Coronary artery ectasia, an independent predictor of no-reflow after primary PCI for ST-elevation myocardial infarction

Prognostic role of coronary artery ectasia in patients with nonobstructive coronary artery disease

AIMS

Coronary artery ectasia (CAE) has been linked to the occurrence of adverse events in patients with ischemia/angina and no obstructive coronary arteries (INOCA/ANOCA), while the relationship between CAE and myocardial infarction with nonobstructive coronary arteries (MINOCA) has been poorly investigated. In our study we aimed at assessing differences in clinical, angiographic and prognostic features among patients with CAE and MINOCA vs. INOCA/ANOCA presentation.

METHODS

Patients with angiographic evidence of CAE were enrolled at the University Hospital of Parma and divided into MINOCA vs. INOCA/ANOCA presentation. Clinical and quantitative angiographic information was recorded and the incidence of major adverse cardiovascular events (MACE) was assessed at follow-up.

RESULTS

We enrolled a total of 97 patients: 49 (50.5%) with MINOCA and 48 (49.5%) with INOCA/ANOCA presentation. The presentation with MINOCA was associated with a higher frequency of inflammatory diseases ( P  = 0.041), multivessel CAE ( P  = 0.030) and thrombolysis in myocardial infarction (TIMI) flow < 3 ( P  = 0.013). At a median follow-up of 38 months, patients with MINOCA had a significantly higher incidence of MACE compared with those with INOCA/ANOCA [8 (16.3%) vs. 2 (4.2%), P  = 0.045], mainly driven by a higher rate of nonfatal MI [5 (10.2%) vs. 0 (0.0%), P  = 0.023]. At multivariate Cox regression analysis, the presentation with MINOCA ( P  = 0.039) and the presence of TIMI flow <3 ( P  = 0.037) were independent predictors of MACE at follow-up.

CONCLUSION

Among a cohort of patients with CAE and nonobstructive coronary artery disease, the presentation with MINOCA predicted a worse outcome.

Impact of hyperuricemia on coronary blood flow and in-hospital mortality in patients with acute myocardial infarction undergoing percutaneous coronary intervention

BACKGROUND

Although serum uric acid (UA) is considered as a risk factor for cardiovascular disease, few data exist regarding the relationship between hyperuricemia, coronary blood flow, and subsequent outcome in patients with acute myocardial infarction (AMI). The purpose of our study is to assess whether hyperuricemia is associated with suboptimal coronary flow and increased risk of mortality in patients with AMI after percutaneous coronary intervention (PCI).

METHODS

Using the Rural AMI registry data, 989 consecutive patients with AMI who underwent emergent PCI and had UA measurement at admission were analyzed. We defined hyperuricemia as serum UA ≥7.0 mg/dL in men and ≥ 6.0 mg/dL in women. The primary endpoint was suboptimal coronary flow, defined as post PCI Thrombosis In Myocardial Infarction flow grade ≤ 2. The secondary outcome was in-hospital mortality.

RESULTS

Hyperuricemia was found in 249 (25.2%) patients. Patients with hyperuricemia were more often complicated with cardiogenic shock compared with those without (16.9% vs. 7.4%, p < 0.001). In addition, the median high-sensitivity C-reactive protein was significantly higher in patients with hyperuricemia (0.18 mg/dL; IQR, 0.09-0.71 mg/dL) than in those without (0.14 mg/dL; IQR, 0.07-0.41 mg/dL, p < 0.05). Under these conditions, the prevalence of suboptimal coronary flow after PCI (17.3% vs. 10.1%, p < 0.05) and in-hospital mortality (10.8% vs. 3.6%, p < 0.001) were significantly higher in patients with hyperuricemia compared with those without. Multivariable logistic regression analysis revealed that hyperuricemia was significantly associated with suboptimal coronary flow [odds ratio (OR), 1.60; 95% confidence interval (CI), 1.02-2.49; p < 0.05] and in-hospital mortality (OR, 2.08; 95% CI, 1.05-4.12; p < 0.05).

CONCLUSIONS

Assessment of serum UA upon admission provides useful information for predicting suboptimal coronary flow and in-hospital mortality in patients with AMI undergoing PCI.

Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma

Coronary artery ectasia (CAE) is defined as a diffuse or focal dilation of an epicardial coronary artery, which diameter exceeds by at least 1. 5 times the normal adjacent segment. The term ectasia refers to a diffuse dilation, involving more than 50% of the length of the vessel, while the term aneurysm defines a focal vessel dilation. CAE is a relatively uncommon angiographic finding and its prevalence ranges between 0.3 and 5% of patients undergoing coronary angiography. Although its pathophysiology is still unclear, atherosclerosis seems to be the underlying mechanism in most cases. The prognostic role of CAE is also controversial, but previous studies reported a high risk of cardiovascular events and mortality in these patients after percutaneous coronary intervention. Despite the availability of different options for the interventional management of patients with CAE, including covered stent implantation and stent-assisted coil embolization, there is no one standard approach, as therapy is tailored to the individual patient. The abnormal coronary dilation, often associated with high thrombus burden in the setting of acute coronary syndromes, makes the interventional treatment of CAE patients challenging and often complicated by distal thrombus embolization and stent malapposition. Moreover, the optimal antithrombotic therapy is debated and includes dual antiplatelet therapy, anticoagulation, or a combination of them. In this review we aimed to provide an overview of the pathophysiology, classification, clinical presentation, natural history, and management of patients with CAE, with a focus on the challenges for both clinical and interventional cardiologists in daily clinical practice.

Characteristics and outcomes of patients with coronary artery ectasia presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The clinical significance of coronary artery ectasia (CAE) is not yet fully understood. We aimed to examine differences in clinical and procedural characteristics, clinical management, and outcomes in patients with CAE undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI).

METHODS

This was a retrospective analysis of consecutive patients presenting with STEMI with a culprit native coronary artery from July 2015 to June 2019. Patients were divided into CAE and Non-CAE groups as detected on coronary angiography during PPCI. Comparison between groups was made for baseline clinical and procedural characteristics, as well as complications, pharmacological treatment, and follow-up outcomes.

RESULTS

36/1780 (2.0%) patients were found to have CAE. Patients with CAE had a median age of 57.1 ± 11.7 years and were more likely to be male 33/36 (91.7%). Diabetes was less commonly seen in the CAE group (11.1% vs 31.4%, p = 0.010), and there were no differences in the proportion of patients with hypertension and hyperlipidemia. Patients with CAE had more involvement of right coronary artery (RCA) culprit vessel (63.9% vs. 38.4%, p = 0.026), less coronary stenting (25.0% vs 87.2%, p < 0.001) and post-PPCI TIMI 3 flow (69.4% vs 95.5%, P < 0.001), and were more likely to be discharged with oral anticoagulants (36.1% vs 7.6%, p < 0.001). At 3-year follow-up, all-cause mortality rates were higher in the non-CAE group (0.0% vs 11.5%, p < 0.028), suggesting that CAE was not associated with unfavorable long-term outcome. On multivariate analysis, CAE was not an independent predictor of MACE.

CONCLUSION

Despite lower rates of post-PPCI TIMI 3 flow, CAE was not associated with unfavorable long-term outcome.

Hypertension and coronary artery ectasia: a systematic review and meta-analysis study

BACKGROUND

Coronary artery ectasia (CAE) is characterized by the enlargement of a coronary artery to 1.5 times or more than other non-ectasia parts of the vessel. It is important to investigate the association of different factors and CAE because there are controversial results between available studies. We perform this systematic review and meta-analysis to evaluate the effects of hypertension (HTN) on CAE.

METHODS

To find the potentially relevant records, the electronic databases, including Scopus, PubMed, and Science Direct were searched on 25 July 2019 by two of the authors independently. In the present study, the pooled odds ratio (OR) accompanied by 95 % confidence intervals (CIs) were calculated by a random-effects model. Heterogeneity presented with the I² index. Subgroup analysis and sensitivity analysis by the Jackknife approach was performed.

RESULTS

Forty studies with 3,263 cases and 7,784 controls that investigated the association between HTN and CAE were included. The pooled unadjusted OR of CAE in subjects with HTN in comparison by subjects without HTN was estimated 1.44 (95 % CI, 1.24 to 1.68) with moderate heterogeneity (I² = 41 %, Cochran's Q P = 0.004). There was no evidence of publication bias in the analysis of HTN and CAE with Egger's test (P = 0.171), Begg's test (P = 0.179). Nine articles reported the adjusted effect of HTN on CAE by 624 cases and 628 controls. The findings indicated the overall adjusted OR was 1.03 (95 % CI, 0.80 to 1.25) with high heterogeneity (I² = 58.5 %, Cochran's Q P = 0.013).

CONCLUSIONS

We found that when the vessel was in normal condition, HTN was not very effective in increasing the chance of CAE and only increased the CAE chance by 3 %. This is an important issue and a warning to people who have multiple risk factors together. More studies need to be performed to further establish these associations by reported adjusted effects.

CHA2DS2-VASc score predicts the slow flow/no-reflow phenomenon in ST-segment elevation myocardial infarction patients with multivessel disease undergoing primary percutaneous coronary intervention

ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) have a higher incidence of slow-flow/no-reflow (SF-NR) phenomenon during primary percutaneous coronary intervention (PPCI) than those with single vessel disease. Currently, no effective tools exist to predict the risk of SF-NR in this population. The present study aimed to evaluate whether CHA2DS2-VASc score can be used as a simple tool to predict this risk.This study consecutively included STEMI patients hospitalized in Beijing Anzhen Hospital from January 2005 to January 2015. Among these patients, 1032 patients with MVD were finally enrolled. Patients were divided into SF-NR (+) group and SF-NR (-) group according to whether SF-NR occurred during PPCI. SF-NR was defined as the thrombolysis in myocardial infarction (TIMI) grade ≤2.There were 134 patients (13%) in the SF-NR (+) group. Compared with the SF-NR (-) group, patients in the SF-NR (+) group are elder, with lower left ventricular ejection fraction and higher CHA2DS2-VASc score. Multiple logistic regression analysis indicated that CHA2DS2-VASc score ≥3 (odds ratio [OR], 2.148; 95% confidence interval [CI], 1.389-3.320; P = .001), current smoking (OR, 1.814; 95% CI, 1.19-2.764; P = .006), atrial fibrillation (OR, 2.892; 95% CI, 1.138-7.350; P = .03), complete revascularization (OR, 2.307; 95% CI, 1.202-4.429; P = .01), and total length of stents ≥40 mm (OR, 1.482; 95% CI, 1.011-2.172; P = .04) were independent risk factors of SF-NR. The incidence of SF-NR in patients with CHA2DS2-VASc score ≥3 was 1.7 times higher than that in patients with CHA2DS2-VASc score <3. Additionally, patients with CHA2DS2-VASc score ≥3 plus ≥2 risk factors have 3 times higher incidence of SF-NR than those with CHA2DS2-VASc score ≥3 plus 0 to 1 risk factor.CHA2DS2-VASc score ≥3 can be used as a simple and sensitive indicator to predict SF-NR phenomenon and guide the PPCI strategy in STEMI patients with MVD.

Prophylactically injection of Nicorandil to reduce no-reflow phenomenon during PCI in acute STEMI patients: Protocol of a double-blinded, randomized, placebo-controlled trial

INTRODUCTION

An acute ST-elevation myocardial infarction (STEMI) is a very serious type of heart attack and a profoundly life-threatening medical emergency, and percutaneous coronary intervention (PCI) is the preferred strategy. However, in patients undergoing primary PCI, 30% to 40% may suffer the no-reflow phenomenon (NRP), and it could expand the myocardial infarction area and accompanied with high rehospitalization rate and fatality rate. In this study, we try to conduct a double blinded, randomized, placebo-controlled trial to observe whether the prophylactically intracoronary administration of Nicorandil could reduce the occurrence of NRP in STEMI patients undergoing PCI.

METHODS

Simple randomization in a 1:1 ratio will be made in blocks of variable size according to a random numbers generated by Excel 2010 to divide the patients to treatment group (Nicorandil) and control group (Saline). The outcomes are the occurrence of NRP, levels of interleukin-6 and HS-CRP, cTnT, and CK-MB before, and every 4 hours following PCI, and major adverse cardiovascular events at day 30. SPSS 23.0 (IBM, Chicago, IL) will be used, and P-value < .05 will be considered statistically significant.

CONCLUSIONS

The findings will determine the efficacy of prophylactically intracoronary administration of Nicorandil to reduce the occurrence of NRP during PCI in acute STEMI patients.

TRIAL REGISTRATION

OSF Registration number: DOI 10.17605/OSF.IO/QPF3V.

Post-PCI outcomes in STEMI patients with coronary ectasia: meta-analysis

BACKGROUND

Coronary ectasia (CE) is defined as dilation of the coronary artery, 1.5 times that of the surrounding vessel. Outcomes of percutaneous intervention (PCI) in patients with CE presenting as ST-elevated myocardial infarction (STEMI) remain a topic of debate.

METHODS

Studies comparing outcomes of PCI in CE versus no-ectasia (NE) STEMI patients were identified. Baseline angiographic characteristics include thrombolysis in myocardial infarction (TIMI) 0-1 flow, right coronary artery (RCA) involvement, and primary outcomes including thrombus aspiration, no-reflow, mortality, and TIMI-3 post-PCI. Odds ratio (OR) and 95% confidence interval (CI) were calculated.

RESULTS

Six studies (n = 5746, CE-340 and NE-5406) qualified for the analysis. RCA involvement was more common in CE than NE, OR-1.39 (95%CI1.06-1.82, p-0.02). Pre-procedure TIMI-0-1 was of comparable results between the groups (p-1.13). Higher thrombus aspiration for CE (OR 2.18, 95%CI1.44-3.32;p-<0.001). CE had higher incidence of no-reflow (OR 4.07, 95%CI2.42-6.84;p-<0.001). TIMI-3 flow post-PCI was achieved less commonly in the CE group (OR-0.64, 95%CI-0.48-0.86;p-<0.001). Mortality on follow-up was comparable (0.83, 95%CI0.39-1.78;p-0.63). Metaregression analysis did not show confounding effects from comorbidities.

CONCLUSION

Coronary ectasia patients with STEMI had higher rates of PCI failure and no-reflow than NE; however, mortality during follow-up was comparable.

One-Year Outcome of Patients with Coronary Artery Ectasia Undergoing Percutaneous Coronary Intervention: Clinical Implications and Question Marks

Background: Coronary artery ectasia (CAE) is a rare condition with unclear pathophysiology, optimal treatment, and prognosis. We aimed to determine the prognostic implications of CAE following coronary angioplasty.

Methods: We conducted a retrospective cohort study on 385 patients, including 87 subjects with CAE, who underwent percutaneous coronary intervention (PCI). Major adverse cardiovascular events (MACE) were considered to consist of mortality, nonfatal myocardial infarction (MI), repeated revascularization, and stroke.

Results: The mean age of the participants was 57.31±6.70 years. Multivariate regression analysis revealed that patients with diabetes, ST-segment–elevation MI at presentation, and high thrombus grades were more likely to have suboptimal post-PCI thrombolysis in myocardial infarction (TIMI) flow. However, CAE was not a predictor of a decreased TIMI flow (OR: 1.46, 95% CI: 0.78–8.32; P=0.391). The Cox-regression model showed that CAE, the body mass index, and a family history of MI were risk factors for MACE, while short lesion lengths (<20 vs >20 mm) had an inverse relationship. The adjusted hazard ratio (HR) for the prediction of MACE in the presence of CAE was 1.65 (95% CI: 1.08–4.78; P=0.391). All-cause mortality (HR: 1.69, 95% CI: 0.12–3.81; P=0.830) and nonfatal MI (HR: 1.03, 95% CI: 0.72–4.21; P=0.341) occurred similarly in the CAE and non-CAE groups. Conversely, CAE increased urgent repeat revascularization (HR: 2.40; 95% CI: 1.13–5.86; P=0.013).

Conclusion: Although CAE had no substantial short-term prognostic effects on post-PCI TIMI flow, considerable concerns regarding adverse outcomes emerged during our extended follow-up. Stringent follow-ups of these patients should be underscored due to the high likelihood of urgent revascularization.

ST-Elevation Myocardial Infarction in Coronary Ectasia: A Case Report

Coronary artery ectasia (CAE) is localized or diffuse dilatation of the coronary artery lumen exceeding the diameter of adjacent healthy reference segments by 1.5 times. It is a rare phenomenon and incidence ranges from 1 to 5% in patients undergoing angiography. We report a case of a 58-year-old man with atherosclerotic CAE who experienced ST-elevation myocardial infarction (STEMI) despite prophylactic antiplatelet therapy. He was successfully treated with IV eptifibatide and aspiration thrombectomy. We reviewed the literature of CAE presentation, etiology and treatment and discussed the most appropriate antithrombotic therapy to prevent STEMIs in patients with CAE. While the current literature appears to favour prophylactic antiplatelet and anticoagulant in these patients, more studies are needed to determine the optimal form and duration of antithrombotic therapy. Currently, there is no gold standard treatment for CAE and further prospective and randomized-controlled studies are needed to guide recommendations.