Multivessel Spontaneous Coronary Artery Dissection With Coronary Artery Fibromuscular Dysplasia.

A 53-year-old woman underwent a cardiac catheterization for evaluation of acute coronary syndrome. The coronary angiogram revealed evidence of spontaneous coronary artery dissection in multiple coronary arteries including the left anterior descending artery, posterior descending artery, and posterior left ventricular artery. Further diagnostic imaging revealed associated bilateral vertebral artery and renal artery fibromuscular dysplasia (FMD). Follow-up coronary angiogram 6 weeks later revealed a "string of beads" appearance of the posterior descending artery. This case highlights the importance of extra-coronary imaging for FMD and demonstrates angiogram findings suggestive of coronary FMD.

Une femme de 53 ans a été soumise à un examen par cathétérisme cardiaque afin d'évaluer le syndrome coronarien aigu dont elle est atteinte. L'angiographie coronarienne a révélé des signes de dissection spontanée de l'artère coronaire dans de multiples artères coronaires, y compris l'artère interventriculaire antérieure, l'artère interventriculaire postérieure et l'artère ventriculaire gauche postérieure. D'autres images diagnostiques ont révélé la présence d'une dysplasie fibromusculaire (DFM) bilatérale connexe des artères rénales et vertébrales. L'artère interventriculaire postérieure avait l'aspect d'un « collier de perles ¼ à l'angiographie coronarienne de suivi effectué six semaines plus tard. Ce cas souligne l'importance de l'imagerie extracoronaire pour la détection d'une DFM et montre que les résultats de l'angiographie sont indicatifs d'une DFM coronaire.

Exploring Armenian Ethnicity as an Independent Risk Factor for Cardiovascular Disease: Findings from a Prospective Cohort of Patients in a County Hospital.

OBJECTIVES: While several studies have examined the risk of cardiovascular disease (CVD) in larger racial and ethnic groups within the United States, limited information is available on smaller sub-populations, such as Armenians, with high rates of CVD in their home country. This study examined the association between Armenian ethnicity and a positive exercise treadmill test (ETT). DESIGN: Prospective cohort study of patients at a 377-bed county hospital in Los Angeles, California from 2008-2011. SETTING: All patients were interviewed at the time of ETT to assess their cardiovascular risk factors at the cardiac laboratory of the hospital. PARTICIPANTS: 5,006 patients between 18-89 years of age, of whom 12.6% were of Armenian ethnicity and 54.4% were female.Main Outcome Measure: ETT results as a proxy for CVD risk. RESULTS: After adjusting for cardiovascular risk factors, Armenian ethnicity was significantly associated with higher odds of positive ETT (OR = 1.40, p = 0.01). Known coronary artery disease CAD (OR = 2.28, p < 0.01), hyperlipidemia (OR = 1.37, p < 0.01), and hypertension (OR = 1.24, p = 0.05) were significantly associated with higher odds of a positive ETT. In subgroup analyses, hyperlipidemia was the only significant predictor of positive ETT (OR = 1.92, p = 0.02) among Armenians, while patient history of CAD (OR = 2.49, p < 0.01), hyperlipidemia (OR = 1.29, p = 0.03), and age (OR = 1.04, p < 0.01) were significant predictors among non-Armenians. Armenian ethnicity remained associated with higher odds of positive ETT (OR = 1.40, p < 0.01) when patients with CAD were excluded. CONCLUSION: Armenian ethnicity may be an independent risk factor for CVD, influenced by the uniformity of the genetic pool and cultural and dietary exposures.

Revascularization Versus Medical Therapy in Patients Aged 80 Years and Older with Acute Myocardial Infarction.

BACKGROUND/OBJECTIVES: Older patients are underrepresented in acute coronary syndrome clinical trials. We sought to evaluate the benefits of revascularization in patients aged 80 years and older presenting with acute myocardial infarction (AMI). DESIGN: Retrospective study utilizing inverse probability of treatment weighting (IPTW). SETTING: Single tertiary referral center for an integrated healthcare system in southern California. PARTICIPANTS: Patients undergoing invasive coronary angiography for AMI between 2009 and 2019, and subsequently treated with percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical therapy alone. MEASUREMENTS: All-cause mortality, nonfatal myocardial infarction (MI), and repeated revascularization. RESULTS: A total of 1,433 patients aged 80 years or older (median age = 83.5 years; 66% male) presenting with AMI who underwent treatment with PCI (50%), CABG (12%), or medical therapy alone (38%) were included. Those treated with medical therapy were more likely to be Black, had one or more chronic total occlusions in any vessel, had more comorbidities, and had lower left ventricular ejection fraction. Baseline characteristics were well balanced after IPTW adjustment. Median follow-up was 2.6 years. Revascularization (PCI or CABG) was associated with reduced mortality (hazard ratio (HR) = 0.66; 95% confidence interval (CI) = 0.60-0.73) and nonfatal MI (HR = 0.68; 95% CI = 0.58-0.78), but an increased need for repeated revascularization (HR = 1.60; 95% CI = 1.15-2.23). Separately comparing PCI or CABG alone versus medical therapy yielded similar results. Revascularization was associated with lower mortality in all subgroups, except in Black patients and those with prior CABG. CONCLUSION: Revascularization is superior to medical therapy in reducing all-cause mortality and nonfatal MI in patients aged 80 years and older with AMI. Age alone should not preclude patients from potentially beneficial invasive therapies.

Defying the Odds of Sudden Cardiac Death in Hypertrophic Cardiomyopathy.

We report an unusual case of a patient with hypertrophic obstructive cardiomyopathy, anomalous aortic origin of a coronary artery, obesity hypoventilation syndrome, and acquired long QT syndrome who was able to defy the odds of sudden cardiac death in the rarest of circumstances. (Level of Difficulty: Advanced.).

Heterogeneity of treatment effect in SPRINT by age and baseline comorbidities: The greatest impact of intensive blood pressure treatment is observed among younger patients without CKD or CVD and in older patients with CKD or CVD.

The Systolic Blood Pressure Intervention Trial (SPRINT), a large randomized controlled trial funded by the National Institutes of Health, randomized 9361 patients with hypertension over 50 years of age and at least one cardiovascular risk factor to intensive (SBP < 120 mm Hg) or standard (SBP < 140 mm Hg) blood pressure treatment. The trial found a significant reduction in primary cardiovascular and mortality outcomes in the intensive treatment group. We performed an IRB-approved post hoc analysis of the SPRINT trial data, recently made available through the NEJM SPRINT Data Analysis Challenge. Our subgroup analysis stratified subjects by age (≥75 years vs. <75 years) and presence or absence of pre-existing chronic kidney disease (CKD) or cardiovascular disease (CVD). We found that intensive blood pressure control was associated with a significantly lower rate of the primary CVD outcome and all-cause mortality in subjects age <75 years with no prior CVD or CKD and in subjects age ≥75 years with pre-existing CVD or CKD.

Cognition, glucose metabolism and amyloid burden in Alzheimer's disease.

The authors investigated relationships between glucose metabolism, amyloid load, and measures of cognitive and functional impairment in Alzheimer's disease (AD). Patients meeting criteria for probable AD underwent (11)C-labeled Pittsburgh Compound-B ([(11)C]PIB) and 18F-fluorodeoxyglucose ([(18)F]FDG) positron emission tomography (PET) imaging and were assessed on a set of clinical measures. The Pittsburgh Compound-B (PIB) Distribution volume ratios and fluorodeoxyglucose (FDG) scans were spatially normalized and average PIB counts from regions-of-interest (ROI) were used to compute a measure of global PIB uptake. Separate voxel-wise regressions explored local and global relationships between metabolism, amyloid burden, and clinical measures. Regressions reflected cognitive domains assessed by individual measures, with visuospatial tests associated with more posterior metabolism, and language tests associated with metabolism in the left hemisphere. Correlating regional FDG uptake with these measures confirmed these findings. In contrast, no correlations were found between either voxel-wise or regional PIB uptake and any of the clinical measures. Finally, there were no associations between regional PIB and FDG uptake. We conclude that regional and global amyloid burden does not correlate with clinical status or glucose metabolism in AD.

Early 11C-PIB frames and 18F-FDG PET measures are comparable: a study validated in a cohort of AD and FTLD patients.

UNLABELLED: The availability of new PET ligands offers the potential to measure fibrillar ß-amyloid in the brain. Nevertheless, physiologic information in the form of perfusion or metabolism may still be useful in differentiating causes of dementia during life. In this study, we investigated whether early (11)C-Pittsburgh compound B ((11)C-PIB) PET frames (perfusion (11)C-PIB [pPIB]) could provide information equivalent to blood flow and metabolism. First, we assessed the similarity of pPIB and (18)F-FDG PET images in a test cohort with various clinical diagnoses (n = 10), and then we validated the results in a cohort of patients with Alzheimer disease (AD) (n = 42; mean age ± SD, 66.6 ± 10.6 y; mean Mini-Mental State Examination [MMSE] score ± SD, 22.2 ± 6.0) or frontotemporal lobar degeneration (FTLD) (n = 31; age ± SD, 63.9 ± 7.1 y, mean MMSE score ± SD, 23.8 ± 6.7). METHODS: To identify the (11)C-PIB frames best representing perfusion, we ran on a test cohort an iterative algorithm, including generating normalized (cerebellar reference) perfusion pPIB images across variable frame ranges and calculating Pearson R values of the sum of these pPIB frames with the sum of all (18)F-FDG frames (cerebellar normalized) for all brain tissue voxels. Once this perfusion frame range was determined on the test cohort, it was then validated on an extended cohort and the power of pPIB in differential diagnosis was compared with (18)F-FDG by performing a logistic regression of regions-of-interest tracer measure (pPIB or (18)F-FDG) versus diagnosis. RESULTS: A 7-min window, corresponding to minutes 1-8 (frames 5-15), produced the highest voxelwise correlation between (18)F-FDG and pPIB (R = 0.78 ± 0.05). This pPIB frame range was further validated on the extended AD and FTLD cohort across 12 regions of interest (R = 0.91 ± 0.09). A logistic model using pPIB was able to classify 90.5% of the AD and 83.9% of the FTLD patients correctly. Using (18)F-FDG, we correctly classified 88.1% of AD and 83.9% of FTLD patients. The temporal pole and temporal neocortex were significant discriminators (P < 0.05) in both models, whereas in the model with pPIB the frontal region was also significant. CONCLUSION: The high correlation between pPIB and (18)F-FDG measures and their comparable performance in differential diagnosis are promising in providing functional information using (11)C-PIB PET data. This approach could be useful, obviating (18)F-FDG scans when longer-lived amyloid imaging agents become available.