Unstable angina with coronary to pulmonary artery fistulae

Three patients presenting with chest pain were found at cardiac catheterization to have fistulae between the left anterior descending coronary and the main pulmonary artery. Two patients presented with unstable angina, the third with atypical chest pain. Of the two patients presenting with unstable angina both had concomitant coronary artery disease. One was successfully treated with percutaneous transluminal coronary angioplasty. The other underwent successful double aorto-coronary bypass grafting and fistulae ligation. The remaining patient's symptoms resolved after informing him that he did not have atheromatous coronary artery disease. In no patient was the presence of the fistula felt to be related to the patients presenting complaint. In the two patients with unstable angina, a coronary steal phenomenon was postulated as a possible contributing factor.     

Claudication pain in the left arm of a coronary artery bypass graft patient using crutches: Coronary subclavian steal syndrome - a case report

A 77-year-old male former smoker with hypercholesterolemia and diabetes, who underwent coronary artery bypass graft surgery three years before admission and right carotid endarterectomy four years before admission, presented with recent-onset exertional chest pain. His medical history revealed that the chest pain was preceded by gradually worsening exertional claudication pain in his left arm when he was using crutches. The chest pain was similar to the pain he experienced before the coronary artery bypass graft surgery was performed. Coronary angiography and bypass graft imaging showed significant stenosis of the left subclavian artery proximal to the origin of the left internal mammary artery bypass, decreased flow in the left internal mammary artery with partial retrograde filling from the left anterior descending artery, and severe narrowing of the left vertebral artery with preserved centrifugal flow. Percutaneous stent implantation into the left subclavian artery was performed together with proximal balloon angioplasty of the left vertebral artery. The patient has been symptom free since the stent implantation.     

The acute cor pulmonale: Report of a case occurring eleven days post partum

A case of congenital dextrocardia with situs inversus is presented in which there is good evidence that a previous coronary thrombosis had taken place. The most interesting feature is the distribution of the pain during the attacks of angina pectoris. Before and after the attacks a feeling of numbness appeared in the right arm. The pain was localized strictly to the right side of the chest and there was no radiation to the left arm or neck. When the organs are situated in their normal position the pain is usually localized to the left side of the chest with radiation to the left arm although the pain may sometimes extend to the right chest with radiation to both arms or to the right arm alone. Anatomical evidence shows that the sensory nerve supply from the heart is bilateral and that impulses pass to both sides of the spinal cord. It seems probable however that when the heart is normally situated the main pain pathways run to the left side of the cord while the present case suggests that in dextrocardia they enter on the right side.     

Provocative ergonovine testing in patients without obstructive coronary disease

Ergonovine administration during coronary angiography is frequently used to rule out coronary spasm as a cause of chest pain. We performed this study to determine which electrocardiographic variables (other than ST segment elevation with pain) and which chest pain characteristics might be predictive of ergonovine test outcome in patients without obstructive coronary disease. Thirty-one patients had an electrocardiogram recorded during chest pain. Three of four patients (75%) who had an ischemic electrocardiogram with pain had a positive ergonovine test while only 1 of 27 (4%) patients who had a nonischemic electrocardiogram during chest pain had a positive ergonovine test (p less than 0.001) Pain that occurred predominantly at rest was present in five of five patients with positive ergonovine tests but pain occurring predominantly at rest was also present in 76% of patients with negative ergonovine tests (85%). Prompt relief of pain with nitroglycerine was also present in all patients with a positive ergonovine test but was also seen in 58% of patients with a negative test (NS). Association of chest pain with nausea, vomiting, diaphoresis, or radiation to left arm, jaw or neck were similarly poor predictors of ergonovine test outcome. We conclude that ergonovine testing in patients without obstructive coronary disease is of low yield if an electrocardiogram recorded during pain does not show evidence of ischemia. Historical features of the chest pain are not good predictors of test outcome.     

Systolic total narrowing of left anterior descending coronary artery and flow interruption secondary to myocardial bridge: a rare case report and review of literature

A 33-y-old man was admitted to the emergency department with sudden onset of severe substernal chest pain radiating to the left arm and neck. No pathological signs were recorded upon physical examination. The admission electrocardiogram (ECG) recorded during chest pain showed a large anterior wall myocardial infarction. Intravenous (IV) infusion of 1.5 million units of streptokinase over 1 h was initiated. Coronary angiography revealed total narrowing and flow interruption in the midsegment of the left anterior descending (LAD) coronary artery secondary to a myocardial bridge during systole and disappearance with diastole. He was discharged on aspirin (300 mg/d), metoprolol (100 mg/d), enalapril (10 mg twice daily), and atorvastatin (40 mg/d) treatment at the follow-up period.     

Coronary and intracerebral arterial aneurysms in a young adult with acute coronary syndrome

A 21-year-old man with no known medical history presented with substernal chest pain. Serial 12-lead electrocardiography showed dynamic ST-segment elevations in the anterolateral leads. Emergent coronary angiography revealed diffuse coronary aneurysmal disease and thrombotic occlusion of the left anterior descending coronary artery. The patient underwent urgent coronary artery bypass grafting. Subsequent imaging showed intracerebral aneurysms that involved his right and left middle cerebral arteries. The incidence, multiple causes, and proposed mechanisms of coronary artery aneurysmal formation are discussed, as is the rare association of these lesions with extracardiac arterial aneurysms.This association between coronary and extracardiac aneurysms is a phenomenon that warrants further study to determine its prevalence and possible causes. Findings could influence recommendations for further screening of patients diagnosed with coronary aneurysmal disease.     

Resolution of congestive failure, mitral regurgitation, and angina after percutaneous transluminal coronary angioplasty of triple vessel disease

Congestive heart failure, unstable angina, and moderate mitral regurgitation improved after double-vessel angioplasty in a 41-year-old woman who was considered inoperable because of high risk of bypass surgery. With the concomitant use of balloon counterpulsation, angioplasty reduced the cross-sectional stenosis in the left anterior descending coronary artery from 98 to 20% and in the left circumflex coronary artery from 90 to 0%. The right coronary artery was completely occluded and angioplasty was not attempted. The ejection fraction was 17% prior to angioplasty and 50% 2 months later at follow-up.     

Myocardial bridging of coronary arteries associated with an impending acute myocardial infarction

A 57-year-old woman developed severe substernal chest pain radiating to the left arm accompanied by pallor and marked diaphoresis. These symptoms appeared at rest, lasted 45 minutes, and terminated spontaneously. The patient had been treated for mild hypertension during the last 6 months. An ECG tracing obtained at the beginning of treatment was unremarkable. However, an ECG tracing recorded shortly after the end of the symptoms showed T-wave inversion in all anterior leads. Coronary arteriography was then performed and showed no fixed obstructive coronary artery disease. Nonetheless, a lengthened and constricted myocardial bridging of both the left anterior descending coronary artery and its major diagonal branch was detected. Also, the left anterior descending coronary artery was observed to be very short, terminating before the cardiac apex. The left ventricle was hypertrophied. The patient was treated with a beta-blocking agent which eliminated all symptoms. An ECG tracing obtained about three months after the onset of the clinical picture was normal. Our findings suggest that marked myocardial ischemia at rest does occur in patients having myocardial bridges under special circumstances, such as lengthened and constricted myocardial bridging of a short coronary artery which supplies a hypertrophied ventricle. This anomaly should be taken into account as a possible cause of a threatened myocardial infarction, which may be successfully treated with a beta-blocking agent.     

Usefulness of ultrasonography in carotid arteries and combined positron emission tomography/ computed tomography for diagnosis of Takayasu arteritis with unusual presentation as acute myocardial infarction: a case report

This unusual case of Takayasu arteritis presenting as acute myocardial infarction could be defined by ultrasonography and 18-fluorodeoxyglucose positron emission tomography (18F-FDG PET) coregistered with computed tomography (CT). A 55-year-old male was admitted to our hospital with continuous chest pain and left-side neck pain. After primary percutaneous coronary intervention, elevation of inflammatory markers persisted and dull pain in the left side of the neck continued. Ultrasonography revealed characteristic wall thickening of the left common carotid artery and subsequent 18F-FDG PET with CT depicted positive uptake in the left common carotid artery and the vessel wall of the ascending aorta, confirming the diagnosis of Takayasu arteritis. Three months after angioplasty, follow-up cardiac catheterization was performed. Coronary angiography showed no restenosis. During the catheterization, angiography confirmed the mild stenosis in the long segment of the left common carotid artery and the left subclavian artery as well as the focal narrowing and the dilation of the abdominal aorta. This case shows that ultrasonography in the cervical region and combined 18F-FDG PET with CT may be useful in the diagnosis and evaluation of Takayasu arteritis. In addition, we should pay attention to underlying disease even in middle-aged or older male patients with acute myocardial infarction.     

Spontaneous coronary artery dissection in an elderly woman presenting with chest pain and positive cardiac biomarkers

A 68-year-old African American female with a prior medical history of hypertension and dyslipidemia presented with sudden onset pressure-like substernal chest pain. Initial ECG showed no ST or T wave abnormalities, and troponin elevation of 2.88 ng/mL. Two hours later, chest pain recurred with ECG change and increase in troponin to 11.97 ng/mL. She underwent urgent coronary angiography, which revealed left anterior descending artery dissection with thrombus. We successfully treated with balloon angioplasty followed by placement of 3 drug-eluting stents resulting in TIMI-3 flow; further testing for vasculitis was negative. Once spontaneous coronary artery dissection is diagnosed, the approach to treatment is controversial and treatment should be patient tailored.     

Concurrent Use of Reteplase and Lepirudin in the Treatment of Acute Anterior Wall Myocardial Infarction

A 61-year-old male with a history of severe heparin-induced thrombocytopenia (HIT) type II after aorto-femoral bypass surgery presented to the emergency department within 8 hours of development of substernal chest pain radiating to the left arm. Electrocardiogram (ECG) on arrival and at 3 hours showed no acute changes; cardiac enzymes revealed minimal MB elevation. Echocardiogram showed normal left ventricular systolic function with mild mitral and tricuspid regurgitation and trace aortic insufficiency. Five hours after arrival, the patient reported a recurrence of severe chest pain. ECG showed marked ST elevations consistent with acute myocardial infarction. Reteplase was administered with concomitant lepirudin. Follow-up ECG showed improvement in ST-segment elevation and eventual resolution to pre-event tracing; cardiac enzymes showed slight elevations. Catheterization revealed 90% midstenosis of the left anterior descending artery, which was successfully treated with percutaneous transluminal coronary angioplasty (PTCA) and stent placement. Repeat PTCA was performed 10 days postdischarge due to intraluminal stent occlusion. The patient was doing well at 6 months follow-up.     

Acute infarction during triple-vessel coronary angioplasty due to acute occlusion of a nonattempted vessel

During angioplasty of the left coronary artery, an acute thrombotic occlusion of the right coronary artery occurred at the site of a borderline stenosis. The source of the unexplained chest pain at the end of the procedure was identified but the next day when inferior Q-waves appeared. It was documented by repeat angiography. The coronary angiogram of the right coronary artery preceding the angioplasty of the left coronary artery is likely to have triggered the occlusion. Chest pain during or after angioplasty without apparent cause in the dilated artery must prompt a contrast medium injection into the nonattempted artery, particularly if the latter had undergone a diagnostic study at the beginning of the procedure.     

Spontaneous coronary dissection associated with sleep deprivation presenting with acute myocardial infarction

Spontaneous coronary dissection is a rare cause of myocardial ischemia, myocardial infarction and sudden cardiac death. Idiopathic spontaneous coronary artery dissection (SCAD) occurs in patient without risk factors for coronary artery disease and without underlying pregnancy. We describe a case of idiopathic spontaneous coronary dissection after sleep deprivation presenting with acute myocardial infarction. A 40 year old woman presented to an emergency department with squeezing substernal chest pain lasting 1 hour following 72 h sleep deprivation due to overtime work. On admission, ECG showed no significant ST change. But the level of CK-MB and Troponin T were increased up to 77.54 ng/ml and 1.62 ng/ml, respectively. Emergent coronary angiography demonstrated a longitudinal dissection of the middle portion in the diagonal artery with TIMI III flow to the distal part of the vessel. Because the dissected vessel was too small to pass the intravascular ultrasound (IVUS) and deploy the stent, angioplasty was not performed. Under medical treatment with aspirin, clopidogrel and unfractionated heparin, conservative management was proposed; she remained free of symptom and discharged free of chest pain and in good condition.     

A 25-year-old patient with low cardiac risk factors having a combination of variant angina and severe coronary arterial lesions--a case report

A 25-year-old man with low cardiac risks underwent coronary arteriography because of chest pain at rest. His only risk factors for coronary artery disease was smoking. Both right and left coronary arteries were ectatic and the left anterior descending artery was obstructed. In the acetylcholine provocation test, the left circumflex coronary artery showed severe constriction. Thus, this patient was diagnosed as having a combination of variant angina and occlusive coronary artery disease.     

Cardiotoxicity of 5-fluorouracil

Three patients developed anterior substernal chest pain in association with ischemic electrocardiographic changes temporally related to continuous infusions of 5-fluorouracil (5-FU). Two patients developed myocardial infarctions and one died. Cardiac toxicity of 5-FU may be more likely when the drug is given by continuous infusion in the presence of preexisting cardiac disease. The pattern of cardiac toxicity suggests cardiac ischemia most likely secondary to coronary artery vasospasm. Patients should not receive 5-FU by infusion if they have significant underlying coronary artery disease or if they develop anterior substernal chest pain while receiving the drug.     

Coronary arterial and left ventriculographic findings in patients with double-vessel disease and angina pectoris

The distribution and severity of coronary artery disease and left ventricular wall abnormalities are described in 119 patients with double-vessel disease and angina pectoris. The coronary arterial patterns were divided into right (84), mixed (17), and left (18) systems, depending upon the blood supply to the inferior surface of the left ventricle. Patterns of double-vessel disease were separated into those with 50% or greater reduction of luminal diameter involving the left anterior descending and circumflex/obtuse marginal arteries (2-LC), circumflex/obtuse marginal and right coronary arteries (2-CR), and left anterior descending and right coronary arteries (2-LR). The following relationships were noted: (1) Left anterior descending and right coronary artery disease occurs with twice the frequency of 2-LC or 2-CR disease, supporting the thesis that of the three major coronary arteries, the circumflex/obtuse marginal arteries contribute least to angina pectoris. (2) The mid portion of the left anterior descending artery is most commonly involved and the left main coronary artery least commonly involved in patients with double-vessel disease. (3) Left ventricular wall motion abnormalities are found in one-half of patients with double-vessel disease and angina pectoris with hypokinesis usually found in all areas except at the apex where dyskinesis is usually seen.     

Relation between the site of origin of ventricular premature complexes and the presence and severity of coronary artery disease

The clinical implications of ventricular premature complexes in patients with coronary heart disease have received increasing interest. It has been suggested that ventricular premature complexes of right ventricular origin have more benign implications than those that originate from the left ventricle. To define more precisely the relation between the site of origin of ventricular premature complexes and the presence and severity of coronary heart disease in patients with a chest pain syndrome, 39 patients with ventricular premature complexes of right or left ventricular contour who were undergoing cardiac catheterization and coronary arteriography for evaluation of chest discomfort were studied. Ninteen patients had left and 17 had right ventricular premature complexes and 3 had both. Of the 19 with left ventricular premature complexes, 15 had coronary artery disease (12 with two or three vessel obstruction and 3 with single vessel obstruction). Four had normal cardiac catheterization studies. Twelve patients had asynergy on ventriculography. The 17 patients with right ventricular premature complexes had similar angiographic findings. Eleven of the 17 had coronary artery disease (8 with triple vessel disease and 3 with isolated obstruction of the left anterior descending coronary artery). Six had normal arteries. Eight of the 11 with coronary artery disease and right ventricular premature complexes also had asynergy. All three patients with both left and right ventricular premature complexes had coronary obstructive disease. These findings indicate that in patients with a chest pain syndrome there is no relation between the site of origin of ventricular premature complexes and either the prevalence or severity of coronary artery disease.     

Evaluation of adjunctive intracoronary administration of acetylcholine following intravenous infusion of ergonovine to provoke coronary artery spasm

A dilemma arises in patients with chest pain or other symptoms suggestive of coronary artery disease but without significant coronary artery stenosis or spasm even after the spasm provocation test by either ergonovine or acetylcholine. Incremental doses of intracoronary acetylcholine (up to 100 micrograms for left coronary artery and 50 micrograms for right coronary artery) were administered when intravenous infusion of ergonovine 0.4 mg showed negative results. A total of 39 patients were studied. Provocation test was performed because of chest pain suggestive of coronary artery disease (n = 19), atypical chest pain (n = 6), post balloon angioplasty status (n = 6), silent ischemia (n = 4), Adams-Stokes syndrome (n = 3), and dead-on-arrival (n = 1). Characteristics of chest pain indicated variant angina (n = 11), rest angina (n = 4), and effort angina (n = 4). No electrocardiographic evidence of ischemia was detected before this test in any patient. Spasm was induced in 23 patients (59.0%) with complete obstruction in 7 (30.4%), diffuse vasoconstriction (90-99%) in 14 (60.9%), and focal spasm in 2 (8.7%). The patients with chest pain showed the highest positive rate of 78.9%. Further, the patients with atypical chest pain and miscellaneous reasons also revealed positive rates of 33.3% and 42.9%, respectively. One ventricular tachycardia and 2 atrial fibrillations occurred but terminated spontaneously. This test is useful for detecting spasm in a variety of patients in whom intravenous ergonovine infusion fails to induce spasm.     

Surgical angioplasty of the left main coronary artery. Evaluation and postoperative follow-up with intravascular ultrasound

We report the case of a 45 year old man presenting to our emergency ward with acute onset of typical chest pain. The ECG showed ST-segment depression in the postero-lateral leads without elevation of any cardiac enzymes. The coronary angiogram showed a three-vessel disease with a subtotal, short stenosis of the right coronary artery and a severe ostial stenosis of the left main coronary artery. An operative revascularization with a venous graft to the right coronary artery and a angioplasty with an autologous vein patch of the left main coronary artery were performed. No peri- or postoperative complications occurred. Because of the importance of the left main coronary artery, the patient underwent an early post-operative coronary angiogram with intravascular ultrasound (IVUS) to confirm the patency of the patch angioplasty. We discuss the historical development, the indications and the main advantages of the patch angioplasty in comparison to conventional CABG procedures. The main issue of the presentation is the special value of IVUS in the pre- and postoperative assessment of the left main coronary artery. Within the last few years, IVUS has emerged from a pure research tool to the gold standard of coronary imaging. It is playing a more and more important role in the assessment of angiographically unclear lesions, mainly in the left main stem and its bifurcation. In addition, IVUS has a large influence in clinical decision making, e.g., reverral to CABG or PCI. It is also a powerful tool for optimizing the operative setting and provides the best possible postoperative control.     

Acute coronary syndrome following massive pulmonary embolism in a 81-year-old woman with thrombophilia

A 81-year-old woman was referred to the emergency department after having syncopal episode two days earlier. A chest computed tomography demonstrated a right main pulmonary artery embolism. The only prominent risk factor for thromboembolism was her poor response to activated protein C. Seven days later she demonstrated acute-onset chest pain with elevated troponin. Cardiac angiography showed stenosis of left anterior descending coronary artery which was successfully treated with angioplasty and stent implantation. This case illustrates the coincidence and the importance of clinical suspicion for the early diagnosis and treatment of acute coronary syndrome during massive pulmonary embolism.