心血管疾患と診断

Background: Coronary artery disease (CAD) has become the major killer in women. The exact mechanism of postmenopausal increase in CAD is still under research. Limited data exists on the comparison of risk factor profiles and angiographic disease patterns in premenopausal and postmenopausal women. Methods: This prospective study included a total of 674 consecutive female patients who underwent coronary angiogram for suspected ischemic heart disease over a period of 2 years from March 2015. Detailed risk factor profiles and angiographic patterns of disease were recorded and analyzed using EPIINFO statistical software. Results: Out of total 674 patients, 137(20.3%) were in the premenopausal group with mean age of (42.05 ± 4.40) years, and 537(79.7%) in the postmenopausal group with mean age of (59.05 ± 8.01) years. Premenopausal women were more likely to be obese (57.7% vs 46.9%, p=0.0), hypothyroid (23.4% vs 10.2%, p<0.0001) and more likely to have a positive family history of premature CAD (38.7% vs 6.3%, p<0.0001). On the other hand, postmenopausal women were more likely to be diabetic (22.5% vs 13.1%, p=0.008), hypertensive (74.3% vs 51.8%, p<0.0001), smokers (29.4% vs 19.7%, p=0.01) and had >3 risk factors more frequently (42.1% vs 30.7%, p=0.009). Atypical chest pain was more common as presenting diagnosis among premenopausal women (23.4% vs 10.2%, p<0.0001). They were also more likely to have positive exercise stress test (62.1% vs 38.3%, p<0.0001) and normal coronary angiogram (59.9% vs 32%, p<0.0002) with endothelial dysfunction (84.7% vs 66.8%, p<0.0001) than post-menopausal women. Post-menopausal women had greater burden of obstructive CAD characterized by more prevalent multivessel disease in the form of double vessel (17.5% vs 8%, p=0.06) and triple vessel disease (20.5% vs 5.8%, p<0.0002). Conclusion: There is a distinct difference between the risk factor profile and angiographic disease pattern among women according to the status of menopause. Recognition of these differences would help in better understanding of relationship of menopause to development of CAD.

Background: Peripheral arterial disease (PAD) and carotid occlusive disease (COD) are both known to be specific manifestations of atherosclerosis so can be correlated to each other. An important area of investigation is to identify those with significant carotid artery stenosis (CAS) to reduce the risk of cerebrovascular events. Duplex ultrasound scanning (DUS) is considered a valuable imaging modality to evaluate carotid arteries with high sensitivity and specificity and virtually non-existent hazards. Objectives: We investigated the prevalence of significant CAS among patients with severe peripheral vascular disease (PVD) using carotid duplex. Methods: A total of 50 patients with PVD diagnosed as having significant PAD by peripheral angiography (PA) underwent carotid duplex scanning. Data were collected concerning known risk factors. Significant CAS was defined as a stenosis of 70% or greater. Results: The mean age was 61.6 ± 8.5 years, male (88%). Out of the 50 patients with significant PAD, 7 patients (14%) had significant Carotid Stenosis of which 6 patients (12%) had severe stenosis and 1 patient (2%) had totally occluded carotid artery. CAS was correlated with diabetes, hypertension, dyslipidemia, smoking, coronary artery disease and severity of symptoms. On multivariate analysis, Diabetes and Dyslipidemia seemed to have independent influence. Conclusion: Significant CAS is prevalent among patients having significant PVD. Patients with PAD may be a suitable subgroup for screening for CAS using Carotid duplex, especially those with diabetes, dyslipidemia and positive CRP. Keywords: Carotid artery stenosis; Carotid duplex peripheral

       A 29 years old male patient, chronic smoker with no history of diabetes, hypertension, ischemic heart disease or renal dysfunction was admitted in our hospital with complaints of acute onset pain in the right iliac fossa radiating to the umbilical region associated with multiple episodes of vomiting without hematemesis. Patient was clinically diagnosed to have acute appendicitis and treated for the same.       Routine electrocardiogram done in the surgical intensive care unit suggested an acute anterior wall ST segment elevation myocardial infarction for which the patient was thrombolysed. Patients symptoms immediately subsided. Coronary and renal angiogram showed a recanalized left anterior descending artery with right renal artery thrombus. The acute renal infarction was responsible for his acute abdomen. A transient left ventricular clot produced by the stunned myocardium was held responsible for the above events.

Chronic total coronary occlusions (CTO) still remain one of the most technically challenging clinical scenarios in which to perform interventions. Although the antegrade approach is the most common method of CTO recanalization, a retrograde attempt improves the success rate and its usage has been increasingly adopted in the recent years. Furthermore, abnormalities such as anomalous origin coronary arteries represent other important technically challenging cases for interventional cardiologist. In this case, we describe a rare case of a CTO in the mid portion of an anomalous right coronary artery (RCA), that originated from a high anterior takeoff and progressed in the downward direction, where retrograde approach has been used to overcome the absence of antegrade guiding catheter support.

Background: Atrial ischemia is a known risk factor of non-valvular atrial fibrillation (AF). However, relationship between coronary vasospasm and AF has not yet been determined. Methods: We investigated consecutive patients with normal sinus rhythm without AF history who underwent coronary angiography with ergonovine provocation test to evaluate vasospastic angina (VA). Patients with spasms over 50% and either typical chest pain or electrocardiogram changes during provocation test were diagnosed as vasospastic angina (VA group). Results: Out of total 683 patients investigated, nine (4.6%) patients in VA group (n=195) and seven (1.4%) patients in control group (n=488) developed new-onset AF (follow-up duration, median 56 months; range, 6-263 months). Annual AF incidence rate was higher in VA group (0.63%/y) than in control group (0.23%/y). In univariate and multivariate analysis adjusted for age, VA was an independent predictor of AF (HR 2.93, p=0.021). In subgroup analysis of 195 patients with VA, there were no cases of AF in patients with spasm observed only in the left anterior descending artery. All nine patients with new onset AF had spasm in the right coronary artery or left circumflex artery. Conclusions: Vasospastic angina could be an independent predictor of new-onset AF.

Background: Mortality rate of pulmonary embolism (PE) at 3 months is over 15% for the high risk presentation and varies from 3% to 15% for the intermediate-risk presentation. Thrombolysis in intermediate-risk PE remains a matter of debate.

Methods: We undertook a retrospective study over a 11-year period including patients with high and intermediatehigh- risk PE, hospitalised in a medical ICU in a University hospital, to assess medium and long-term prognosis.

Results: Our series involved 145 patients, of whom 63 presented high risk PE and 82 had an intermediate-highrisk PE. Thirty-six patients (24.8%) died in the intensive care unit (ICU) including high-risk PE: 34/63 (53.9%), of whom 25 after inaugural cardiac arrest (CA); intermediate-high-risk PE: 2/82 (2.4%). On multivariate analysis, high blood lactates (OR: 1.88; IC 95% 1.18-3.02, p=0.0083), resuscitated CA (OR: 12.33; IC 95% 1.1-137.4, p=0.041), low subaortic velocity time integral (VTI) (OR: 9.22, IC 0.38-0.81, p=0.0024) were independent factors of in-ICU mortality. Twenty-seven patients died after ICU discharge. Echocardiographic checks were performed in 63 patients, in which 4 (6.3%) presented a chronic thromboembolic pulmonary hypertension (CTPH).

Conclusion: High-risk PE still has a high mortality rate in the ICU especially when revealed by a cardiac arrest. High blood lactates, resuscitated CA, and low subaortic VTI were independent predictive factors of mortality. In our retrospective cohort, long-term prognosis was good with only 4 cases of CTPH. The low mortality observed with anticoagulant-only treatment do not encourage thrombolysis for management of intermediate-high-risk PE patients.