Anomalous origin of the right coronary artery from pulmonary artery in an adult presenting with rapid atrial fibrillation: a case report.

Background: An anomalous origin of the right coronary artery from pulmonary artery (ARCAPA) is a very rare coronary anomaly. Case summary: A 56-year-old man, presenting haemodynamically unstable due to very rapid atrial fibrillation, was found to have ARCAPA by coronary computed tomography angiography. He had normal left ventricular ejection fraction and without reversible ischaemia on an adenosine stress rubidium positron emission tomography. He was treated solely with betablockers and has been well since. Discussion: Numerous case reports on ARCAPA have previously been published, but no previous reports have found rapid atrial fibrillation to be the primary symptom of presentation. Current evidence level concerning the treatment is low; nevertheless, surgical intervention should always be considered to prevent sudden cardiac death. The patient in this case was offered surgical intervention but declined.

Subclinical Coronary Atherosclerosis and Risk for Myocardial Infarction in a Danish Cohort : A Prospective Observational Cohort Study.

BACKGROUND: Coronary atherosclerosis may develop at an early age and remain latent for many years. OBJECTIVE: To define characteristics of subclinical coronary atherosclerosis associated with the development of myocardial infarction. DESIGN: Prospective observational cohort study. SETTING: Copenhagen General Population Study, Denmark. PARTICIPANTS: 9533 asymptomatic persons aged 40 years or older without known ischemic heart disease. MEASUREMENTS: Subclinical coronary atherosclerosis was assessed with coronary computed tomography angiography conducted blinded to treatment and outcomes. Coronary atherosclerosis was characterized according to luminal obstruction (nonobstructive or obstructive [≥50% luminal stenosis]) and extent (nonextensive or extensive [one third or more of the coronary tree]). The primary outcome was myocardial infarction, and the secondary outcome was a composite of death or myocardial infarction. RESULTS: A total of 5114 (54%) persons had no subclinical coronary atherosclerosis, 3483 (36%) had nonobstructive disease, and 936 (10%) had obstructive disease. Within a median follow-up of 3.5 years (range, 0.1 to 8.9 years), 193 persons died and 71 had myocardial infarction. The risk for myocardial infarction was increased in persons with obstructive (adjusted relative risk, 9.19 [95% CI, 4.49 to 18.11]) and extensive (7.65 [CI, 3.53 to 16.57]) disease. The highest risk for myocardial infarction was noted in persons with obstructive-extensive subclinical coronary atherosclerosis (adjusted relative risk, 12.48 [CI, 5.50 to 28.12]) or obstructive-nonextensive (adjusted relative risk, 8.28 [CI, 3.75 to 18.32]). The risk for the composite end point of death or myocardial infarction was increased in persons with extensive disease, regardless of degree of obstruction-for example, nonobstructive-extensive (adjusted relative risk, 2.70 [CI, 1.72 to 4.25]) and obstructive-extensive (adjusted relative risk, 3.15 [CI, 2.05 to 4.83]). LIMITATION: Mostly White persons were studied. CONCLUSION: In asymptomatic persons, subclinical, obstructive coronary atherosclerosis is associated with a more than 8-fold elevated risk for myocardial infarction. PRIMARY FUNDING SOURCE: AP Møller og Hustru Chastine Mc-Kinney Møllers Fond.

Subclinical atherosclerosis in patients with cyanotic congenital heart disease.

INTRODUCTION: Survival in patients with cyanotic congenital heart disease (CCHD) has improved dramatically. The result is an ageing population with risk of acquired heart disease. Previous small uncontrolled studies suggested that these patients are protected against the development of atherosclerosis. To test this hypothesis, we sought to determine the prevalence of subclinical atherosclerosis in a larger population of patients with CCHD. METHOD: We compared the prevalence of subclinical atherosclerosis in adult CCHD patients from Denmark, Sweden, Norway and Australia, with that in age-, sex-, smoking status-, and body mass index matched controls. Coronary artery atherosclerosis was assessed on computed tomography with coronary artery calcification (CAC) score. Subclinical atherosclerosis was defined by CAC-score > 0. Carotid artery atherosclerosis was evaluated using ultrasound by measuring carotid plaque thickness (cPT-max) and carotid intima media thickness (CIMT). Lipid status was evaluated as an important atherosclerotic risk factor. RESULTS: Seventy-four patients with CCHD (57% women, median age 49.5 years) and 74 matched controls (57% women, median age 50.0 years) were included. There were no differences between the groups in: CAC-score > 0 (21% vs. 19%, respectively; p = 0.8), carotid plaques (19% vs. 9%, respectively; p = 0.1), cPT-max (2.3 mm vs. 2.8 mm, respectively; p = 0.1) or CIMT (0.61 mm vs. 0.61 mm, respectively; p = 0.98). And further no significant differences in lipoprotein concentrations measured by ultracentrifugation. CONCLUSION: Young adults with CCHD have similar cardiovascular risk factor profiles and measures of subclinical atherosclerosis, compared with controls. Given their increasing life expectancies, athero-preventive strategies should be an important part of their clinical management.

Diagnostic accuracy of static CT perfusion for the detection of myocardial ischemia. A systematic review and meta-analysis.

OBJECTIVES: The aim of this study is to provide a meta-analysis of all published studies assessing the diagnostic accuracy of stress CT myocardial perfusion imaging (CTP) in patients suspected of or with known coronary artery disease. This analysis is limited to static stress CTP. METHODS: Systematic literature review and meta-analysis of studies examining the diagnostic accuracy of static CTP imaging alone or combined with coronary CT angiography (CTA) in comparison to single photon emission computed tomography (SPECT), magnetic resonance perfusion (MRP), and/or invasive coronary angiography with and without fractional flow reserve (FFR). RESULTS: The search revealed 19 eligible studies including 1188 patients. Pooled results showed that CTP had a good agreement with SPECT and MRP. On a per-patient level, sensitivity, specificity and AUC were 0.85 (95% CI: 0.70-0.93), 0.81 (95% CI: 0.59-0.93), 0.90 (95% CI: 0.87-0.92). On a per-artery level, sensitivity, specificity and AUC were 0.80 (95% CI: 0.67-0.88), 0.81 (95% CI: 0.72-0.88) and 0.87 (95% CI: 0.84-0.90). When invasive coronary angiography was used as reference standard, combined coronary CTA and CTP compared to coronary CTA alone significantly improved the specificity from 0.62 (95% CI: 0.52-0.70) to 0.84 (95% CI: 0.74-0.91) on a per-patient level (p = 0.008) and from 0.72 (95% CI: 0.63-0.79) to 0.90 (95% CI: 0.85-0.93) on a per-artery level (p = 0.0001) without significant decrease in sensitivity (p = 0.59 and p = 0.23, respectively). CONCLUSION: In selected patients, static CT myocardial perfusion has high diagnostic accuracy to detecting myocardial ischemia. Specificity increases significantly when CT myocardial perfusion is combined with coronary CTA.