantly higher risk of recurrent MI than those without CAE.