Dissecção espontânea da artéria coronária, uma doença multifatorial: perspectivas da experiência de um centro / Spontaneous coronary artery dissection, a multifactorial disease: insights from a center experience

Introdução: Embora seja uma doença pouco conhecida, a dissecção espontânea da artéria coronária é uma causa importante e frequentemente subdiagnosticada da síndrome coronariana aguda não aterosclerótica, principalmente em mulheres. O objetivo deste estudo foi caracterizar uma amostra consecutiva de pacientes diagnosticados com dissecção espontânea da artéria coronária quanto a fatores predisponentes e desencadeadores; quadro clínico e angiográfico; abordagem terapêutica; ocorrência de eventos cardíacos adversos; recorrência e dissecção espontânea de artéria coronária de novo. Métodos: Estudo retrospectivo observacional longitudinal, unicêntrico, que incluiu pacientes diagnosticados com dissecção espontânea da artéria coronária (n=60) admitidos entre janeiro de 2010 e dezembro de 2020. Resultados: A mediana da idade foi de 55 anos, e 83% eram mulheres. A maioria dos pacientes (60%) não apresentava nenhum ou tinha apenas um fator de risco cardiovascular. O infarto agudo do miocárdio sem supradesnivelamento do segmento ST foi o quadro clínico em 67% dos casos. A artéria coronária mais frequentemente envolvida foi a descendente anterior (47%). A maioria das lesões (77%) aparecia na angiografia como dissecção espontânea da artéria coronária tipo 2. O tratamento conservador foi selecionado como abordagem inicial na maioria dos pacientes (72%). A incidência geral de dissecção espontânea da artéria coronária de novo não foi significativamente diferente entre os pacientes tratados primeiramente com revascularização, em comparação com os que receberam tratamento conservador (p=0,953). No entanto, a recidiva da dissecção espontânea da artéria coronária ocorreu no vaso originalmente envolvido em 3 dos 15 pacientes tratados com revascularização, em comparação com apenas um entre os 43 pacientes que foram tratados de forma conservadora (p<0,05). Conclusão: A dissecção espontânea da artéria coronária é mais frequente em mulheres jovens. O infarto agudo do miocárdio sem supradesnivelamento do segmento ST foi o quadro clínico mais observado, envolvendo principalmente a artéria descendente anterior. A revascularização não protegeu da recorrência.

Background: Although it is a poorly known disease, spontaneous coronary artery dissection is an important and frequently underdiagnosed cause of non-atherosclerotic acute coronary syndrome, particularly in women. The objective of this study was to characterize a consecutive sample of patients diagnosed with spontaneous coronary artery dissection with respect to predisposing and precipitating factors; clinical and angiographic presentation; management; occurrence of adverse cardiac events; recurrence; and de novo spontaneous coronary artery dissection. Methods: Longitudinal, observational, retrospective, single-centre study, including patients diagnosed with spontaneous coronary artery dissection (n=60) admitted between January 2010 and December 2020. Results: Median age was 55 years, and 83% were women. Most patients (60%) presented without any or just one cardiovascular risk factor. Non-ST-segment elevation acute myocardial infarction accounted for 67% of clinical presentations. The most frequently affected coronary artery was the left anterior descending (47%). Most lesions (77%) appeared on angiography as type 2 spontaneous coronary artery dissection. Conservative management was chosen as the initial approach in most patients (72%). The overall incidence of de novo spontaneous coronary artery dissection was not significantly different among patients initially managed with revascularization as compared to conservative treatment (p=0.953). However, spontaneous coronary artery dissection recurrence occurred in the originally involved vessel in 3 of 15 patients initially managed with revascularization, as compared to only one among 43 patients treated conservatively (p<0.05). Conclusion: Spontaneous coronary artery dissection occurs more often in young women. Non- ST-segment elevation acute myocardial infarction was the most frequent clinical presentation involving mainly the left anterior descending artery. Revascularization did not protect from recurrence.

Evaluation of Left Ventricular Systolic Function in Patients with Coronary Microvascular Dysfunction by Three-Dimensional Speckle-Tracking Imaging

Abstract Introduction: The objective of this study is to evaluate the left ventricular systolic function of patients with coronary microvascular dysfunction (CMD) using the three-dimensional speckle-tracking imaging (3D-STI) technique. Methods: From June 2018 to June 2019,72 subjects from Huzhou Central Hospital were enrolled, including 42 CMD in-patients with typical chest pain or chest tightness and positive treadmill exercise stress test, but without coronary stenosis on coronary angiography, (the CMD group) and another 30 healthy individuals who were undergoing physical examinations in an outpatient clinic (the control group). Using 3D-STI technique, the global longitudinal strain (GLS), global radial strain (GRS), global circumferential strain (GCS), global area strain (GAS), and left ventricle were measured. Results: Compared with the control group, GLS and GAS were significantly reduced in the CMD group (P<0.05), while GRS and GCS were similar in both groups (P>0.05). Univariate logistic regression analysis showed that GLS and GAS were the influencing factors of CMD. For the diagnosis of CMD, the area under the receiver operating characteristic (ROC) curve of GLS was 0.883, and the area under the ROC curve of GAS was 0.875. GAS of -29.3% (log-rank test chi-square=34.245, P<0.001) was a strong predictor of major adverse cardiac events. Conclusion: 3D-STI technique has obvious advantages in the evaluation of the left ventricular systolic function for CMD patients. Moreover, 3D-STI parameters, especially GLS and GAS, can detect the early abnormal changes in the ischaemic myocardium. Being timelier and more sensitive than echocardiography, 3D-STI should be recommended for clinical application.

Análise dos desfechos em intervenção coronária percutânea de tronco de coronária esquerda não protegido / Analysis of percutaneous coronary intervention outcomes in unprotected left main coronary artery lesions

Introdução: Lesões significativas no tronco de coronária esquerda são encontradas em aproximadamente 5% dos pacientes submetidos à coronariografia, sendo a maioria dos casos multiarteriais e com envolvimento do tronco distal. A cirurgia de revascularização do miocárdio é considerada o tratamento preferencial para lesões de tronco de coronária esquerda não protegido. No entanto, com o avanço de técnicas e a introdução dos novos stents liberadores de fármacos, a intervenção coronariana percutânea tem sido considerada estratégia viável, apresentando resultados favoráveis. O objetivo deste estudo foi analisar os desfechos em pacientes com lesões de tronco de coronária esquerda não protegido submetidos à intervenção coronariana percutânea. Métodos: Foram analisados dados eletrônicos de pacientes submetidos à intervenção coronariana percutânea entre dezembro de 2017 e janeiro de 2020 em um único centro, com o objetivo de avaliar características clínicas, angiográficas e os desfechos clínicos. Resultados: Foram incluídos 103 pacientes portadores de lesões significativas de tronco não protegido, 66% eram do sexo masculino, 88,3% eram hipertensos, e 87,4% possuíam função ventricular normal. Lesões envolvendo a bifurcação foram identificadas em 73,8% dos pacientes, 36,9% apresentavam lesões concomitantes nos três grandes vasos epicárdicos e 42,7% com escore SYNTAX intermediário (23 a 32 pontos). O sucesso angiográfico foi obtido em 100% dos casos, com quatro (3,9%) eventos cardíacos e cerebrovasculares adversos, sendo 2,9% de mortalidade. Conclusão: Os resultados hospitalares sustentam a intervenção coronariana percutânea como um procedimento seguro, de excelente resultado angiográfico e eventos cardíacos e cerebrovasculares adversos comparáveis aos da cirurgia de revascularização do miocárdio, configurando opção bastante viável em relação ao tratamento cirúrgico.

Background: Significant lesions in the left main coronary artery are found in approximately 5% of patients undergoing coronary angiography, with most cases involving multiple vessels and affecting the distal bifurcation. A coronary artery bypass graft surgery is considered the preferred treatment for unprotected left main coronary artery lesions. However, with the advancement of techniques and the introduction of new drug-eluting stents, percutaneous coronary intervention has been considered a viable strategy, with favorable results. The objective of this study was to analyze the outcomes in patients with unprotected left main coronary artery lesions undergoing percutaneous coronary intervention. Methods: Electronic data from patients undergoing percutaneous coronary intervention between December 2017 and January 2020 at a single center were analyzed to assess clinical and angiographic characteristics and clinical outcomes. Results: A total of 103 patients with significant unprotected left main coronary artery lesions were included; in that, 66% were male, 88.3% were hypertensive, and 87.4% had normal ventricular function. Lesions involving the bifurcation were identified in 73.8% of patients, 36.9% had concomitant lesions in the three major epicardial vessels, and 42.7% had an intermediate SYNTAX score (23 to 32 points). Angiographic success was achieved in 100% of cases, with four (3.9%) adverse cardiac and cerebrovascular events, with 2.9% mortality. Conclusion: Hospital results support percutaneous coronary intervention as a safe procedure, with excellent angiographic results and low rates of adverse cardiac and cerebrovascular events. We concluded that percutaneous coronary intervention is an option to coronary artery bypass graft surgery and is a very viable option for surgical treatment of unprotected left main coronary artery lesions.

Rationale and design of the worldwide prospective multicenter registry on radiation dose estimates of cardiac CT angiography in daily practice in 2017 (PROTECTION VI).

BACKGROUND: Cardiac computed tomography angiography (cardiac CTA) is an increasingly used versatile imaging method to evaluate coronary and cardiac morphology. Owing to improvements in technology, image quality has continuously improved over the last 10-20 years. At the same time, numerous non-randomized and randomized studies have been performed to reduce the associated radiation exposure. Currently, it is unclear if the advances in technology and knowledge about radiation reduction translated into reduced levels of cardiac CTA radiation dose in daily clinical practice as well as a wide utilization of dose-saving strategies. METHODS: The PROTECTION VI study is a multicenter, prospective, worldwide registry designed to evaluate radiation dose exposure, utilization of dose-saving strategies and diagnostic image quality during cardiac CTA in current daily practice. Assessment of image quality will be addressed by the evaluation of diagnostic image quality at the local study site and the calculation of quantitative image quality parameters in an imaging core laboratory. Above 4000 patients will be enrolled from approximately 70 sites in Europe, North America, South America, Asia and Australia. The study will analyze median radiation dose levels, image quality, frequency of use and efficacy of algorithms for dose reduction, and patient and study-related predictors associated with radiation dose. CONCLUSIONS: The PROTECTION VI study is designed to provide a reliable estimate of current radiation dose for cardiac CTA and to assess the potential for additional dose reductions.

Radial artery spasm associated with transradial cardiovascular procedures: results from the RAS registry.

OBJECTIVES: To report the incidence and predictors of moderate/severe radial artery spasm (RAS) in patients undergoing cardiovascular percutaneous procedures through a transradial approach (TRA) in centers with TRA expertise. BACKGROUND: Data regarding the actual rate of clinically meaningful RAS are limited due to difference in study designs and operator expertise. METHODS: The RAS registry, an international (14 centers from Argentina, Chile, India, Indonesia, Macedonia, The Netherlands and United States of America) registry that included 1,868 patients undergoing TRA cardiovascular procedures (63.5% diagnostic and 56.5% therapeutic).All selected centers used TRA as default strategy in the cardiac catheterization laboratory. Throughout 2012, each center included all consecutive TRA cases (during a 2-month period) into a dedicated database covering clinical characteristics as well as procedural topics related to TRA patterns and RAS occurrence. RESULTS: The incidence of moderate/severe RAS was 2.7%. Only 0.7% of patients required crossover (8 to transfemoral and 5 to contralateral TRA). Patients with moderately/severe spasm were more frequently females, had a history of dyslipidemia, received more often a 7F sheath and more puncture attempts than patients without spasm. By multivariate analysis, the need for more than one attempt and the use of a 7 F sheath were independent predictors of the development of moderate/severe RAS. CONCLUSIONS: The incidence of moderate/severe RAS is low in centers with a default TRA. Its development appears to be strongly related to the numbers of puncture attempts and the use of large sheaths.