Should we screen for occult coronary artery disease among asymptomatic patients with diabetes?

Diabetes mellitus predisposes people to premature atherosclerotic coronary artery disease (CAD). The risk of a myocardial infarction in diabetics without overt evidence of obstructive CAD matches that of patients without diabetes who have had a previous myocardial infarction. The available data suggest that occult CAD is a common finding among asymptomatic diabetics, ranging from 20% to >50%. The diagnostic accuracy of myocardial perfusion single-photon emission computed tomography (SPECT) in diabetics appears to be comparable to that observed in nondiabetic individuals. As shown in other patient groups, the ischemic burden assessed by stress SPECT in subjects with diabetes is also linked to their increased risk of adverse cardiovascular events. Among patients with normal stress SPECT, however, those with diabetes are at significantly greater risk than non-diabetics. Testing diabetics with an abnormal resting electrocardiogram or with evidence of peripheral or carotid occlusive arterial disease appears to result in an excellent yield of abnormal SPECT findings, as does testing in the setting of dyspnea. However, recent evidence suggests that achieving an adequate yield in asymptomatic diabetics without overt evidence of CAD is a greater challenge. Further investigation of sequential testing strategies is needed in order to identify an efficient means for screening asymptomatic patients with diabetes.     

Left anterior descending coronary artery pseudoaneurysm compressing the main pulmonary artery in a patient with Behçet's disease

Behçet's disease is a systemic inflammatory vascular disorder that may affect the cardiovascular system. Left anterior descending (LAD) artery aneurysm is a rare but potentially fatal complication of Behçet's disease. An accurate diagnosis of this clinical entity requires multimodal imaging (computerized tomography, angiography, and echocardiography) and is essential to guide appropriate therapeutic management. We report the case of a 22‐year‐old female with LAD pseudoaneurysm who underwent surgical repair with transesophageal echocardiography guidance. We describe the importance of the use of an alternative view to define the origin and location of this unusual pathology. (Echocardiography 2012;29:E91‐E93)     

Does angina vary with the menstrual cycle in women with premenopausal coronary artery disease?

OBJECTIVE—To determine whether angina in women with established coronary heart disease varies with changes in hormone concentrations during the menstrual cycle.
DESIGN—Subjects were prospectively studied once a week for four weeks.
SETTING—Cardiology outpatient department of tertiary referral centre.
SUBJECTS—Nine premenopausal women, mean (SEM) age 38.89 (2.18) years, with established coronary heart disease, symptomatic angina, and a positive exercise test.
MAIN OUTCOME MEASURE—Myocardial ischaemia as determined by time to 1 mm ST depression during symptom limited exercise testing. Position in the menstrual cycle was established from hormone concentrations.
RESULTS—The early follicular phase, when oestradiol and progesterone concentrations were both low, was associated with the worst exercise performance in terms of time to onset of myocardial ischaemia, at 290 (79) seconds; the best performance (418 (71) seconds) was when oestrogen concentrations were highest in the mid-cycle (p < 0.05). Similar trends were observed in other measured variables. Progesterone concentrations did not influence exercise performance.
CONCLUSIONS—During the menstrual cycle myocardial ischaemia was more easily induced when oestrogen concentrations were low. This may be important for timing the assessment and evaluating treatment in women with coronary heart disease.


Keywords: myocardial ischaemia; exercise testing; oestradiol; progesterone     

Should we treat all patients with coronary heart disease or the equivalent with statins?

Statins have proven benefit in preventing cardiovascular events and should be prescribed for almost all patients with coronary heart disease (CHD) or equivalent. However, evidence is lacking to support treating all such individuals. Potential exceptions include those in the initial days of acute coronary syndrome, those with symptomatic systolic heart failure, those with very low low-density lipoprotein cholesterol, diabetic patients without associated metabolic syndrome, and those with high CHD risk calculated mainly on the basis of advanced age. In these cases, the decision to prescribe statins depends on clinical judgment, and surrogate tests for CHD may be useful.     

Bilateral aortoostial coronary artery disease: moyamoya of the heart?

Moyamoya is a vascular occlusive disease typically limited to the cerebral arterial system. We report a case of severe stenosis of the left main and right coronary arteries occurring in association with moyamoya disease, supporting the concept that moyamoya may be an intracranial manifestation of a systemic arterial disorder.