Background Myocardial bridge (MB) is the most common inborn coronary artery variant, in which a portion of myocardium overlies a major epicardial coronary artery segment. Myocardial bridge has been for long considered a benign condition, although it has been shown to cause effort-related ischaemia. Case summary We present the case of a 17-year-old female patient experiencing chest pain during physical activity. Since her symptoms became unbearable, electrocardiogram and echocardiography were performed together with a coronary computed tomography scan, revealing an MB on proximal-mid left anterior descending artery. In order to unequivocally unmask the ischaemic burden lent by MB, the patient underwent coronary angiography and physiological invasive test: instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) were calculated, both at baseline and after dobutamine infusion (5 µg/kg/min). At baseline, iFR value was borderline (= 0.89), whereas after dobutamine infusion and increase in the heart rate, the patient suffered chest pain. This symptom was associated with a decrease in the iFR value up to 0.77. Consistently, when FFR was performed, a value of 0.92 was observed at baseline, while after inotrope infusion the FFR reached the haemodynamic significance (= 0.79). Therefore, a medical treatment with bisoprolol was started. Discussion Our clinical case shows the importance of a comprehensive non-invasive and invasive assessment of MB in young patients experiencing chest pain, with significant limitation in the daily life. The coronary functional indexes allow to detect the presence of MB-derived ischaemia, thus guiding the decision to undertake a medical/surgical therapy.
Aims Myocardial bridge (MB) is the most common inborn coronary artery variant in which a segment of an epicardial coronary artery takes a tunneled course under a bridge of myocardium. MB has been documented from 1.5% to 16% of invasive angiographic series thus the true prevalence of MB is uncertain. The clinical relevance of MB is heterogeneous, being usually an asymptomatic bystander. However, a growing body of evidence suggests its association with myocardial ischaemia. In the present work, by setting up a database of patients affected by MB, we sought to assess their clinical characteristics and risk of major adverse cardiac events (MACE). Methods and results This is a prospective/retrospective study and observational study in which we included 17 681 patients referred to undergo invasive coronary angiography (ICA) for suspected coronary artery disease. During the screening phase, we found that 338 cases (26 non-recruitable) were reported to have MB (1.9%). In-hospital clinical-instrumental data was acquired after ICA. The data obtained in the follow-up (FUP) visit is also included in the study. In particular, we recorded MACE and Seattle Angina Questionnaire (SAQ). The most frequent location of MB was the LAD coronary artery (96.8%). Other locations were the circumflex artery (1.3%), the right coronary artery (1%), the posterior interventricular artery (0.6%), and the first diagonal artery (0.3%). Chronic coronary syndrome (CCS) was the most frequent clinical presentation (47.5%). A big proportion (34.6%) of our patients were found to have MB during the occurrence of an acute coronary syndrome (ACS). In acute setting, unstable angina was the most frequent clinical presentation (17.6%). 47 patients (15%) underwent coronary angiography with provocative test (intracoronary acetylcholine) in order to search vasomotor disorders: according to COVADIS criteria, 17 procedures (5.5%) resulted positive for vasospastic angina (VSA). Invasive functional assessment with FFR/iFR was accomplished to assess the haemodynamic significance both of MBs and atherosclerotic plaques proximal to the MB segment in 35 patients (11.2%): in nine procedures (2.9%), functional tests resulted positive. β-Blockers (BBs) are suggested as first-line drugs as they increase diastolic filling time, by decreasing heart rate. Calcium channel blockers (CCBs) are useful, in VSA setting, to reduce epicardial spasm. In our court, 40% of patients toke BBs and 20% of patients toke CCBs at admission. The primary endpoint of the study is the incidence of MACE, defined as the composite of cardiac death, myocardial infarction and cardiac hospitalization. Considering patients who have already undergone FUP (114; 36.5%), we recorded 19 MACE (16.7% of patients with FUP). The secondary endpoint is the rate of patients with SAQ Angina Summary Score < 70: the rate of patients with SAQ < 70 is 23.7% at 6 months, 23.8% at 12 months and 23.2% at 24 months. Conclusions MB has been typically considered benign and asymptomatic, but its clinical relevance is still matter of debate. A remarkable proportion of our patients were found to have a MB during the occurrence of ACS or CCS, highlighting that different mechanisms of ischaemia may coexist. Furthermore, invasive functional assessment shows a plausible correlation between MB and vasomotor disorders. Our study is still ongoing, and we hope to maximize the data in order to have a solid comprehension of MB and to propose the assessment that may indicate a tailored therapy.
Aims Over the last decades, both the improvement in cardiovascular prevention programmes and the advancement in medical and invasive therapies facing ischaemic heart disease have granted an outstanding reduction in mortality rates. However, coronary heart disease remains, by far, the most common disease in developed countries, and the progressive ageing of population leads to a constantly increasing prevalence of chronic coronary syndrome (CCS). The consequence is an unsustainable demand for access to collapsing hospital clinic and doctor’s office. The dramatic Covid-19 era has become the testing ground for alternative ways to deliver healthcare avoiding in-hospital contacts, thus affirming the validity of telemedicine as a key tool to improve the patient journey. In our centre, video consults have been integrated to CCS patients’ clinical care pathway, not only preventing the risk of contagion but also laying the groundwork for a paradigm shift in clinical care course. Methods and results Since pandemic outbreak, Lazio Region offered to its inhabitants free of charge teleconsulting for both primary care and specialist referral. At the cardiovascular department of Fondazione Policlinico Gemelli IRCCS, this opportunity has been recently applied to optimize the chronic coronary syndrome patient journey. Specifically, videoconsulting has been used in different steps of CCS clinical course, replacing both in-person first visit and follow-up consultation after percutaneous myocardial revascularization. Being CCS a context in which the therapy optimization or the transition to higher level tests are mainly indicated by symptoms, these remote consultations could work as well as in-hospital visits to assess risk stratification and to consequently arrange the best therapeutic–diagnostic pathway. Besides, as COVID-19 pandemic caused significant delays, further remote visits have addressed the need to keep in contact with patients waiting for coronary angiography and to reassess their urgency criteria. In our department, over last 9 months, 141 patients have been examined and followed-up through teleconsulting, amounting to 34.1% of all supplied visits. Despite a high median age (67 ± 19.7 years), the drop-out rate of the contacted patients due to inability or denial was quite low (7.5%) and this high adherence to videoconsulting suggests time is ripe for a full telemedicine employment in clinical care course. In the cohort of patients waiting for coronary angiography, a telemedical reassessment led to a significant rate of priority class switch (42.7%), probably preventing adverse cardiac events in those individuals with worsening symptoms (systematically evaluated using Seattle Angina Questionnaire). Of note, the implementation of this parallel virtual pathway for these patients allowed us to decrease the waiting times for in-person visits at our CCS clinic, with an estimated time reduction of almost 3 months. This result supports our idea that the adoption of a remote pathway for chronic illness management, like CCS, may provide more opportunities for treatment of severe cases at in-person clinics that are often overcrowded. Conclusions In conclusion, all the potential of telehealth to empower primary and specialty health care is gradually emerging, and CCS seems the perfect setting for an integrated physical and virtual health system.
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