Prevalence of noncalcified plaques and coronary artery stenosis in patients with coronary calcium scores of zero.

OBJECTIVES: A higher coronary artery calcium score (CACS) is associated with increased coronary artery plaque burden resulting in increased cardiovascular risk. Conversely, the absence of calcium indicates a low risk of cardiovascular events. However, coronary plaque calcification is a late manifestation of atherosclerosis; earlier stages of atherosclerosis present noncalcified plaques (NCPs) A recent study demonstrated that the absence of coronary artery calcification deposit does not preclude obstructive stenosis or the need for revascularization in patients with a high suspicion of coronary artery disease (CAD). Our study aimed to investigate the prevalence of NCP and the severity of coronary artery stenosis in symptomatic patients in our local population who were referred for coronary artery computed tomography angiogram (CCTA) with 0 CACS. METHODS: A total of 299 patients who had undergone CACS and CCTA, and had scored zero for coronary artery calcium. Patients included had clinically appropriate indications, mainly chest pain with variable severity with no history of CAD. The presence of CAD risk factors, such as diabetes, hypertension, and smoking, was obtained from reviewing patient charts. The CCTA analysis was performed to evaluate for coronary artery stenosis and the presence of NCP. The severity of stenosis was quantified by visual estimation and divided into 0% stenosis, 1-25% stenosis, 26-50% stenosis, and more than 50% stenosis. RESULTS: The prevalence of NCP was 6.4% (19 of the 299). Among the 19 patients with NCP, 52.6% had no identified coronary artery stenosis, 26.3% had less than 25%, and 21% had stenosis between 25 and 50%. None had stenosis greater than 50%. There was a strong association between male sex (P = 0.001), smoking (P = 0.0.004), hypertension, and NCP (P = 0.042), but no association was found between NCP and age or diabetes. CONCLUSIONS: In patients with a high clinical suspicion of CAD, the absence of coronary artery calcification does not rule out CAD; up to 6.4% of these patients have early CAD as evidenced by NCP detected by CCTA, and none have more than 50% stenosis, However, future prognostic and long-term follow-up studies are needed to determine prognostic value of NCP in patients with 0 CACS.

A case report of constrictive pericarditis: a forgotten cause of refractory ascites.

Constrictive pericarditis is well known but rare and commonly forgotten cause of ascites. Early diagnosis of constrictive pericarditis is difficult due to absence of typical cardiopulmonary signs and multiple vague symptoms and its insidious course. In this case report, we present, a 61-year-old male referred for liver transplantation vs transjugular intrahepatic portosystemic shunt work-up for presumptive diagnosis of nonalcoholic steatohepatitis cirrhosis and refractory ascites. Comprehensive work-up before liver transplantation including liver biopsy, liver ultrasound, and Doppler, magnetic resonance imaging was not consistent with liver cirrhosis. Echocardiographic was suggestive of constrictive pericarditis, further work-up with right heart catheterization, cardiovascular magnetic resonance and multidetector cardiac computed tomography confirmed the diagnosis of constrictive pericarditis. Patient underwent surgical pericardiectomy, he reminded stable after surgery and did not require further paracentesis and discharged in stable condition.