Normal angiogram after myocardial infarction in young patients: a prospective clinical-angiographic and long-term follow-up study.

This is an observational study in which we compared the clinical characteristics and the long-term course of young patients having acute myocardial infarction and angiographically normal coronary arteries and young patients showing significant coronary artery disease. In 87 patients aged < or = 40 years who suffered an acute myocardial infarction, enrolled in a prospective study over a period of 6.5 years, coronary anatomy was determined by angiography within a month of admission. The risk factors, clinical data, ventricular function and the long-term outcome were compared between patients with normal angiograms (Group 1, n = 12) and patients with coronary artery disease (Group 2, n = 75). Patients in Group 1 had a lower number of risk factors associated with them (17% vs. 64% with > 1 risk factor, P < 0.005), were younger (32 +/- 5 vs. 36 +/- 4, P < 0.01), lighter smokers (25% vs. 55% for > or = 2 packs per day, P < 0.05), had less frequent hypertension (0 vs. 25%, P < 0.05), hypercholesterolemia (17% vs. 52%, P = 0.02) and had a lower mean total cholesterol level (201 +/- 42 vs. 245 +/- 60 mg/100 ml, P < 0.05) than patients in Group 2. They also had a more common onset of their infarction during heavy physical exertion (67% vs. 17%, P < 0.001). A history of previous myocardial infarction, infarct location, global left ventricular function and regional wall motion were similar in both groups. After a mean follow-up period of 41 +/- 23 months, no patient died or had a second myocardial infarction in Group 1, and 4 patients had died in Group 2. The appearance of angina, less frequent in Group 1 than Group 2, tended to correlate with the extension of the coronary artery disease. We concluded that young patients with myocardial infarction have good prognosis irrespective of the coronary anatomy, although patients with normal coronary angiograms had less risk factors and less frequent new ischaemic events.

[Occlusion of the left main coronary artery with silent ischemia and syncope]. / Oclusión del tronco de la arteria coronaria izquierda con isquemia silente y síncope.

Mortality in the total occlusion of the left main coronary artery is very high, and the few cases who lived reported were very ill and symptomatic patients. We present a case with angiographic documentation of total occlusion of the left main coronary artery in a patient without angina and with a normal rest electrocardiogram in which a syncope was the only symptom. Severe isolated silent ischemia was induced during an exercise test. Total occlusion of the left main coronary artery associated to silent myocardial ischemia without cardiac failure has never been previously reported.

Myocardial infarction in men aged 40 years or less: a prospective clinical-angiographic study.

HYPOTHESIS: The study was undertaken to characterize acute myocardial infarction (AMI) in young patients. METHODS: In all 108 consecutive Mediterranean patients with AMI (102 men and 6 women), aged < or = 40 years, were prospectively included in this study over a period of 6.5 years. Coronary angiography was carried out within the first month and data from these patients with normal or diseased coronary arteries were compared. Clinical features, risk factors, and in-hospital and late morbidity and mortality were evaluated. RESULTS: Young patients with AMI represent 4.1% of the 2,644 patients admitted because of definite AMI during this period. The most common risk factors were cigarette smoking (94.5%) and hypercholesterolemia (48%). Location of the AMI was anterior in 37%, inferior in 57.5%, and non-Q in 5.5%. A history of previous angina was present in 42.5% of the patients, including all seven patients with previous myocardial infarction (6.5%). However, in 52% of the patients the anginal episodes started in the week prior to the AMI. In-hospital mortality and mortality during a mean follow-up of 41 +/- 23 months were 3.7 and 3.8%, respectively. The Kaplan-Meier actuarial curve assessed on 97 of 104 survivors was 100 and 94% at 1 and 5 years, respectively. Coronary arteries were angiographically normal in 17 (20%) of 87 survivors. Compared with young patients who had obstructive lesions, this subset had a lower age and fewer risk factors, reinfarction (p < 0.05), and late angina (p < 0.01), but development of congestive heart failure and survival were similar in both groups. CONCLUSION: These data suggest that young patients with AMI are very frequently heavy smokers, have a high incidence of angiographically normal coronary arteries, and that the short- and long-term prognosis is excellent.

[Coronary angioplasty in a case of dextrocardia with situs inversus and myocardial infarct]. / Angioplastia coronaria en un caso de dextrocardia con situs inversus e infarto de miocardio.

Dextrocardia and situs inversus totalis is a rare congenital anomaly in adults. Usually, the patients have structurally normal hearts and experience normal longevity. The risk of coronary atherosclerosis is similar to that of the general population. However, the report of coronary angioplasty and/or coronary arteriography on patients with dextrocardia is scant. We describe herein a case of successful percutaneous transluminal coronary angioplasty to the right coronary artery. We comment the technical particularities of the procedure, and a review of the literature is made.

Spontaneous coronary artery dissection in mitral stenosis.

Spontaneous coronary artery dissection is a rare disease that occurs most commonly in young people, especially in peripartum or postpartum women. It has rarely been diagnosed during life and has never before been observed associated with any other non-ischaemic heart disease. We report a case associated with mitral stenosis, in which successful valvular and coronary surgery were carried out. We speculate whether rheumatic coronary arteritis was a cause of the dissection.

Coronary angioplasty of anomalous right coronary artery originating from the left sinus of Valsalva.

Coronary angioplasty of an anomalous coronary artery can be technically challenging because of difficulty in cannulating the aberrant vessel and in obtaining a stable guiding catheter position. Only three cases with the right coronary artery originating from the left sinus of Valsalva were previously reported. We present a new case in which a successful angioplasty was obtained using a Williams LR guiding catheter.

Selective ergonovine-induced coronary artery spasm and ST-segment alternans after blunt thoracic trauma.

A 24-year-old man was found to have angiographically normal coronary arteries shortly after suffering blunt thoracic trauma. Selective ergonovine administration into the left coronary artery induced total occlusion of the left anterior descending branch and electrical alternans of the ST-segment. This case demonstrates coronary artery spasm as a possible mechanism of coronary occlusion after blunt thoracic trauma.

[Chest pain of esophageal origin in patients with a normal coronary angiogram and ergonovine-induced coronary spasm]. / Dolor torácico de origen esofágico en pacientes con arteriograma coronario normal y espasmo coronario inducido por ergonovina.

In order to differentiate the cardiac or oesophageal origin of chest pain, 55 patients with chest pain, normal coronary arteriogram and normal left ventricular function, were studied. Patients were evaluated with ergonovine test to induce coronary artery spasm and oesophageal function study (including basal manometry in all cases, ClH acid instillation in 53, manometry during ClH instillation in 32 and edrophonium test in 9). There was coronary artery spasm following ergonovine test in 8 patients (group 1) and negative results in 47 (group 2). There was oesophageal disfunction in 50% patients in group 1 and in 62% patients in group 2 (p = NS). The incidence of motor disorders or chest pain following acid instillation was not significatively different in both groups. Nevertheless, in group 1 a tendency to a greater incidence of oesophageal spasm was observed while in group 2 unspecified disorders were more frequent. Thus, in patients with chest pain and normal coronary arteriogram, we always must discard coronary artery spasm and oesophageal disfunction, because, due to a probably common cause, association between both disorders is frequent.

[Acute myocardial infarct and coronary artery aneurysm during pregnancy]. / Infarto agudo de miocardio y aneurisma arterial coronario durante el embarazo.

We present the first published case in Spain on a gestant woman with acute myocardial infarction. She was angiographically studied showing a coronary artery aneurysm with inner thrombus. This is also the first time that such a lesion is described in vivo in a gestant woman.

[The selective induction of a spasm with ergonovine in a normal coronary artery in the presence of contralateral stenosis]. / Inducción selectiva de espasmo con ergonovina en una arteria coronaria normal en presencia de estenosis contralateral.

We present a patient with circumflex artery stenosis and recent unstable angina. Selective ergonovine administration on angiographically normal right coronary artery evidenced that at least some of the anginal crisis could be due to spasms of it. We comment the usefulness of the ergonovine intracoronary test in the presence of fixed obstructive lesions.

[The local and systemic effects of intracoronary ergonovine in patients with normal and nonspastic coronary arteries. A comparison with the intravenous ergonovine test]. / Efectos local y sistémico de la ergonovina intracoronaria en pacientes con arterias coronarias normales y no espásticas. Comparación con el test de ergonovina intravenoso.

Local and systemic effects of intracoronary (two bolus injections of 25 micrograms at 3-min intervals) ergonovine were determined in 60 patients with angiographic non-spastic normal coronary arteries and were compared with the most usual intravenous ergonovine dose to induce coronary artery spasm (incremental doses of 50, 100 and 200 micrograms at 3-min intervals). The mean diameter of the vessels was reduced by 15% after selective injections (baseline 2.38 +/- 0.7; after intracoronary ergonovine 2.02 +/- 0.6 mm; p less than 0.001) and no significant changes were induced in the heart rate (before 80 +/- 15; after 79 +/- 15 beats/min) and systolic aortic pressure (before 147 +/- 27; after 149 +/- 28 mmHg). Following intravenous administration, the mean coronary diameter decreased by 20% (1.90 +/- 0.6 mm; p less than 0.01 vs intracoronary dose) and the heart rate diminished slightly (76 +/- 12 beats/min; p less than 0.01). Nevertheless, the systolic aortic pressure did increase by 16% (171 +/- 28 mmHg; p less than 0.001). No major complications were observed and the appearance of side effects was minimal. Thus, the intracoronary delivery route, at the applied dosage, induces lesser vasoconstriction than usual intravenous administration, and systemic effects, such as hypertension, are avoided.

Effects of intracoronary injection of ergonovine on angiographic normal coronary arteries: study of 108 consecutive patients.

To assess the local and systemic intracoronary (IC) ergonovine maleate (EM), single or repeated 25 micrograms bolus injections were administered to 108 consecutive patients with chest pain and normal coronary arteriograms. Coronary artery spasm (CAS) was induced in 17 (15.7%) patients. None of these patients developed ST-segment depression, and ST-segment elevation appeared in only 6 (35.3%). In 59 of the 91 patients without CAS, both the IC and the intravenous (IV) EM arteriographic and hemodynamic effects were compared. The mean diameter of the vessels was reduced by 15% (p less than 0.001) after two single 25 micrograms ICEM injections. Only insignificant changes were induced in the heart rate (baseline 80 +/- 15; after ICEM 79 +/- 15 beats/min; p = NS) and systolic aortic pressure (baseline 147 +/- 27; after ICEM 149 +/- 28 mmHG; p = NS). Following 350 micrograms of cumulative IVEM, the mean coronary diameter decreased by 20% (p less than 0.01 vs. ICEM dose) and the heart rate diminished slightly (76 +/- 12 beats/min, p less than 0.01). However, the systolic aortic pressures did increase by 16% (171 +/- 28 mmHg; p less than 0.001). No major complications were observed. Thus, to induce CAS the IC delivery route appears to be safe, allows for more accurate titration, and adverse systemic effects, such as hypertension, are avoided.

Vasospastic angina mimicking graft failure and spontaneously appearing after left ventriculography.

A 49-year-old female with significant (75%) left main coronary artery stenosis was initially considered to have developed early obstruction of a saphenous vein graft to the left anterior descending coronary artery, because of recurrent postoperative angina. In a second catheterization study, left ventriculography showed normal contractility of all segments and was immediately followed by the onset of angina and angiographic demonstration of diffuse spasm of the entire left coronary artery system beyond the stenosis. Vasospasm of the left coronary artery before or during ventriculography was unlikely in the absence of regional contractility impairment. The close temporal association between the left ventricular angiogram and the angiographic demonstration of vasospasm suggested a direct cause and effect relationship.

Familial migraine and coronary artery spasm in two siblings.

A common pathophysiology for the clinical association of variant angina and migraine has been suggested, but the pathogenesis of both illnesses is yet unknown. Our report presents two siblings with both illnesses and a familial history of migraine where coronary artery spasm was documented, spontaneously in one and after the administration of ergonovine maleate in the other one. Our study strongly supports the hypothesis that genetic factors possibly play a role in the etiology of variant angina and migraine at least in some patients.