The clinical significance and subsequent management of the various types of coronary artery anomalies (CAAs) are different, as is the relationship to sudden death, coronary artery disease, and myocardial ischemia. A practical global classification based on clinical significance has not yet been proposed. This retrospective study was aimed at evaluating the current clinical significance of CAAs and the effectiveness of a clinical-significance-based classification. In a single-center retrospective study at a public hospital, a review of the last 5,100 coronary angiographies was performed in order to select patients with CAAs. The CAAs were classified into 4 categories on the basis of a literature review according to angiographic appearance and clinical significance: benign (class I); relevant-associated with fixed myocardial ischemia (class II); severe-related to sudden death (class III); and critical-associated with superimposed coronary artery disease (CAD) (class IV). Clinical and instrumental records of the selected patients were reviewed as well as the occurrence of cardiovascular events from the date of diagnosis to July 2002. Sixty-two patients (1.2%, women/men 20/42, mean age 65.3 +/-10.6 years) had CAA on coronary angiography. From the above-described classification, 40 patients were categorized in class I (64.5%), 9 in class II (14.5%), 7 in class III (11.3%), and 6 in class IV (9.7%). During the follow-up (mean duration 60.4 +/-12.3 months) most cardiovascular events and death occurred in class III and IV patients (71.3% and 100% respectively). A high correlation was found between significance level and percentage of patients with cardiovascular events (r = 0.99). Actuarial survival at 5 years was 82.9%. CAAs can be practically classified on the basis of clinical presentation and significance. This clinical classification may be useful in managing patients with CAA and personalizing their follow-up and therapeutic options according to their class and case histories.
The study is aimed at evaluating the real incidence of normal coronary arteries and the role of alternative substrates of myocardial ischemia in patients with acute coronary syndrome (ACS) but with no coronary artery disease (CAD) in a real world secondary care public hospital. The medical records of 941 patients undergoing coronary arteriography for ACS within 48 h of onset between January 1st 2000 and November 1st 2003 were critically reviewed. In 70 patients (7.4%, 35 males, mean age 60 +/- 17.2 years) no CAD was documented. Alternative substrates of acute myocardial ischemia included coronary artery anomalies (7 patients, 10%), coronary spasm (10 patients, 14.3%), spontaneous coronary dissection (2 patients, 2.8%), paradoxical embolism through a patent foramen ovale (4 patients, 5.7%), embolism from left atrium or calcified aortic valve (4 patients, 5.7%), imbalance between oxygen demand and supply (20 patients, 28.5%), mitral valve prolapse (11 patients, 15.7%). No alternative substrates were found in 12 patients (17.1%). Patients with no CAD are more frequently female and younger. Absence of CAD is an uncommon finding in patients undergoing coronary artery angiography for ACS.
The relevance of benign congenital coronary anomalies (CAAs) in the atherosclerotic process is still confused despite the number of single reports of coronary artery disease in CAAs. The present study is aimed at assessing the role of CAAs on the progression of coronary artery disease (CAD). A review of the last 15,000 coronary angiographies was performed to select patients with CAAs, and they were divided into 2 groups on the basis of the presence (group I) or the absence (group II) of CAD. Clinical and instrumental records of the selected patients were reviewed and the numbers of cardiovascular events for each group (acute myocardial infarct, unstable angina, silent ischemia, bypass or percutaneous transluminal coronary angioplasty (PTCA) interventions, and cardiovascular death) were recorded from the date of diagnosis to July 2002. Group I (22 patients, mean age 64.1 +/- 9.1 years, F/M = 10/12) and group II (17 patients, mean age 66.5 +/- 10.6 years, F/M = 7/10) were similar for age and ejection fraction values. The presence of risk factors was statistically higher in group I. The number of patients with cardiovascular events was significantly higher in group I: 50% (11 patients) in group I vs 12% (2 patients) in group II, p<0.05). Repeated coronary angiography in 8/11 patients of group I and in the 2 patients of group II confirmed that the causes of the events were precedent atherosclerotic lesions in 7 patients and newly developed lesions in 3. At a mean follow-up of 60.4 +/- 12.3 months, mean actuarial survival was lower in group I than in group II (74.8% vs 100%, p=0.045), whereas mean event-free survival was 41.7% in group I and 88.7% in group II (p=0.02). Benign CAAs do not seem per se to be an accelerating factor for coronary atherosclerosis development in patients with no or few classical risk factors.
The feasibility, safety and usefulness of dipyridamole echocardiography (two-dimensional echocardiography and 12 lead electrocardiographic monitoring during dipyridamole infusion, up to 0.84 mg/kg over 10 min) were evaluated in 94 asymptomatic patients 8 to 10 days after uncomplicated acute myocardial infarction. The results were compared with those of symptom-limited treadmill exercise testing and correlated with coronary angiography. Two mechanical patterns of positivity of dipyridamole echocardiography could be identified: 1) a new wall motion abnormality confined to the infarct zone or to the adjacent segments (24 patients), and 2) transient remote asynergy (33 patients). The success rate in recording adequate images during dipyridamole infusion was 100%. Interobserver agreement concerning diagnosis occurred in 89 (93%) of 94 patients. Dipyridamole echocardiography was well tolerated; no complication was observed during or after the test. Seventy-three patients underwent coronary angiography within 6 weeks after acute myocardial infarction. Transient remote asynergy on echocardiography was present in 27 of 40 patients with multivessel disease and in none of 33 patients without multivessel disease. Results of treadmill exercise testing were positive in 28 patients with multivessel disease and 8 patients without multivessel disease. Thus, the sensitivity of dipyridamole-induced transient remote asynergy was 68% compared with 52% for treadmill testing (p less than 0.05); specificity was 100% and 72%, respectively (p less than 0.005). The overall accuracy of dipyridamole echocardiography (81%) was higher than that of dipyridamole stress electrocardiography (63%) or exercise electrocardiography (60%) (p less than 0.02). It is concluded that dipyridamole echocardiography is a useful, feasible and inexpensive nonexercise-dependent test for detecting the extent of coronary artery disease early after acute myocardial infarction.
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