Coronary artery ectasia: local pathology or diffuse disease?

Safety and efficacy results of percutaneous renal stent implantation in patients with acute coronary syndrome with ectatic and aneurysmatic coronary arteries

BACKGROUND

For the treatment of stenotic lesions developing in dilated coronary arteries, it is difficult to find an appropriately sized coronary stent given that the vessel diameter is too large. This poses a greater problem, especially in patients who require urgent intervention, such as acute coronary syndrome.

OBJECTIVE

We aimed to evaluate the efficacy and safety of renal stents implanted in ectatic/aneurysmatic coronary arteries in such patients.

METHODS

In total, 18 patients (renal stent group) who underwent renal stent implantation in ectatic/aneurysmatic coronary arteries requiring percutaneous coronary intervention (PCI) and 45 patients who underwent large-sized bare-metal coronary stent (BMCS) implantation (BMCS group) at our center were included in the study. The primary endpoints were MACE (myocardial infarction and cardiovascular mortality), and the secondary endpoints were restenosis and all-cause mortality.

RESULTS

In the study patients with a mean follow-up of 25.3 ± 14.6 months (1-48 months), the control coronary angiography duration was 24.6 ± 14.8 months for the renal stent group and 22.8 ± 15.7 months for the BMCS group (p = 0.06). The MACE was observed in 2 (11.1%) patients in the renal stent group and 4 (8.9%) patients in the BMCS group (HR: 1.39 (0.24-7.82), p = 0.70). The secondary composite outcome was identified in 4 (22.2%) patients in the renal stent group and 6 (13.7%) patients in the BMCS group (HR: 1.93 (0.53-6.91), p = 0.31). No significant differences in primary and secondary outcomes were noted between the groups.

CONCLUSION

Renal stents used during PCI in patients with acute coronary syndrome with ectatic/aneurysmatic coronary arteries have similar efficacy, and mid-term follow-up results those noted for BMCS. These findings support that renal stents can be used in ectatic and aneurysmatic coronary arteries when necessary.

CLINICAL TRIAL REGISTRATION

This study has been registered on ClinicalTrials.gov (NCT05410678).

Can increased intestinal permeability and low-grade endotoxemia be the triggering pathogenesis in isolated coronary artery ectasia?

PURPOSE

Isolated coronary artery ectasia (ICAE) is a rare coronary artery disease (CAD) encountered during coronary angiography. Although many mechanisms have been suggested today that may be associated with ICAE, the underlying pathogenesis has not been fully understood. In this study, we aimed to reveal the possible relationship between intestinal permeability and ICAE.

METHODS

Of the 12 850 patients who underwent coronary angiography, 138 consecutive patients with ICAE and 140 age- and sex-matched subjects with normal coronary arteries as the control group and 140 subjects with stenotic CAD were included in the study.

RESULTS

Serum zonulin and lipopolysaccharide levels were significantly higher in patients with ICAE than in the control group and CAD group. Additionally, zonulin and lipopolysaccharide levels were significantly higher in the CAD group than in the ICAE group. In the correlation analysis, serum zonulin levels were correlated with the mean diameter and length of the ecstatic segment. In multivariate analysis, zonulin and lipopolysaccharide were identified as independent predictors for ICAE.

CONCLUSION

These results suggest that there may be a pathophysiological relationship between increased intestinal permeability and ICAE.

Association of C-Reactive Protein to Albumin Ratio in Patients with Isolated Coronary Artery Ectasia

Fundamento

A ectasia da artéria coronária (EAC) é definida como a dilatação difusa ou localizada do lúmen da artéria coronária com diâmetro de 1,5 a 2,0 vezes o diâmetro da artéria coronária normal adjacente. A relação proteína C-reativa/albumina (CAR, sigla em inglês) é um marcador inflamatório útil que tem sido documentado em doença arterial coronariana.

Objetivo

Analisar a associação entre a EAC e a CAR.

Métodos

Um protocolo caso-controle foi utilizado neste estudo. Foram incluídos 102 pacientesconsecutivos com EAC isolada sem estenose (56 homens e 46 mulheres; idade média de 60,4 ± 8,8 anos). O grupo controle era constituido pelo mesmo número de pacientes pareados por sexo e idade com artérias coronárias normais (55 homens e 47 mulheres; idade média de 61,2 ± 9,1 anos). Características clínicas, achados laboratoriais e histórico de uso de medicamentos foram registrados. Foram realizados teste t de Student, teste U de Mann-Whitney, teste do qui-quadrado, análise de regressão linear e logística. Foi considerado estatisticamente significativo p bilateral < 0,05.

Resultados

A CAR estava aumentada nos pacientes com EAC em comparação com os controles (32 e 16; p < 0,001). Além disso, foi verificado que a CAR era um preditor independente da EAC (razão de chances = 2,202; intervalo de confiança 95%, 1,184 – 5,365; p < 0,001).

Conclusão

No presente estudo, determinamos que os níveis da CAR estavam significativamente mais altos no grupo EAC que no grupo controle e a CAR estava significativamente correlacionada com a EAC. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Cardiac Outpouchings: A Multimodality Imaging Review

Cardiac outpouchings pose a diagnostic challenge when encountered in practice, as the signs, symptoms, and initial investigations, such as radiographs and electrocardiogram, are nonspecific. They may remain asymptomatic and be incidentally detected. However, a few may present with progressive shortness of breath, thromboembolic complications, arrhythmias, pressure effects, rupture, or even death. Imaging is of paramount importance in establishing an accurate diagnosis, delineating morphology and extent of the lesion along with its hemodynamic significance, planning management, and in the follow-up.

Association of serum prolidase activity in patients with isolated coronary artery ectasia

Objective:

Coronary artery ectasia (CAE) is defined as an angiographic enlargement of a portion of the coronary artery between 1.5 and 2 times the diameter of the adjacent normal coronary artery. It has been demonstrated that increased serum prolidase activity (SPA) is associated with increased collagen turnover. We aimed to analyze the relationship between CAE and serum SPA levels.

Methods:

This study used a prospective case protocol design. A total of 40 consecutive patients with isolated right CAE and normal coronary arteries (23 men, 17 women; mean age, 62.4±10.8 years) were evaluated. The control group included the same number of consecutive patients with angiographically normal coronary arteries (20 men, 20 women; mean age, 63.8±11.1 years). Clinical characteristics, laboratory results, cardiovascular risk factors, and medication use were recorded. SPA was measured using a spectrophotometer. Student’s t-test, Mann–Whitney U test, chi-square test, Pearson’s and Spearman’s correlations, logistic regression analysis, and ROC curve analysis were used for statistical analysis.

Results:

SPA was significantly higher in the CAE group compared with the control group (1635.2±492.0 U/L and 986.2±422.3 U/L, respectively; p<0.001). The relationship of SPA with CAE proved to be significant (r=0.512; p<0.001). SPA also served as an independent predictor of CAE (OR=1.003; 95% CI, 1.001–1.005; p=0.002). The SPA value of 1170 U/L was predictive of CAE, with a sensitivity of 85% and specificity of 60% (AUC=0.854; 95% CI, 0.763–0.944; p<0.001).

Conclusion:

The activity of this enzyme was significantly correlated with CAE.

Evaluation of the Tp-Te Interval, QTc and P-Wave Dispersion in Patients With Coronary Artery Ectasia

Background

Coronary artery ectasia (CAE) is defined as a diffuse dilatation of the diameter of the ectatic segment of the coronary artery, 1.5 times greater than that of the adjacent segment. The Tp-Te interval, P-wave and QTc dispersions are relatively new electrocardiographic markers associated with an increased risk of developing arrhythmias. Despite CAE increasing in prevalence in recent years, there is a sparsity of data available about its arrhythmogenic effect. The aim of the study was to evaluate QTc, P-wave dispersion and Tp-Te and Tp-Te/QT ratio in patients with CAE.

Methods

A retrospective comparative study was designed for consecutive age- and sex-matched patients. Twenty patients with isolated CAE (group 1) and 20 control subjects (group 2), with normal coronary arteries, were included. All patients presented with chest pain and coronary angiogram was indicated. Outcome measures included Tp-Te interval, Tp-Te/QT ratio, QTc dispersion and P-wave dispersion. Measurement of electrocardiogram (ECG) parameters was conducted using standardized digital online software. Descriptive and inferential statistics were performed.

Results

Mean Tp-Te (95.5 ± 9.01 ms) and Tp-Te/QT ratio (0.22 ± 0.02) were significantly prolonged in CAE group (Tp-Te: 84 ± 5.62 ms, P = 0.00009; Tp-Te/QT ratio: 0.20 ± 0.01, P = 0.00004). In addition, QTc (31.2 ± 3.71 ms) and P-wave dispersion (31.9 ± 5.46 ms) were significantly increased in comparison to the control group (QTc: 27.6 ± 2.82 ms, P = 0.00532 and 20 ± 3.77 ms, P = 0.00003 respectively). However, there was no difference in ventricular activation time (VAT) between groups.

Conclusions

CAE ECGs were found to be associated with increased Tp-Te, Tp-Te/QT ratio, QTc intervals and P-wave dispersions. This may suggest that CAE existence has a pro-arrhythmogenic nature.

Relationship between platelet-to-lymphocyte ratio and the presence and severity of coronary artery ectasia

Objective:

The aim of this study was to investigate the relationship between platelet-to-lymphocyte ratio (PLR), an easily available inflammatory marker, and coronary artery ectasia (CAE).

Methods:

After applying the exclusion criteria, the retrospective study population consisted of 330 patients, including 110 patients with isolated CAE, 110 with obstructive coronary artery disease (CAD), and 110 with normal coronary artery angiograms (NCA). The severity of isolated CAE was determined according to the Markis classification. SPSS 22.0 statistical package program was used for data analysis.

Results:

PLR was significantly higher in patients with isolated CAE than in those with NCA and obstructive CAD [123 (113–156), 100 (86–138), and 110 (102–141), respectively]. Logistic regression analysis showed that PLR and C-reactive protein level were significantly correlated with the severity of isolated CAE.

Conclusion:

To the best of our knowledge, this study showed for the first time that PLR was significantly associated with CAE.

Relation Between Monocyte to High-Density Lipoprotein Cholesterol Ratio With Presence and Severity of Isolated Coronary Artery Ectasia

The aim of this study was to investigate an easily available inflammatory and oxidative stress marker and monocyte to high-density lipoprotein cholesterol ratio (MHR) in patients with coronary artery ectasia (CAE). The study population included 405 patients of which 135 patients had isolated CAE, 135 patients had obstructive coronary artery disease (CAD), and 135 patients had normal coronary angiograms (NCAs). The severity of isolated CAE was determined according to the Markis classification. The MHR was significantly greater in patients with isolated CAE than those with obstructive CAD and NCAs: 14.8 (11.6 to 19.8), 11.4 (9.6 to 13.5), 9.8 (7.5 to 11.9), respectively. Linear regression analyses showed that MHR and C-reactive protein were significantly related with the severity of isolated CAE. In conclusion, the MHR is significantly greater in patients with CAE compared to controls with obstructive CAD and NCAs, and MHR is associated with the severity of CAE.

High prevalence of coronary artery events and non-coronary events in patients with coronary artery aneurysm in the observational group

Background

Coronary artery aneurysm (CAA) is occasionally detected on a small percentage of coronary angiography or multi-detector computed tomography (MDCT). CAA itself is considered benign entity despite the potential risks of rupture, thromboembolism, and compression of surrounding structures. However, the optimal management including other vascular comorbidity has yet to be fully clarified.

Objective

The aim of this study was to evaluate cardiovascular events in the patients with CAA in the observational group.

Methods

Between January 2010 and August 2015, 48 CAAs were identified in 37 patients out of consecutive 10,010 patients (0.37%) by MDCT. Twenty-eight patients treated conservatively were included in this study. Their major adverse cardiovascular events (MACE) were evaluated retrospectively: death, non-fatal myocardial infarction (MI), revascularizations; coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), and other vascular events.

Results

The average age was 62.0 ± 15.5 year sold, and median follow-up period was 49.6 months (IQR 23.6 to 78.1). Mean CAA diameter was 7.5 ± 2.8 mm. Twenty-two MACE occurred in 15 patients (53.6%): 1 sudden death, 4 MI, 1 CABG for CAA, 3 PCI for CAA, 7 PCI for non-CAA lesions, and 6 other vascular treatments for aorta and cerebral and peripheral artery. Follow-up MDCT was performed for 22 CAAs in 16 patients. In 9 CAAs of them, the maximal diameter increased significantly (Δ diameter: 1.5 ± 1.1 mm).

Conclusions

Presence of CAA may be associated with adverse vascular events including non-coronary diseases. This study could suggest the management for CAA should include the evaluation of not only CAA itself but also other vascular diseases.

Increased mean platelet volume is associated with coronary artery ectasia

Aim

The present study was designed to investigate mean platelet volume (MPV) values in coronary artery ectasia (CAE) patients in comparison with individuals with coronary artery disease and normal coronary angiograms.

Material and methods

Patients with stable angina pectoris and scheduled for angiography were included in the study. Those with isolated coronary ectasia were evaluated in the coronary angiography. Mean platelet volume was measured in 126 patients (mean age: 57.2 ±11.3 years) with isolated CAE, 126 patients (mean age: 56.3 ±10.4 years) with coronary artery disease (CAD) and 122 control subjects (mean age: 58.1 ±11.1 years). Coronary artery ectasia was defined as lack of stenotic lesion, on visual assessment, of the coronary arteries with a luminal dilatation 1.5-fold or more of the adjacent normal coronary segments. Mean platelet volume values were recorded in all patients. Ectasia severity was evaluated and categorized in accordance with the Markis categorization.

Results

A significant difference with respect to age, sex, hypertension, diabetes mellitus, and cigarette use between the study groups was not found (p > 0.05). Mean platelet volume was significantly higher in patients with CAE and CAD than in the control group (9.8 ±3.8 fl and 9.7 ±3.9 fl vs. 8.8 ±3.3 fl, p < 0.001). There were no statistically significant differences between CAE and CAD groups. When type I and type IV subgroups were compared in patients with coronary artery ectasia, MPV was detected as statistically high in the type I subgroup (p = 0.026).

Conclusions

It was shown that patients with CAE and CAD have higher MPVs than subjects with normal coronary angiograms. Moreover, it was detected that in coronary artery ectasias, the increase in MPV is related to both the atherosclerotic process and severity of the disease.

Coronary artery aneurysms and ectasia: role of coronary CT angiography

Coronary artery dilatations-aneurysms and ectasia-are an uncommon and frequently unrecognized incidental finding in patients with coronary artery disease. Aneurysms and ectasia are associated with a vast group of disorders, and the evaluation and characterization of coronary aneurysms and ectasia represent a great diagnostic task with clinical and therapeutic implications. The underlying etiology is variable and includes degenerative, congenital, inflammatory, infectious, toxic, and traumatic causes. Unlike aneurysms, ectasia is more frequently seen in association with atherosclerosis or as a compensatory mechanism in those cases in which a proximal stenosis is noted in the opposite coronary artery; ectasia is also seen in some coronary artery anomalies, such as anomalous origin from the pulmonary artery, or as a result of a high-flow state, as seen in coronary artery fistulas. The diagnostic approach depends on the clinical scenario, and nowadays, noninvasive evaluation with multidetector computed tomography is possible. Imaging assessment should include evaluation of (a) the distribution, (b) maximal diameter, (c) presence or absence of intraluminal thrombi, (d) number, (e) extension, and (f) associated complications such as myocardial infarction. This article presents an overview of the definition, classification, etiology, clinical manifestations, and potential complications of coronary artery aneurysms and ectasia.

Assessment of left ventricular functions in patients with isolated coronary artery ectasia by conventional and tissue Doppler imaging

The authors sought to determine left ventricular functions by conventional and tissue Doppler imaging in patients with isolated coronary artery ectasia and controls. Peak early (E) and late (A) mitral inflow velocity, E/A ratio, E deceleration time, and isovolumetric relaxation time were obtained. Peak systolic velocity (Sm), diastolic early (Em), and late (Am) velocities were measured by tissue Doppler imaging. Interventricular septum velocities, including peak systolic (Ss), diastolic early (Es), and late (As) velocities, were recorded. Peak early (E) velocity, E/A ratio, and E deceleration time were different in both groups. Isovolumetric relaxation time was prolonged in patients with coronary artery ectasia than controls. Em and Em/Am ratio were lower in patients with coronary artery ectasia than controls. Diastolic early and Es/As velocities were lower in patients with coronary artery ectasia compared with controls. The authors showed that mitral inflow-lateral annulus and interventricular septum velocities were lower in patients with coronary artery ectasia than controls indicating left ventricular diastolic dysfunction.

Identifying cardiovascular risk factors in a patient population with coronary artery ectasia

Coronary artery ectasia (CAE) is frequently considered as a form of coronary artery disease. Cardiovascular risk factors were determined in a patient population with CAE. The 51 patients with isolated CAE (group 1), 61 patients with CAE coexisting with significant coronary stenosis (group 2), and 62 subjects with significant coronary stenosis (group 3) were included in the study, and the distribution of cardiovascular risk factors was compared. Thirty of 51 patients with isolated CAE had presented with typical angina pectoris, 8 patients with unstable angina pectoris, and 13 patients had atypical chest pain or palpitation. The 21 of 51 patients with isolated CAE had definitive positive treadmill exercise test results. Positive family history was similar in each group. The history of smoking was similar in group 1 and group 2 but higher than group 3. Frequency of hypertension was similar in group 1 and group 2 but higher than that in group 3. Frequency of diabetes mellitus was similar in group 1 and group 2 but lower than group 3. Plasma lipid levels and the number of patients with lipid disturbances were also similar in each group. In addition, C-reactive protein (CRP) levels were above the normal limits and there was no difference among groups with respect to plasma CRP levels. CAE appears to be associated with traditional cardiovascular risk factors such as hypertension, smoking, and hyperlipidemia. In addition, elevated CRP level in patients with CAE may suggest the role of inflammatory process in development of CAE.

Increased platelet activity in patients with isolated coronary artery ectasia

BACKGROUND

The common coexistence with coronary artery disease has led to the suggestion that coronary artery ectasia (CAE) is a variant of coronary artery disease. The mechanisms, however, responsible for CAE formation during the atherosclerotic process and the exact clinical significance are not well known. In this study, we aimed to investigate platelet activity in patients with isolated CAE by using specific markers of platelet activation as P-selectin, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4).

METHODS

Thirty-two patients with isolated CAE without significant stenosis and 30 control participants with angiographically normal coronary arteries were included in this study. According to the angiographic definition used in the Coronary Artery Surgery Study, a vessel is considered to be ectasic when its diameter is > or = 1.5 times that of the adjacent normal segment in segmental ectasia. Plasma P-selectin, beta-TG and PF4 levels were measured in all patients and control participants using enzyme-linked immunosorbent assay method.

RESULTS

Patients with isolated CAE were detected to have significantly higher levels of plasma P-selectin, beta-TG and PF4 in comparison with control participants with angiographically normal coronary arteries (P-selectin: 248+/-46 vs. 154+/-32 ng/ml, respectively, P<0.001; beta-TG: 51+/-19 vs. 21+/-9 ng/ml, respectively, P<0.001; PF4: 58+/-23 vs. 33+/-11 ng/ml, respectively, P<0.001).

CONCLUSION

In conclusion, we have shown for the first time that patients with isolated CAE have raised levels of plasma P-selectin, beta-TG and PF4 compared with control participants with angiographically normal coronary arteries, suggesting increased platelet activation in patients with CAE.

Increased plasma levels of cystatin C and transforming growth factor-beta1 in patients with coronary artery ectasia: can there be a potential interaction between cystatin C and transforming growth factor-beta1

Cystatin C, known as an inhibitor of the cathepsin family of cysteine proteases, has been evaluated in several cardiovascular disorders such as atherosclerosis and acute myocardial infarction. The potential interaction between transforming growth factor-beta1 and cystatin C has also been demonstrated in some cell types. Accordingly, we aimed to compare the plasma levels of cystatin C and transforming growth factor-beta1 in patients with coronary artery ectasia coexisting with coronary artery disease and those with coronary artery disease alone. Thirty-nine patients with coronary artery ectasia and coronary artery disease and 35 age and sex-matched patients with coronary artery disease alone were prospectively enrolled in the study. Blood samples of all patients and control participants for measuring plasma cystatin C and transforming growth factor-beta1 levels were drawn>or=24 h after the coronary angiography. Cystatin C concentrations in plasma were measured by latex-enhanced reagent on a Behring Nephelometer II. Plasma levels of transforming growth factor-beta1 were measured by using transforming growth factor-beta1 enzyme-linked immunosorbent assay kit (BioSource International, Inc., Camarillo, California, USA). Plasma level of cystatin C was significantly higher in patients with coronary artery ectasia+coronary artery disease than in patients with coronary artery disease alone (1.05+/-0.30 mg/dl vs. 0.92+/-0.18 mg/mdl, P=0.025, respectively). Transforming growth factor-beta1 was also found to be significantly higher in patients with coronary artery ectasia+coronary artery disease compared with those with coronary artery disease (2.47+/-0.43 vs. 2.22+/-0.43 pg/ml, P=0.02, respectively). The plasma level of cystatin C was significantly but weakly correlated with that of transforming growth factor-beta1 (r=0.217 P=0.02). We conclude that plasma levels of cystatin C and transforming growth factor-beta1 are significantly higher in patients with combined coronary artery ectasia and coronary artery disease than in those with coronary artery disease. Correlation between transforming growth factor-beta1 and cystatin C may also suggest that pathogenesis of coronary artery ectasia might have some different pathways from atherosclerosis with respect to the regulation of extracellular matrix remodeling. Therefore, the role of cystatin in the pathogenesis of coronary artery ectasia and its potential interaction with transforming growth factor-beta1 should be evaluated in further studies.

Novel insights into an old controversy: is coronary artery ectasia a variant of coronary atherosclerosis?

Coronary artery ectasia (CAE) is defined as a localized or diffuse non-obstructive lesion of the epicardial coronary arteries with a luminal dilation exceeding 1.5-fold the diameter of the normal adjacent arterial segment. The incidence of CAE has been reported to range between 2% and 4%, which might be an overestimation of the true frequency. The coincidence of CAE with other systemic vascular dilatations has suggested that the mechanism underlying CAE is not only localized to coronary arteries, but also to other vascular compartments such as aorta or peripheral veins. Although the pathophysiology of CAE remains largely unknown, it was supposed to represent a variant of coronary atherosclerosis. This review focuses on this controversy of whether CAE and coronary artery disease (CAD) are two manifestations of the same underlying process. There are clear differences between CAD and CAE with respect to cardiovascular risk factors such as diabetes mellitus, and pathogenic steps in disease progress such as inflammation or extracellular matrix remodeling. As this review will underscore, the current knowledge of the field is insufficient to finally clarify the causative interrelation between CAE and CAD. The clinical course and treatment of CAE mainly depends on its coexistence with CAD. When coexisting with CAD, the prognosis and treatment of CAE are the same as for CAD alone. In isolated CAE, prognosis is better and anti-platelet drugs are the mainstay of treatment. Surgical treatment can be considered in selected patients. For clarifying the mechanism underlying CAE, additional clinical, histopathological and pathophysiological investigations are required. In fact, every patient with CAE should be evaluated systematically for pathological changes in other vascular territories, both in the arterial system as well as in the venous system, which might occur in the disease process.

The level of hs-CRP in coronary artery ectasia and its response to statin and angiotensin-converting enzyme inhibitor treatment

BACKGROUND/AIM

Coronary artery ectasia (CAE) was thought of as a variant of atherosclerosis. C-reactive protein (CRP) which is among the most sensitive markers of systemic inflammation, and elevation of systemic and local levels of this inflammatory marker which has been associated with an increased risk for cardiovascular disease in the obstructive coronary artery disease (O-CAD) are well known, but little was known in CAE. The anti-inflammatory effects of statins and the effect of angiotensin-converting enzyme (ACE) inhibitors on endothelial dysfunction are well established in atherosclerosis. The aim of the present study was to investigate CRP level and its response to statin and ACE inhibitor treatment in CAE.

MATERIALS AND METHOD

We measured serum hs-CRP level in 40 CAE (26 males, mean age: 56.32 +/- 9 years) and 41 O-CAD (34 males, mean age: 57.19 +/- 10 years) patients referred for elective coronary angiography at baseline and after 3-month statin and ACE inhibitor treatment.

RESULTS

Plasma hs-CRP levels were significantly higher in CAE group than O-CAD group at baseline (2.68 +/- 66 mg/L versus 1, 64 +/- 64, resp., P < .0001). Plasma hs-CRP levels significantly decreased from baseline 3 months later in the CE (from 2.68 +/- 0.66 mg/L to 1.2 +/- 0.53 mg/L, P < .0001) as well as in the O-CAD group (from 1.64 +/- 0.64 mg/L to 1.01 +/- 0.56 mg/L, P < .001).

CONCLUSION

We think that hs-CRP measurement may be a good prognostic value in CAE patients as in stenotic ones. Further placebo-controlled studies are needed to evaluate the clinical significance of this decrease in hs-CRP.

Decreased carotid intima-media thickness in patients with coronary artery ectasia compared with patients with coronary artery disease

BACKGROUND

Although atherosclerosis is supposed to be responsible for more than 50% of coronary artery ectasia, the precise pathology of coronary artery ectasia is not clearly understood. A histopathological examination of ectatic segments has revealed mainly destruction of the media layer of the artery. In the present study, we assessed carotid intima-media thickness and common carotid artery diameter in patients with and without coronary artery ectasia.

MATERIALS AND METHODS

Thirty-five consecutive patients with coronary artery ectasia and coronary artery disease and 35 age and sex-matched patients with coronary artery disease alone were included in the study. The common carotid artery was studied as the longitudinal plane within 10 mm from the bifurcation of the common carotid artery. The intima-media thickness was measured in the far wall at end-diastole from the B-mode screen to a point within the 10-mm segment proximal to the bifurcation by one investigator blinded to clinical data.

RESULTS

No significant differences with respect to age, body mass index, hypertension, diabetes mellitus, hypercholesterolemia and smoking habits were observed between the two groups studied. Intima-media thickness of the common carotid artery of the patients with coronary artery ectasia was significantly lower than that of the patients with coronary artery disease alone (0.71 +/- 0.13 vs. 0.77 +/- 0.09 mm, respectively, P = 0.04).

CONCLUSION

Decreased intima-media thickness of the carotid artery in patients with coronary artery ectasia and coronary artery disease may have pathogenic mechanisms different from coronary artery disease per se.

Decreased nitrate-mediated dilatation in patients with coronary artery ectasia: an ultrasonographic evaluation of brachial artery

BACKGROUND

Coronary artery ectasia has been defined as localized or diffuse nonobstructive lesions of the epicardial coronary arteries with a luminal dilation exceeding the 1.5-fold of normal adjacent segment or vessel diameter. Although coronary artery disease is supposed to be responsible for more than 50% of coronary ectasia, the precise pathology of coronary artery ectasia is not clearly understood. The brachial artery ultrasound test for flow-mediated endothelial-dependent vasodilatory function includes administration of sublingual nitrates to examine the vasodilating effect of an exogenous source of nitric oxide. In the present study, we aimed to compare flow-mediated and nitrate-mediated responses of brachial artery in patients with coronary artery ectasia and patients with coronary artery disease.

MATERIALS AND METHODS

Thirty-six consecutive patients with coronary artery ectasia in combination with coronary artery disease and 42 age-matched and sex-matched patients with coronary artery disease alone were included in the study. Flow-mediated and nitrate-mediated dilatations were measured in all patients using a high-resolution B-mode ultrasonographic system.

RESULTS

Baseline brachial artery diameters in patients with coronary artery ectasia were not statistically different from those in patients with coronary artery disease (4.2+/-0.6 vs. 4.0+/-0.6 mm, respectively, P=0.16). Although the forearm flow-mediated dilatation of the patients with coronary artery ectasia did not differ from that of patients with coronary artery disease alone (5.5+/-3.8 vs. 4.8+/-3.6%, respectively, P=0.41), nitrate-mediated dilatation was significantly lower than that of patients with coronary artery disease alone (7.9+/-5.2 vs. 10.9+/-5.4%, respectively, P=0.02).

CONCLUSION

We have shown that patients with coronary artery ectasia have decreased nitrate-mediated response of brachial artery compared with patients with coronary artery disease alone, suggesting more severe dysfunction or, possibly, destruction of the media layer in coronary artery ectasia than in coronary artery disease.

Increased prevalence of varicocele in patients with coronary artery ectasia

BACKGROUND

Coronary artery ectasia (CAE) is defined as localized or diffuse non-obstructive lesions of the epicardial coronary arteries with a luminal dilation exceeding the 1.5-fold of normal adjacent segment or vessel diameter. Varicocele is the dilatation of the pampiniform plexus. Recently increased prevalence of peripheral varicose veins has been shown in patients with CAE. In this study we aimed to assess the prevalence of varicocele, which is dilatation of another venous system, in patients with CAE.

MATERIALS AND METHODS

Thirty-five male consecutive patients with coronary artery ectasia in combination with or without coronary artery disease (CAD) and 63 male, age-matched patients with coronary artery disease were included in the study. All patients were evaluated for the presence of varicocele.

RESULTS

Twenty-one patients with CAE were found to have varicocele (62% of group I patients). In patients with CAD, 24 patients (38%) were found to have varicocele. The difference between the two groups in respect to presence of varicocele was statistically significant (P=0.02; odds ratio=1.57; 95% confidence interval 1.05- 2.3).

CONCLUSION

We have shown that patients with coronary artery ectasia have an increased prevalence of varicocele compared to those with coronary artery disease. The mechanism underlying coronary artery ectasia might further increase the prevalence of varicocele in susceptible patients.

Elevated plasma homocysteine levels in patients with isolated coronary artery ectasia

OBJECTIVE

Coronary artery ectasia is a variant of coronary atherosclerosis. Hyperhomocysteinemia has emerged as a major, independent risk factor for cardiovascular diseases. The purposes of this study were to determine plasma hyperhomocysteine levels in patients with coronary artery ectasia, and to compare patients with coronary artery ectasia, coronary artery disease, and controls with normal coronary angiogram.

METHOD

The study population included 37 patients with coronary artery ectasia and 36 patients with coronary artery disease. The control group consisted of 32 patients with angiographically proven normal coronary arteries. Plasma hyperhomocysteine levels were measured in all study patients with an enzyme-linked immunosorbent assay.

RESULTS

Plasma homocysteine levels were significantly higher in patients with both coronary artery ectasia and coronary artery disease than in the controls (14.8+/-1.1 and 15.9+/-0.8 vs. 2.5+/-0.6 micromol/l; P<0.001 and P<0.001, respectively). No significant differences in plasma homocysteine levels were found among CAE and CAD groups (P>0.05).

CONCLUSIONS

We have demonstrated that patients with coronary artery ectasia and coronary artery disease have increased plasma hyperhomocysteine levels compared with the controls. These findings suggest that hyperhomocysteinemia may play an important role in the pathogenesis of coronary artery ectasia as in coronary artery disease.

Increased aortic stiffness in patients with coronary artery ectasia

OBJECTIVE

Alterations in aortic stiffness may reflect the elastic properties of the larger arteries. In many diseases, aortic elastic properties have been investigated to show whether the larger arteries are involved. The elastic properties of aorta in patients with coronary artery ectasia, however, have not been studied yet. We aimed to investigate aortic stiffness parameters in patients with coronary artery ectasia and to compare patients with coronary artery ectasia and coronary artery disease with the control group.

METHOD

Thirty-three patients with coronary artery ectasia, 31 patients with coronary artery disease and 30 patients with angiographically normal coronary arteries were included in this study. Aortic diameters were measured on the M-mode tracing obtained at a level 3 cm beyond the aortic valve at parasternal long-axis view. Aortic diameter change, aortic strain, aortic distensibility and stiffness parameters were measured as aortic stiffness parameters.

RESULTS

Aortic diameter changes were fewer in the coronary artery ectasia and coronary artery disease group than in the control group (0.4 +/- 0.1 and 0.3 +/- 0.1 vs. 0.8 +/- 0.2; P < 0.001). Aortic distensibility and aortic strain were significantly lower in patients with coronary artery ectasia and coronary artery disease than in the controls (for aortic distensibility P < 0.001 and for aortic strain P < 0.001, < 0.001, respectively). In contrast, a significantly higher aortic stiffness index was observed in patients with coronary artery ectasia and coronary artery disease than in the control group (14.2+/-2.6 and 18.1 +/- 2.9 vs. 5.9 +/- 1.8; P < 0.001, respectively).

CONCLUSIONS

The impairment in aortic elastic properties in patients with coronary artery ectasia indicates that this disease is a generalized disease rather than a localized disease of the coronary arteries.

Effect of ectasia size or the ectasia ratio on the thrombosis in myocardial infarction frame count in patients with isolated coronary artery ectasia

Coronary blood flow was quantified using the thrombosis in myocardial infarction (TIMI) frame-count method. This measurement has been significantly correlated with flow velocity measured invasively by use of a Doppler flow wire. Coronary artery ectasia or aneurysm (CEA) is thought to be present in patients with a slow blood flow. In this study, we aimed to assess the relationship between the ectasia size or ectasia ratio and TIMI frame count in patients with CEA. The study population included 58 patients with isolated CEA of the right coronary artery. In patients with CEA, an ectasia ratio was calculated as diameter of the ectatic segment/diameter of the adjacent normal segment. According to the ectasia ratio, ectatic vessels were divided into two groups: ectasias with a 1.5- to 2.0-fold increase (group A) and more than 2.0-fold increase (group B) in normal vessel diameter. Patients with a significant stenotic lesion (>50%) in the ectatic vessel were excluded. The control group was formed from a matched population of 35 patients with angiographically proven normal coronary arteries. Characteristics of the ectasia and control groups are similar. The TIMI frame counts for the right coronary artery (RCA) were significantly higher in the ectasia group as compared with the control group (43 +/- 12 vs 23 +/- 8, P < 0.001). The ectasia group had 38 patients in group A and 20 patients in group B. The TIMI frame counts were significantly higher in group B than in group A (43 +/- 10 vs 51 +/- 15, P < 0.05). The TIMI frame count of the RCA showed a significant correlation with the ectasia ratio and the maximum diameter of the ectatic segment (r = 0.578, P < 0.001 and r = 0.435, P < 0.001, respectively). Our data suggest that TIMI frame count measurement depends on the ectasia size or ectasia ratio, and an increased ectasia ratio is markedly associated with decreased TIMI frame counts in patients with CEA.

Plasma homocysteine levels in patients with isolated coronary artery ectasia

OBJECTIVE

Hyperhomocysteinemia is recognized as an independent risk factor for arterial disease including coronary artery disease, cerebrovascular disease and peripheral vascular disease. Previously, an association between increased plasma homocysteine level and peripheral arterial aneurysms has been reported. However, the relationship between coronary artery ectasia (CAE) and plasma homocysteine level has not been investigated. Accordingly, this study was designed to investigate plasma homocysteine level in patients with isolated CAE.

METHODS

Thirty-two patients with isolated CAE without significant stenosis and 30 control subjects with angiographically normal coronary arteries were included in this study. Fasting plasma homocysteine concentrations were measured by Fluorescence Polarization Immunoassay method using homocysteine kids. Hyperhomocysteinemia is defined as plasma homocysteine levels above the 95th percentile of the control subjects (13.6 mumol/l).

RESULTS

According to the definition of hyperhomocysteinemia, 19 (59%) of patients with isolated CAE had elevated levels of plasma homocysteine compared to 2 (7%) in the control subjects with angiographically normal coronary arteries (p<0.001). In addition, patients with isolated CAE had significantly higher levels of plasma homocysteine compared to control subjects (14.9+/-4.5 micromol/l vs. 8.6+/-1.9 micromol/l respectively, p<0.001). Besides, we detected a significant positive correlation between the number of ectasic segment and plasma homocysteine level (r=0.537, p=0.002).

CONCLUSION

We have shown for the first time an association between elevated plasma homocysteine level and isolated CAE. Larger prospective studies are needed to confirm the role of hyperhomocysteinemia in CAE and to evaluate the usefulness of homocysteine-lowering therapies.

Plasma soluble adhesion molecules; intercellular adhesion molecule-1, vascular cell adhesion molecule-1 and E-selectin levels in patients with isolated coronary artery ectasia

Plasma soluble adhesion molecules, intercellular adhesion molecule-1 (ICAM)-1, vascular cell adhesion molecule-1 (VCAM-1) and E-selectin leves of patients with isolated coronary artery ectasia (CAE), patients with obstructive coronary artery disease without CAE and subjects with angiographically normal coronary arteries were evaluated. Patients with isolated CAE were detected to have significantly higher levels of plasma soluble ICAM-1, VCAM-1 and E-selectin in comparison with patients with obstructive coronary artery disease without CAE (ICAM, 673 +/- 153 versus 381 +/- 106, respectively, P < 0.001; VCAM-1, 2366 +/- 925 versus 1136 +/- 208, respectively, P < 0.001; E-selectin, 74 +/- 21 versus 61 +/- 18, respectively, P = 0.01) and subjects with normal coronary arteries (ICAM-1, 673 +/- 153 versus 303 +/- 131, respectively, P < 0.001; VCAM-1, 2366 +/- 925 versus 729 +/- 231, respectively, P < 0.001; E-selectin, 74 +/- 21 versus 49 +/- 9, respectively, P < 0.001), suggesting the presence of a more severe and extensive chronic inflammation in the coronary circulation in patients with isolated CAE.

BACKGROUND

The common coexistence of coronary artery ectasia (CAE) with coronary artery disease (CAD) suggests that it may be a variant of CAD. However, it is not clear why some patients with obstructive CAD develop CAE whereas most do not. Inflammation has been reported to be a major contributing factor to both obstructive and aneurysmatic vascular disorders and therefore, in the present study, the plasma soluble adhesion molecules, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin levels in isolated CAE were investigated.

METHODS

The study population consisted of three groups: the first consisted of 32 patients with isolated CAE without stenotic lesion; the second of 32 patients with obstructive CAD without CAE; and the third group of 30 control subjects with normal coronary arteries. Coronary diameters were measured as the maximum diameter of the ectasic segment by use of a computerized quantitative coronary angiography analysis system. According to the angiographic definition used in the Coronary Artery Surgery Study, a vessel is considered to be ectasic when its diameter is > or =1.5 times that of the adjacent normal segment in segmental ectasia. Plasma soluble ICAM-1, VCAM-1 and E-selectin levels were measured in all patients and control subjects using commercially available enzyme-linked immunosorbent assay kits.

RESULTS

Patients with isolated CAE were found to have significantly higher levels of plasma soluble ICAM-1, VCAM-1, and E-selectin in comparison with patients with obstructive CAD without CAE (ICAM, 673 +/- 153 versus 381 +/- 106, respectively; P < 0.001; VCAM-1, 2366 +/- 925 versus 1136 +/- 208, respectively; P < 0.001; E-selectin, 74 +/- 21 versus 61+/-18, respectively; P = 0.01) and control subjects with normal coronary arteries (ICAM-1, 673 +/- 153 versus 303 +/- 131, respectively;, P < 0.001; VCAM-1, 2366 +/- 925 versus 729 +/- 231, respectively; P < 0.001; E-selectin, 74 +/- 21 versus 49 +/- 9, respectively; P < 0.001). In addition, we detected statistically significant positive correlation between the total length of ectasic segments and the levels of plasma soluble ICAM-1 (r = 0.625; P < 0.001), VCAM-1 (r = 0.548; P = 0.001) and E-selectin (r = 0.390; P = 0.027). Multivariate logistic regression analysis revealed a significant independent relation between isolated CAE and ICAM-1 [odds ratio (OR) = 1.023; 95% confidence interval (CI) = 1.0048-1.0414; P = 0.0129] and VCAM-1 (OR = 1.0057; 95% CI = 1.0007-1.0106; P = 0.0240).

CONCLUSIONS

We have shown that patients with isolated CAE have raised levels of plasma soluble ICAM-1, VCAM-1 and E-selectin in comparison with patients with obstructive CAD without CAE and control subjects with normal coronary arteries, suggesting the presence of a more severe and extensive chronic inflammation in the coronary circulation in these patients.

Association of coronary artery ectasia with plasma insulin levels in Japanese men of heterozygous familial hypercholesterolemia with the low-density lipoprotein receptor gene mutation K790X

BACKGROUND

Hyperinsulinemia is widely believed to be an important coronary risk factor. We investigated the effect of plasma insulin levels on the development of coronary ectasia in Japanese men with heterozygous familial hypercholesterolemia (FH).

METHODS

A cross-sectional study was conducted in 20 FH men with the LDL receptor mutation (K790X) [age 42.3+/-2.8 years old, body mass index (BMI) 24.6+/-0.7 kg/m2, total cholesterol (TC) 8.68+/-0.36 mmol/l, triglycerides (TG) 1.76+/-0.23 mmol/l, high-density lipoprotein cholesterol (HDL-C) 0.977+/-0.065 mmol/l]. Subjects with diabetes mellitus were excluded. Plasma insulin levels, either fasting or during oral glucose tolerance test, were compared between subjects with and without coronary artery ectasia.

RESULTS

FH subjects with coronary ectasia had significantly higher fasting plasma insulin levels than those without (12.6+/-1.4 vs. 7.7+/-0.5 mU/l; p<0.05). Also, plasma insulin levels during oral glucose tolerance test tended to be higher in the former than in the latter.

CONCLUSIONS

Plasma insulin level could be an important determinant of the development of coronary artery ectasia in Japanese heterozygous FH men.

Effects of Co-existence of Coronary Stenosis and the Extent of Coronary Ectasia on the TIMI Frame Count in Patients With Coronary Artery Ectasia

The measurement of the thrombosis in myocardial infarction (TIMI) frame count is a simple method for evaluating coronary blood flow. Although it is well known that slow coronary flow is present in patients with coronary artery ectasia (CAE), the effects of coexisting stenosis and the severity of ectatic involvement on coronory flow have not been adequately studied. Thus, we examined (1) the effect of coexistence of obstructive coronary artery disease on TIMI frame count (TFC) and (2) the relation between the severity of ectatic involvement and TFC in patients with CAE. Ninety-seven study patients with CAE were examined in two steps to determine if they were appropriate in terms of the aim of this study. In the first step, ectasias were divided into three groups: an isolated CAE group, a CAE group with coexisting nonsignificant stenosis, and CAE with coexisting significant stenosis. In the second step, ectasias were subdivided into three groups: CAE with one segment, two segments, and three segments (or diffuse) involvement. The TIMI frame counts for the right coronary artery (RCA), the left circumflex coronary artery (LCx), and the left anterior descending artery (LAD) in the ectasia group were significantly higher than that of the control group (P < 0.001, P < 0.05, P < 0.05, respectively). The presence of coexisting nonsignificant stenosis or coexisting significant stenosis in patients with CAE did not influence TFC (P > 0.05, for all). In addition, the severity of ectasia involvement, regardless of the localization of ectatic segments and the type of the affected vessel, did not change the TFC (P > 0.05, for all). These results suggest that neither the coexisting stenosis nor the extent of involvement significantly affect TFC in patients with coronary ectasia.

Comparison of C-reactive protein levels in patients with coronary artery ectasia versus patients with obstructive coronary artery disease

This study evaluated plasma C-reactive protein (CRP) levels, a specific marker of inflammation, in 32 patients with isolated coronary artery ectasia (CAE) and compared the results with those of 32 patients with obstructive coronary artery disease without coronary artery ectasia and 30 subjects with angiographically normal coronary arteries. CRP levels were found to be significantly higher in patients with isolated CAE (p <0.001), suggesting that more severe inflammation may be involved in the pathogenesis of CAE.

Pulse-spray thrombolysis in acute myocardial infarction caused by thrombotic occlusion of an ectatic coronary artery

Pulse-spray thrombolysis was performed in 2 patients with acute myocardial infarction (AMI) caused by thrombotic occlusion of coronary artery ectasia. Case 1, a 66-year-old woman with an inferior AMI underwent emergency coronary arteriography, which revealed occlusion of an ectatic right coronary artery. Primary balloon angioplasty failed to reestablish distal flow. Urokinase was administered through the pulse-spray infusion catheter (UltraFuse) and intravenous recombinant tissue plasminogen activator was also administered. Angiographic disappearance of the thrombus was observed within 30 min of starting the infusion, and there was only mild irregularity in the ectatic coronary artery. Case 2, a 45-year-old man with an inferior AMI underwent emergency coronary arteriography, which revealed occlusion of an ectatic right coronary artery. TIMI-3 flow was soon obtained after administration of 480,000 units of urokinase through the pulse-spray infusion catheter. There was diffuse right coronary ectasia without angiographic evidence of coronary stenosis. Coronary ectasia sometimes develops into AMI without the coexistence of coronary stenosis. Because a massive thrombus plays a major role, pulse-spray thrombolysis is a possible treatment in coronary artery ectasia with thrombotic occlusion.

Transesophageal echocardiography (TEE) in the evaluation of the coronary arteries

With technical advancements, including high frequency, multiplane transducers, digital acquisition and display, and left-sided contrast agents, TEE is emerging as a promising method for evaluating coronary artery disease. Visualization of proximal coronary artery stenoses and coronary artery anomalies is already possible. Research studies using TEE measurement have contributed to understanding coronary artery physiology and may prove to be a valuable clinical tool in the future.

Exercise-induced myocardial ischemia in isolated coronary artery ectasias and aneurysms ("dilated coronopathy")

OBJECTIVES

The purpose of our study was to evaluate the clinical significance of isolated coronary artery ectasias or aneurysms (CEA).

BACKGROUND

It has been postulated that altered coronary blood flow in CEA predisposes patients to the development of myocardial ischemia (CI) and infarction.

METHODS

Sixty-seven patients with bilateral nonobstructive CEA without associated cardiac defects ("dilated coronaropathy") were derived from 16,341 cardiac catheterizations between 1986 and 1997. Ectasias were defined as luminal dilation of 1.5- to 2.0-fold, aneurysms of >2.0-fold of normal limits. Eleven of 25 patients presented with myocardial infarction due to an occlusion of the infarct vessel. In 42 patients without infarction (study group), exercise-induced CI was investigated.

RESULTS

A corresponding CI was documented in 32 of 42 patients in a coronary sinus lactate study (reduced lactate extraction 5.6 +/- 4.1%) and in 29 of 40 patients in an ergometry (0.25 +/- 0.06 mV ST depressions). The results differed significantly from a control group of 29 patients without heart disease (p < 0.001). Nitroglycerin (0.8 mg) provoked a further significant deterioration of CI in the 32 of 42 developing a frank cardiac lactate production (-2.6 +/- 6.8%, p < 0.001). The metabolic extent of CI was significantly correlated to the coronary diameters of the proximal and middle segments of left anterior descending artery and the middle segment of left circumflex artery (r = 0.87, p < 0.001). Stigmata of an impaired coronary blood flow such as delayed antegrade filling, segmental backflow phenomenon and local deposition of dye were found significantly more often with increasing coronary diameters (p < 0.04).

CONCLUSIONS

"Dilated coronaropathy" is an entity of nonobstructive, ischemic coronary artery disease. Nitroglycerin is of no therapeutic benefit but leads to an aggravation of exercise-induced CI.

Postpartum myocardial infarction induced by methergine

A 28-year-old woman presented to the emergency department for evaluation of acute chest pain. She lacked risk factors for coronary artery disease and her initial electrocardiogram (ECG) was nondiagnostic. Within 45 minutes of presentation she developed nausea, vomiting, restrosternal chest pain, and ECG changes compatible with an acute inferoposterior myocardial infarction. Emergent cardiac catheterization revealed three-vessel coronary artery ectasia and two-vessel occlusion. She underwent emergency coronary artery bypass grafting. Her myocardial ischemia was believed to have been induced by methergine, which she had been taking over the preceding 3 days. The etiology and pathophysiology of coronary artery ectasia, as well as the cardiovascular effects of methergine and a related drug, ergotamine, are discussed.

Simultaneous presence of a large coronary aneurysm and ectasia in a young patient with myocardial infarction--a case report

Idiopathic or congenital coronary artery ectasias and aneurysms are uncommon forms of coronary artery disease. The prognosis and optimal management of such patients remains unknown. The authors describe the case of an otherwise healthy 30-year-old man with concomitant severe right coronary artery ectasia and left main coronary artery aneurysm who sustained a mild anterior myocardial infarction. There was no obstructive coronary artery disease, and no cause for the lesions could be identified. Chronic anticoagulation and antiplatelet therapy were initiated with resolution of symptoms.

Documentation by intravascular ultrasound of thrombus overlying a small atheromatous plaque in a coronary artery in unstable angina pectoris and in acute myocardial infarction

Rupture of atheromatous plaques leading to acute coronary syndromes usually occur in lipid-reach and well-developed coronary lesions. We describe 2 unusual patients with acute coronary syndromes in whom there was angiographic and intravascular ultrasound evidence of an intraluminal thrombus overlying a small, nonocclusive plaque in an enlarged coronary artery.