Coronary Vasculitis

Coronary Artery Vasculitis and Encasement: Multimodality Imaging Findings and Mimics

Coronary artery vasculitis (CAV) and coronary artery encasement are rarely diagnosed conditions that are important diagnostic considerations, particularly in patients with acute coronary syndrome without traditional cardiovascular risk factors or systemic illness. Vasculitis refers to inflammation of the blood vessel walls, which can be primary or secondary. This process should be distinguished from neoplastic involvement of the coronary arteries, termed coronary artery encasement. Prospective diagnosis of these diseases is challenging, often requiring multidisciplinary workup with careful attention to clinical presentation and multiorgan findings. While CAV and coronary artery encasement can be indistinguishable at coronary CT angiography, certain imaging features help order the differential diagnosis. CAV should be considered when there is smooth wall thickening that is circumferential and/or continuous. A diagnosis of coronary artery encasement is favored when there is irregular or nodular wall thickening that is eccentric to the vessel lumen. Epicardial fat stranding may also appear more extensive compared with CAV. Potential mimics of CAV include atherosclerosis, acute plaque rupture, coronary artery aneurysm, and spontaneous coronary artery dissection. Detection and diagnosis of CAV may help avoid complications related to accelerated atherosclerosis and infarction. Radiologists should be familiar with the range of pathologic conditions that can affect the coronary arteries beyond atherosclerosis as they may be the first to raise such diagnostic possibilities, guiding next steps in patient workup and management. ©RSNA, 2024 Supplemental material is available for this article.

Sudden cardiac death caused by Kawasaki coronary artery vasculitis in a child with Hodgkin's lymphoma. Case report and literature review

Coronary artery vasculitis is a rare pathological condition and is often a manifestation of systemic vasculitis, such as Polyarteritis Nodosa, Kawasaki Disease, Takayasu Arteritis, and Giant Cell Arteritis, with Kawasaki Disease being the most common cause in children. We present the autopsy case of a 6-year-old boy with classic Hodgkin lymphoma who died of sudden cardiac death due to thrombosis caused by vasculitis, which exclusively affected the coronary arteries and was suggestive of Kawasaki Disease. To further investigate the histological features of Kawasaki Disease across all age groups, we conducted a literature review using the search terms "Kawasaki AND vasculitis AND histopathology" and "Kawasaki vasculitis histopathology" in Scopus, Google Scholar, and PubMed, covering the period from 1967 to 2023. The inclusion criteria were as follows: coronary histology (inflammation and/or aneurysm and/or thrombosis), postmortem studies, English language, free articles, all age groups, case reports, and case series.

Management of Coronary Artery Diseases in Systemic Vasculitides: Complications and Strategies

Coronary artery disease (CAD) presents a significant risk for patients with systemic vasculitides, a group of disorders characterized by the inflammation of blood vessels. In this review, we focus on the pathophysiological mechanisms, complications, and management strategies for CAD in systemic vasculitides. We highlight how the inflammatory processes inherent in vasculitis contribute to accelerated atherosclerosis and myocardial ischemia. Key strategies in managing CAD in this patient population include using medicine treatments to mitigate vascular inflammation while balancing the risk of promoting cardiovascular events and lifestyle modifications. Understanding the nuanced relationship between systemic vasculitides and CAD is crucial for improving patient outcomes and guiding therapeutic approaches.

Shifting perspectives in coronary involvement of polyarteritis nodosa: case of 3-vessel occlusion treated with 4-vessel CABG and review of literature

BACKGROUND

Polyarteritis Nodosa (PAN) is a systemic vasculitis (SV) historically thought to spare the coronary arteries. Coronary angiography and contemporary imaging reveal coronary stenosis and dilation, which are associated with significant morbidity and mortality. Coronary arteries in PAN are burdened with accelerated atherosclerosis from generalized inflammation adding to an inherent arteritic process. Traditional atherosclerotic risk factors fail to approximate risk. Few reports document coronary pathology and optimal therapy has been guarded.

METHODS

Database publication query of English literature from 1990-2022.

RESULTS

Severity of coronary involvement eludes laboratory monitoring, but coronary disease associates with several clinical symptoms. Framingham risk factors inadequately approximate disease burden. Separating atherosclerosis from arteritis requires advanced angiographic methods. Therapy includes anticoagulation, immunosuppression and revascularization. PCI has been the mainstay, though stenting is confounded by vagarious alteration in luminal diameter and reports of neointimization soon after placement.

CONCLUSIONS

When graft selection avoids the vascular territory of SV's, CABG offers definitive therapy. We have contributed report of a novel CABG configuration in addition to reviewing, updating and discussing the literature. Accumulating evidence suggests discrete clinical symptoms warrant suspicion for coronary involvement.

Rare Manifestation of COVID-19 Resulting in Coronary Artery Vasculitis

We present the case of a 59-year-old African American female with end-stage renal disease (ESRD) who presented to the emergency department with chest discomfort. She had a coronary angiogram six months ago that showed no occlusive epicardial coronary artery disease. She had elevated troponin I levels and new regional wall motion abnormalities on echocardiogram. Her SARS-CoV-2 returned positive. After a multidisciplinary team approach, she underwent another coronary angiogram that showed new severe multivessel ostial lesions and a left main coronary artery aneurysm. COVID-19-related coronary artery vasculitis was suspected based on her clinical presentation, angiogram findings, and negative autoimmune workup. The patient underwent successful coronary artery bypass grafting and recovered without complications.

Sudden Death Due to Coronary Vasculitis: An Unexpected Autopsy Finding and Unusual Association With Thymic Hyperplasia

A 43-year-old Asian woman was found unresponsive on the sidewalk, prompting a call to 911. Upon transportation to the hospital, no signs of trauma were evident, but her condition deteriorated, leading to her eventual passing. An autopsy revealed a complete occlusion of the right coronary artery due to segmental coronary artery vasculitis. Without details of the individual's social or medical history, the specific type of coronary vasculitis couldn't be determined. The internal examination also showed thymic hyperplasia of unknown origin. While there is no conclusive evidence, a potential link between thymic hyperplasia, immune dysregulation, and coronary artery vasculitis is discussed, considering the case and existing literature.

Isolated Coronary Arteritis in Adults: a Single-Center Experience from China

Isolated coronary arteritis (ICA) is an extremely rare and life-threatening vasculitis with only a limited number of reports in the literature. We retrospectively reviewed the clinical data of 10 ICA patients in our center from 2012 to 2022 and compared them with patients with Takayasu arteritis who presented with coronary arteritis initially (TAK-CA patients). We found that ICA predominantly affected women and most commonly involved the ostium and the proximal segment of the coronary arteries, causing mainly stenotic lesions. The C-reactive protein and erythrocyte sedimentation rate were grossly normal and significantly lower than those of TAK-CA patients (p = 0.027, p = 0.009, respectively). Intravascular ultrasound imaging showed superiority in differentiating coronary vasculitis from atherosclerosis. Restenosis of the coronary arteries occurred rapidly if not treated promptly and appropriately. Systemic glucocorticoid combined with immunosuppressive agents, especially cyclophosphamide, was a promising strategy for treating ICA.

Atteintes coronariennes et artérite a cellules géantes : à propos de 2 cas et revue de la littérature

INTRODUCTION

Coronaritis is a rare but serious complication of giant-cell arteritis (GCA), with an estimated prevalence of less than 1%, however difficult to establish, and of early onset.

METHODS

We describe 2 cases of GCA presenting with coronaritis and present a review of the literature on this complication.

RESULTS

The first patient presented with stable angina on common trunk coronaritis with ostial stenosis. Corticosteroid combined with tocilizumab from the outset resulted in improvement. Angioplasty was performed at 6months with good outcome. The second patient presented with asymptomatic tritruncular ostial coronaritis. Corticosteroid allowed clinic-biological improvement of GCA. Two years later, he presented relapse with an acute coronary syndrome, with favorable evolution after angioplasty, increase of corticosteroids and addition of tocilizumab.

CONCLUSION

Patients presented were successfully treated with corticosteroids combined with tocilizumab and angioplasty of their coronary stenoses. Efficacy of tocilizumab in GCA has not been evaluated especially on coronaritis due to the rarity of this complication. Our experience and the cases reported in the literature suggest good results of angioplasty in this indication. Studies with long-term follow-up will be necessary to evaluate the risk of restenosis.

SARS-CoV-2 and Its Bacterial Co- or Super-Infections Synergize to Trigger COVID-19 Autoimmune Cardiopathies

Autoimmune cardiopathies (AC) following COVID-19 and vaccination against SARS-CoV-2 occur at significant rates but are of unknown etiology. This study investigated the possible roles of viral and bacterial mimicry, as well as viral-bacterial co-infections, as possible inducers of COVID-19 AC using proteomic methods and enzyme-linked immunoadsorption assays. BLAST and LALIGN results of this study demonstrate that SARS-CoV-2 shares a significantly greater number of high quality similarities to some cardiac protein compared with other viruses; that bacteria such as Streptococci, Staphylococci and Enterococci also display very significant similarities to cardiac proteins but to a different set than SARS-CoV-2; that the importance of these similarities is largely validated by ELISA experiments demonstrating that polyclonal antibodies against SARS-CoV-2 and COVID-19-associated bacteria recognize cardiac proteins with high affinity; that to account for the range of cardiac proteins targeted by autoantibodies in COVID-19-associated autoimmune myocarditis, both viral and bacterial triggers are probably required; that the targets of the viral and bacterial antibodies are often molecularly complementary antigens such as actin and myosin, laminin and collagen, or creatine kinase and pyruvate kinase, that are known to bind to each other; and that the corresponding viral and bacterial antibodies recognizing these complementary antigens also bind to each other with high affinity as if they have an idiotype-anti-idiotype relationship. These results suggest that AC results from SARS-CoV-2 infections or vaccination complicated by bacterial infections. Vaccination against some of these bacterial infections, such as Streptococci and Haemophilus, may therefore decrease AC risk, as may the appropriate and timely use of antibiotics among COVID-19 patients and careful screening of vaccinees for signs of infection such as fever, diarrhea, infected wounds, gum disease, etc.

Takayasu Arteritis: A Difficult Diagnosis in a Patient With an Extensive Cardiovascular History

Large vessel vasculitides, such as Takayasu arteritis (TAK), are rare inflammatory conditions primarily affecting the aorta and its major branches. Its nonspecific symptoms and potential resemblance to atherosclerotic disease often pose diagnostic challenges. We present a case of a 57-year-old male with a history of extensive cardiovascular disease, initially attributed to atherosclerosis, resulting in several interventions, such as catheterization and major cardiac surgery, which didn't help improve his symptoms. Further evaluation revealed diffuse wall thickening of the aorta and its roots, as well as labs that suggested elevated inflammatory markers, comprehensive review of his chart and previous admissions, revealed that he had a well-documented aortitis for which he underwent a biopsy, which at the time was unrevealing. Furthermore, as he had significant aortic aneurysmal dilation, a thoracic cardiovascular surgeon remitted him to the rheumatology clinic, where he was placed on a prednisone taper and methotrexate regimen. Unfortunately, he redeveloped symptoms, and plans were made to transition to a tumor necrosis alpha (TNF-alpha) inhibitor. Our case highlights the importance of an accurate diagnosis and the prompt initiation of appropriate treatment in challenging cases of large vessel vasculitides. This case also underscores the need for heightened clinical awareness and interdisciplinary collaboration to ensure optimal patient care.

The "Viral" Form of Polyarteritis Nodosa (PAN)-A Distinct Entity: A Case Based Review

Classic polyarteritis nodosa (PAN) is a vasculitis with systemic manifestations that is characterized by inflammatory and necrotizing lesions affecting medium and small muscular arteries, most frequently at the bifurcation of the vessels. These lesions lead to the formation of microaneurysms, hemorrhaging ruptured aneurysms, thrombosis, and, consequently, ischemia or organ infarction. Background and Objectives: We present a complex clinical case of a patient with a late diagnosis of polyarteritis nodosa with multiorgan involvement. Materials and Methods: The 44-year-old patient, in an urban environment, presented on her own in the emergency room for acute ischemia phenomena and forearm and right-hand compartment syndrome, requiring surgical decompression in the Plastic Surgery Clinic. Results: Significant inflammatory syndrome is noted, alongside severe normocytic hypochromic iron deficiency anemia, nitrogen retention syndrome, hyperkalemia, hepatic syndrome, and immunological disturbances: absence of cANCA, pANCA, anti Scl 70 Ac, antinuclear Ac, and anti dDNA Ac, as well as a low C3 fraction of the plasmatic complement system. The morphological aspect described in the right-hand skin biopsy correlated with the clinical data supports the diagnosis of PAN. Conclusions: The viral form of PAN seems to be individualized as a distinct entity, requiring early, aggressive medication.

Acute coronary syndrome in antineutrophil cytoplasmic antibody-associated vasculitis: a Korean single-centre cohort study

Objective

This study investigated the incidence and patterns of the acute coronary syndrome (ACS) after AAV diagnosis and searched for the predictors of ACS in a single-centre cohort of Korean patients diagnosed with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

Methods

A total of 262 patients with AAV were included in this study. ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA) were defined as ACS in this study. Only ACS that occurred during or after AAV diagnosis was counted.

Results

The incidence of ACS in patients with AAV was 2.7% (7 patients), and the most common type of ACS was NSTEMI regardless of the affected site or the number of coronary arteries. Five patients with ACS were diagnosed with microscopic polyangiitis (MPA) and all of them had myeloperoxidase (MPO)-ANCA (or perinuclear [P]-ANCA), whereas the remaining two patients were diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). Of the seven patients, 2 patients experienced ACS within the first year after AAV diagnosis, and 2 experienced ACS 5 years after AAV diagnosis. Among clinical variables, only the male sex was a predictor of ACS during the follow-up period in patients diagnosed with AAV.

Conclusion

The incidence of ACS was 2.7%, and the most common type of ACS was NSTEMI in Korean patients with AAV.

Coronary Artery Aneurysm Rupture in a Patient With Polyarteritis Nodosa

We present the case of a 42-year-old male patient with ST-segment elevation myocardial infarction and pericardial effusion due to rupture of the left anterior descending artery most likely secondary to polyarteritis nodosa. Successful surgery was performed under cardiopulmonary bypass using antegrade and retrograde cardioplegia combined. (Level of Difficulty: Intermediate.).

Inflammation of Pericardial Transverse Sinus Leading to Suspicion of Takayasu Syndrome

BACKGROUND The purpose of this case report was to present a rare course of pericarditis starting with transverse sinus inflammation in a patient with recurrent chest pain. Typically, the effusion accumulates along the diaphragmatic surface of the back heart, and other localizations, such as the transverse sinus, are uncommon. The main risk factor for pericarditis in Europe is viral infection. In this uncommon case, we strongly suspected underlying Takayasu syndrome. The positive response to treatment with steroids in pericarditis and Takayasu arteritis may be misleading. CASE REPORT A 61-year-old woman was admitted to the Cardiology Clinic because of recurrent chest pain in the form of a retrosternal burning pain with radiation to both arms. With the results of laboratory tests, electrocardiogram, and computer tomography (CT), we excluded acute coronary syndrome, pulmonary embolism, and aortic dissection. In chest CT and transthoracic echocardiography (TTE), we found an effusion around the ascending aorta with uncertain inflammation and in the transverse sinus of the pericardium. After typical pericarditis treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and afterward with steroids, which is similar to Takayasu syndrome treatment, we observed a significant improvement of the patient's clinical condition and no recurrence of chest pain. CONCLUSIONS Despite clinical symptoms, laboratory results, and aorta thickening with surrounding inflammation, Takayasu syndrome was excluded by rheumatologists because of the patient's age. Transverse sinus inflammation is a very rare presentation of pericarditis, but should be considered, especially based on TTE and CT imaging, when other possible causes of retrosternal pain are excluded.

A challenging case of rheumatoid arthritis-associated aortitis presenting with erythema nodosum after ST-segment elevation myocardial infarction: A case report

Rheumatoid arthritis is a systemic inflammatory disease that has many extra-articular manifestations. Cardiovascular involvement, including coronary vasculitis and aortitis and skin lesion of erythema nodosum are uncommon findings of patients with rheumatoid arthritis, and thus, it is challenging for diagnosis of this case from those unusual extra-articular presentation.

Coronary Arteries Aneurysms: A Case-Based Literature Review

Coronary artery aneurysm (CAA) is an abnormal dilatation of a coronary artery segment; those coronary artery aneurysms that are very large in size are defined as giant. However, a standardized dimension cut-off to define giant CAAs is still missing. The reported prevalence of coronary aneurysms in the population who underwent coronary angiography ranges from 0.3% to 5%, and often CAAs are found in patient with aneurysms in other sites, such as the ascending or abdominal aorta. In half of the cases an atherosclerotic etiology could be recognized; often, CAA is found in the context of acute coronary syndrome. Seldomly, CAA is found at the autopsy of patients who died due to sudden cardiac death. Currently, very few data exist about CAA management and their prognostic relevance; moreover, CAA treatment is still not clearly codified, but rather case-based. Indeed, currently there are no published dedicated studies exploring the best medical therapy, i.e., with antiplatelets or anticoagulant agents rather than an interventional approach such as an endovascular or surgical technique. In this review, through two clinical cases, the current evidence regarding diagnostic tools and treatment options of CAAs will be described.

Predictors of Acute Myocardial Infraction in Patients With Vasculitis: A Nationwide Inpatient Cross-Sectional Study

Objectives

The primary goal of this study is to explore demographic and comorbid factors that increase the hospitalization risk of acute myocardial infarction (AMI) in patients with vasculitis along with the utilization rate of percutaneous coronary intervention (PCI)/angioplasty. Additionally, we aim to study the prevalence of AMI in vasculitis inpatients based on geographical distribution.

Methods

We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) in 2019 involving 33,210 inpatients hospitalized on emergency-based admissions with a co-diagnosis of vasculitis, subdivided into cohorts without AMI (N = 31,790) and with AMI (N = 1,420) as the primary diagnosis. A binomial logistic regression model was used to evaluate the odds ratio (OR) of predictors associated with AMI in patients with vasculitis compared to the non-AMI cohort.

Results

The prevalence of AMI in the total inpatient population with vasculitis was 4.28%, with a majority of patients being in the older age group of 51-65 years (63%), males (59.2%), and white (59%). Inpatients with vasculitis having pre-existing co-morbid conditions were at greater risk for AMI, such as obesity (OR 2.84, 95%CI 2.78-2.89), metastatic cancer (OR 1.73, 95%CI 1.26-2.37), complicated hypertension (OR 1.64, 95%CI 1.46-1.85), and arthropathies (OR 1.48, 95%CI 1.30-1.68). The in-hospital mortality rate was significantly higher in the AMI cohort compared to the non-AMI cohort (13% vs 2.9%). The utilization rate of PCI/endovascular angioplasty was 13.02% (185 out of 1,420) and had a lower in-hospital mortality rate compared to those managed by medical treatment (8.1% vs 13.8%).

Conclusion

AMI is an important differential diagnosis to consider in vasculitis patients admitted into the hospital with chest pain. Due to the low prevalence of vasculitis and diagnostic challenges, these primary conditions can be often missed. There is a greater risk of inpatient mortality among vasculitis patients with AMI. Therefore, a higher index of suspicion should be exercised, especially in elderly males with risk factors. Vasculitis patients with chronic comorbidities such as arthropathies, obesity and hypertension are at a greater risk for suffering from AMI. Careful screening and management of cardiovascular risk factors is mandatory in vasculitis patients.

Autoimmune Disease Classification Based on PubMed Text Mining

Autoimmune diseases (AIDs) are often co-associated, and about 25% of patients with one AID tend to develop other comorbid AIDs. Here, we employ the power of datamining to predict the comorbidity of AIDs based on their normalized co-citation in PubMed. First, we validate our technique in a test dataset using earlier-reported comorbidities of seven knowns AIDs. Notably, the prediction correlates well with comorbidity (R = 0.91) and validates our methodology. Then, we predict the association of 100 AIDs and classify them using principal component analysis. Our results are helpful in classifying AIDs into one of the following systems: (1) gastrointestinal, (2) neuronal, (3) eye, (4) cutaneous, (5) musculoskeletal, (6) kidneys and lungs, (7) cardiovascular, (8) hematopoietic, (9) endocrine, and (10) multiple. Our classification agrees with experimentally based taxonomy and ranks AID according to affected systems and gender. Some AIDs are unclassified and do not associate well with other AIDs. Interestingly, Alzheimer's disease correlates well with other AIDs such as multiple sclerosis. Finally, our results generate a network classification of autoimmune diseases based on PubMed text mining and help map this medical universe. Our results are expected to assist healthcare workers in diagnosing comorbidity in patients with an autoimmune disease, and to help researchers in identifying common genetic, environmental, and autoimmune mechanisms.

Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher-A Reaction to Return-to-Work Stress After COVID-19?

INTRODUCTION

Takayasu's arteritis (TA) is a systemic inflammatory disease that affects aorta and its major branches. There are several cardiac manifestations of TA and an association with Takotsubo syndrome (TTS) - but not coronary vasospasm - has been previously reported. The role of emotional stress in this context is unknown.

CASE PRESENTATION

A 58-year-old Caucasian female elementary school teacher, with a history of generalized anxiety disorder (GAD), severe asymptomatic aortic regurgitation (AR), and TA in remission under corticosteroids, was admitted in the emergency department with worsening chest pain and dyspnea, initiated after a period of intense emotional stress (increased workload during COVID-19 pandemic). Physical examination revealed signs of heart failure (HF) with hemodynamic stability and an early diastolic heart murmur. The electrocardiogram showed sinus tachycardia, T wave inversion in left precordial and lateral leads, and a corrected QT of 487 ms. Laboratorial evaluation presented high values of high-sensitivity troponin I (3494 ng/L) and B-type natriuretic peptide (4759 pg/mL). The transthoracic echocardiogram revealed severe dilation of left ventricle (LV) with moderate systolic dysfunction, due to apical and midventricular akinesia, and severe AR. The coronary angiography showed normal coronary arteries. An acetylcholine provocative test induced spasm of both the left anterior descending and circumflex arteries, accompanied by chest pain and ST depression, completely reverted after intracoronary nitrates administration. The patient was switched to diltiazem and a drug multitherapy for HF was started. A cardiac magnetic resonance revealed severe dilation of the LV, mild apical hypokinesia, improvement of ejection fraction to 53%, signs of myocardial edema and increased extracellular volume in apical and mid-ventricular anterior and anterolateral walls, and absence of myocardial late gadolinium enhancement, compatible with TTS. At discharge, the patient was clinically stable, without signs of HF, and a progressive reduction of troponin and BNP levels was observed. A final diagnosis of TTS and coronary vasospasm in a patient with GAD and TA was done.

DISCUSSION

We present the first case of acute HF showing coexistence of TA, TTS and coronary vasospasm. TA is a rare inflammatory disease that can be associated with TTS and coronary vasospasm. Besides that, coronary vasospasm may also be involved in TTS pathophysiology, suggesting a complex interplay between these diseases. Mood disorders and anxiety influence the response to stress, through a gain of the hypothalamic-pituitary-adrenal axis and an increased cardiovascular system sensitivity to catecholamines. Therefore, although the mechanisms behind these three pathologies are not yet fully studied, this case supports the role of inflammatory and psychiatric diseases in TTS and coronary vasospasm.

Cardiac allograft vasculopathy: current review and future research directions

Cardiac allograft vasculopathy (CAV) is a pathologic immune-mediated remodelling of the vasculature in transplanted hearts and, by impairing perfusion, is the major cause of late graft loss. Although best understood following cardiac transplantation, similar forms of allograft vasculopathy occur in other vascularized organ grafts and some features of CAV may be shared with other immune-mediated vasculopathies. Here, we describe the incidence and diagnosis, the nature of the vascular remodelling, immune and non-immune contributions to pathogenesis, current therapies, and future areas of research in CAV.