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Aim: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a condition characterized by clinical findings of acute myocardial infarction (AMI) and detection of normal/close to normal narrowing coronary arteries in coronary angiography (CAG). The aim of this study was to analyze the prevalence and demographic characteristics of MINOCA in a tertiary hospital. Materials and Methods: This observational retrospective study included patients aged 18 years who presented to the emergency department in 2016, met the criteria for universal AMI, and had a CAG of

Aim: To evaluate the validity of the longitudinal speckle tracking echocardiography (STE) in the detection of early changes in the performance of the left ventricle for hypertensive patients with normal ejection fraction (EF) and coronary angiography. Patients and Methods: A case-control study enrolled 50 patients and a randomly collected control group of 30, who consulted Ibn-Albitar Cardiac Center from November 2016 to the first September 2017. The patients had hypertension while the control did not. Both had normal coronary angiography, assessed by conventional echocardiography, two-dimensional STE, and anthropometric measures. Results: The mean age for the patients or cases was 52.48 ± 4.292 years, and their mean body mass index (BMI) was 30.10 ± 1.854 kg/m2. They had been diagnosed with hypertension for a mean duration of 8.14 ± 3.326 years. All were on treatment; the mean left ventricular (LV) mass was 108.96 ± 19.469 (g/m2) while the mean global longitudinal strain (GLS) was −16.720 ± 3.191. There was an approximately equal number of males and females among the cases: 24 (48.0%) and 26 (52.0%), respectively. Twenty-seven (54.0%) had LV hypertrophy (LVH), and only 4 (8.0%) cases had diastolic dysfunction with GLS −12. The mean age of the controls was 55 ± 4.792 years, and their BMI was 30.77 ± 2.063 kg/m2. They had a mean LV mass of 92.50 ± 10.058 (g/m2) and their GLS was slightly lower (more negative) than the cases, at −17.517 ± 2.222. Thirteen controls were males (43.3%) while 17 (56.7%) were females. Only 2 (6.7%) had diastolic dysfunction with GLS −14. GLS was significantly higher (less negative) in the cases with LVH compared to the controls: 15.278% compared to −17.517% respectively, with a mean difference of −2.238%. There was no statistically significant difference between controls and cases without LVH. Conclusions: The use of STE is beneficial in the detection of subtle changes in the LV of hypertensive patients with normal coronary angiography and normal EF. [ABSTRACT FROM AUTHOR]

Introduction: Myocardial infarction with non-obstructive coronary arteries (MINOCA) occurs in ~10% of all patients with acute myocardial infarction (AMI), with an over-representation amongst women. Remarkably, it is estimated that as many as 1 in 4 patients with MINOCA experience ongoing angina at 12 months despite having no flow-restricting stenoses in their epicardial arteries. This manuscript presents the rationale behind Randomized Evaluation of Beta Blocker and Angiotensin-converting enzyme inhibitors/Angiotensin Receptor Blocker Treatment (ACEI/ARB) for Post Infarct Angina in MINOCA patients—The MINOCA BAT post infarct angina sub study.Methods: This trial is a registry-based, randomized, parallel, open-label, multicenter trial with 2 × 2 factorial design. The primary aim is to determine whether oral beta blockade compared with no oral beta blockade, and ACEI/ARB compared with no ACEI/ARB, reduce post infarct angina in patients discharged after MINOCA without clinical signs of heart failure and with left ventricular ejection fraction ≥40%. A total of 664 patients will be randomized into four groups; (i) ACEI/ARB with beta blocker, (ii) beta blocker only, (iii) ACEI/ARB only, or (iv) neither ACEI/ARB nor beta blocker and followed for 12 months.Results: The trial is currently recruiting in Australia and Sweden. Fifty six patients have been recruited thus far. Both sexes were equally distributed (52% women and 48% men) and the mean age was 56.3 ± 9.9 years.Conclusions: It remains unclear whether conventional secondary preventive therapies are beneficial to MINOCA patients in regard to post infarct angina. Existing registry-based literature suggest cardioprotective agents are less likely to be used in MINOCA patients. Thus, results from this trial will provide insights for future treatment strategies and guidelines specific to MINOCA patients.

Usually, the diagnosis of myocardial infarction based on patient symptoms, electrocardiogram (ECG) changes, and cardiac enzymes, is not a challenge for cardiologists. The correlation between coronary anatomy and the ECG territories that present ischemic changes can help the clinician to estimate which coronary artery presents lesions upon performing a coronary angiogram. In certain situations, the diagnosis of myocardial infarction can be difficult due to the lack of correlations between the clinical and paraclinical examinations and the coronary angiogram. In some cases, patients with chest pain and ST-segment elevation on the ECG tracing present with a normal coronary angiography. In other cases, patients without important changes on the ECG can present critical lesions or even occlusions upon angiographic examination. The aim of this article is to highlight the role of noninvasive coronary magnetic resonance and multi-slice computed tomography in patients with ST-segment elevation myocardial infarction and normal coronary angiography.

Abstract Background Patients with chest pain, elevated troponin, and unobstructed coronary disease present a clinical dilemma. The purpose of this study was to investigate the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in a cohort of patients with suspected acute coronary syndrome (ACS) and unobstructed coronary arteries. Results Data files of patients meeting the inclusion criteria in two cardiology centres were searched and analysed. The inclusion criteria included: 1) thoracic pain suspected with ACS; 2) a significant increase in the high-sensitive Troponin T value; 3) ECG changes; 4) coronary arteries without any significant stenosis; 5) a CMR examination included in the diagnostic process; 6) an uncertain diagnosis before the CMR exam; and 7) the absence of known CMR and contrast media contraindications. Special attention was paid to the benefits of CMR in determining the final diagnosis. In total, 136 patients who underwent coronary angiography for chest pain were analysed. The most frequent underlying causes were myocarditis (38%) and perimyocarditis (18%), followed by angiographically unrecognised acute myocardial infarction (18%) and Takotsubo cardiomyopathy (15%). The final diagnosis remained unclear in 6% of the patients. The contribution of CMR in determining the final diagnosis determination was crucial in 57% of the patients. In another 35% of the patients, CMR confirmed the suspicion and, only 8% of the CMR examinations did not help at all and had no influence on diagnosis or treatment. Conclusion CMR provided a powerful incremental diagnostic value in the cohort of patients with suspected ACS and unobstructed coronary arteries. CMR is highly recommended to be incorporated as an inalienable part of the diagnostic algorithms in these patients.

Troponin elevation usually indicates myocardial cell injury. However, elevated values of troponin are not always a consequence of infarction or ischemia. The aim of this study was to elucidate the diverse etiologies of elevated troponin in patients with normal coronary angiography. There were 947 patients at the Zagreb University Hospital Centre identified from the catheterization database who underwent coronary angiography in 2014 due to suspected acute coronary syndrome. We identified 32 (3.38%) patients who had an alternative cause for myocyte injury other than coronary artery disease, defined as coronary artery lumen stenosis above 30%. The elevation of cardiac troponin T (cTnT) in patients with normal coronary angiography was found to be the consequence of diverse etiologies, including hypertensive heart disease, Takotsubo syndrome, supraventricular tachycardia, myocarditis, and dilated cardiomyopathy, to name a few. Apart from acute coronary syndrome, cTnT can be elevated in a number of different conditions, which should be considered according to clinical presentation, and that could still reflect myocardial necrosis even in the absence of significant coronary artery disease. [ABSTRACT FROM AUTHOR]

Purpose: This psychiatric and cardiological study aim to compared patients with normal coronary angiography and coronary hearth disease patients with respect to sociodemografic features, psychiatric comorbidities, anxiety and depression level, mental and physical quality of life. We also determined associated factors with normal coronary patients. Material and Methods: Eighty-seven patients with normal coronary angiography (NCA) and thirty-one coronary artery disease (CAD) patients were included the study after coronary angiography. Groups were compared with regard to sociodemographic characteristics, comorbid psychiatric disorders and Beck Anxiety (BAI) and Beck Depression (BDI) Inventories and Health Related Quality of Life (SF-36) scale scores. Results: There was statistically significant difference between the groups in terms of age, gender, marital status, occupation, family history for psychiatric disorders. Mental disorders were found in 82.8% of the patients with NCA and in 48.1% of the patients with angiographic coronary disease. The patients with NCA have a higher prevalence of psychiatric comorbidity, family history of psychiatric disorder, are relatively young, female and unmarried. There was significant difference in pain, general health and social function subgroups of quality of life scale between groups. The impact of mental and physical quality of life with NCA patients were as significant as those with CAD. Conclusion: The present study revealed that prevalence of psychiatric co morbidities is high and impairment in quality of life is notable in the patients with NCA patients [Cukurova Med J 2016; 41(1.000): 129-135]

Abstract Background Coronary tortuosity (CT) had different definitions and scores in literature with unclear pathophysiological impact. Objectives To study degree of CT and it's relation to ischemic changes in patients with angina but normal coronary angiography (CA). Methods We conducted a prospective study at University hospitals between May 2016 and January 2017. We included 200 consecutive patients who underwent CA due to chest pain assumed to be of cardiac origin, and their CA was normal (no diameter stenosis >30%, nor myocardial bridging). Patients were prospectively divided into 2 groups based on the presence (n = 113) or absence (n = 87) of ischemic changes during stress study and compared for clinical, echocardiographic and CA characteristics. A newly proposed Tortuosity Severity Index (TSI) was developed into significant (mild/moderate CT with more than 4 curvatures in total, or severe/extreme CT with any number of curvatures) or not significant TSI (mild CT with curvatures less than or equal to 4 curvatures in total). Results Patients with ischemic changes had the highest rate of CT (76.5 vs 18%, p = 0.004) compared to those without. CT mostly affects the left anterior descending (LAD) coronary artery in mid and distal segments. Females, elderly, and hypertensives with left ventricular hypertrophy were strongly related to CT. Multivariate logistic regression analysis identified CT with significant TSI as the only predictor of ischemic changes in these patients (OR = 6.2, CI = 2.5–15.3, P = <0.001). Conclusions Coronary tortuosity is a strong predictor of anginal pain among patients with normal CA, despite positive stress study. This finding is more pronounced among elderly, hypertensive female patients. [ABSTRACT FROM AUTHOR]

Background: Revascularization within a 90-min door-to-balloon time is a strict policy enacted in Taiwan. Prompt diagnosis is critical to avoid an unnecessary procedure and catheterization laboratory activation. This study was aimed to investigate the clinical and prognostic characteristics of the patients with ST-elevation myocardial infarction (STEMI) referred for primary percutaneous coronary intervention (PCI) and normal coronary arteries found following coronary angiography (CAG). Materials and Methods: From October 2009 to December 2012, 216 consecutive patients with STEMI referred for primary PCI were enrolled. The data of clinical history, physical examination, laboratory results, electrocardiography, echocardiography, CAG findings, diagnosis, and outcomes were collected and analyzed. Results: A total of 17 patients were proved normal coronaries angiographically. The incidence of the conditions mimicking as STEMI is 7.9%. Alternative diagnosis was coronary spasm (n = 7), peri-myocarditis (n = 6), apical ballooning syndrome (n = 3), anaphylactic shock (n = 1). Compared with STEMI group, patients in normal coronaries group were younger, with a less premature family history of coronary artery disease (CAD), and reported angina. The 30-day mortality rate in the normal coronaries group was 5.9%. Conclusions: Cautiously evaluating CAD risk factors and symptoms of angina and awareness of alternative diagnosis are important to make a prompt diagnosis without compromising accuracy in the patients presenting as suspected STEMI.

Background: Patients with chest pain, elevated troponin, and unobstructed coronary disease present a clinical dilemma. The purpose of this study was to investigate the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in a cohort of patients with suspected acute coronary syndrome (ACS) and unobstructed coronary arteries.Results: Data files of patients meeting the inclusion criteria in two cardiology centres were searched and analysed. The inclusion criteria included: 1) thoracic pain suspected with ACS; 2) a significant increase in the high-sensitive Troponin T value; 3) ECG changes; 4) coronary arteries without any significant stenosis; 5) a CMR examination included in the diagnostic process; 6) an uncertain diagnosis before the CMR exam; and 7) the absence of known CMR and contrast media contraindications. Special attention was paid to the benefits of CMR in determining the final diagnosis. In total, 136 patients who underwent coronary angiography for chest pain were analysed. The most frequent underlying causes were myocarditis (38%) and perimyocarditis (18%), followed by angiographically unrecognised acute myocardial infarction (18%) and Takotsubo cardiomyopathy (15%). The final diagnosis remained unclear in 6% of the patients. The contribution of CMR in determining the final diagnosis determination was crucial in 57% of the patients. In another 35% of the patients, CMR confirmed the suspicion and, only 8% of the CMR examinations did not help at all and had no influence on diagnosis or treatment.Conclusion: CMR provided a powerful incremental diagnostic value in the cohort of patients with suspected ACS and unobstructed coronary arteries. CMR is highly recommended to be incorporated as an inalienable part of the diagnostic algorithms in these patients. [ABSTRACT FROM AUTHOR]

Kounis syndrome is a relatively rare entity in which allergic or hypersensitivity reactions (including anaphylaxis) coexist with acute coronary syndromes. We report a case of Kounis syndrome type I variant in a 51-year-old male, victim of an out-of-hospital cardiac arrest a few minutes after a hymenoptera sting. Ιn-hospital cardiopulmonary resuscitation was provided and return of spontaneous circulation was achieved. The post-resuscitation electrocardiogram revealed ST-segment elevation in leads II, III, aVF, and ST depression in leads V 2 , V 3 , and V 4 . After administration of corticosteroids, antihistamines, nitrates, and a calcium-channel blocker the electrocardiogram rapidly returned to normal. There was no elevation in markers of myocardial necrosis and the coronary angiography revealed normal coronary arteries. According to the clinical course and the laboratory findings the diagnosis of Kounis syndrome type I variant was made. Only a few cases of Kounis syndrome in the setting of cardiopulmonary arrest have been published. We believe that in these cases, the recognition of the main underlying cause that lead to arrest (acute coronary syndrome or severe anaphylactic reaction) plays an important role in the choice of the most appropriate treatment for the patient. < Learning objective: Kounis syndrome is a rare clinical condition. However, every cardiologist should be capable of diagnosing it, because under specific circumstances it can be life-threatening.> [ABSTRACT FROM AUTHOR]

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Objective Myocardial Infarction with Non-Obstructed Coronary Arteries (MINOCA) is common, but the causes are to a large extent unknown. Thus, we aimed to study the prevalence of myocarditis and “true” myocardial infarction determined by cardiac magnetic resonance (CMR) imaging in MINOCA patients, and risk markers for these two conditions in this population. Methods A search was made in the PubMed and Cochrane databases using the search terms “Myocardial infarction”, “Coronary angiography”, “Normal coronary arteries” and “MRI”. All relevant abstracts were read and seven of the studies fulfilled the inclusion criteria; studies describing case series of patients fulfilling the diagnosis of acute myocardial infarction with normal or non-obstructive coronary arteries on coronary angiography that were investigated with CMR imaging. Data from five of these studies are presented. Results A total of 556 patients from 5 different sites were included. Fifty-one percent were men with a mean age of 52 ± 16 years. Thirty-three per cent of the patients had myocarditis (n = 183), whereas 21% of the patients had infarction on CMR (n = 115). Young age and a high CRP were associated with myocarditis whereas male sex, treated hyperlipidemia, high troponin ratio and low CRP were associated with “true” myocardial infarction. Conclusion and relevance The results of this meta-analysis of individual data showed that myocarditis and “true” myocardial infarction are common in MINOCA when determined by CMR imaging. This information emphasizes the importance of performing CMR imaging in MINOCA patients and can be used clinically to guide diagnostics and treatment of MINOCA patients. [ABSTRACT FROM AUTHOR]

The pathophysiology of angina pectoris in patients with a normal coronary angiogram is not clear. Furthermore, the pathophysiological impact of ST changes in syndrome X is controversial. The purpose of this study was to investigate cardiac autonomic function, by measuring 24 h heart rate variability, in patients with and without electrocardiographic evidence of ischaemia during exercise. Thirty-two patients with angina pectoris, a normal coronary angiogram, echocardiogram, hyperventilation test and gastro-oesophageal investigation were studied. Fourteen healthy subjects served as controls. Fifteen patients had significant ST segment depression during stress testing, whereas 17 had no electrocardiographic signs of ischaemia. Heart rate variability was calculated as (1) mean RR= θmean of all normal RR intervals, (2) the difference in mean RR level between when awake and when asleep (mean RR wake-sleep)—a tentative index of sympathetic activation, (3) the standard deviation (SD)—a broad band measure of autonomic balance, and (4) a percentage of successive RR interval differences θ6% (pNN6%)—an index of vagal modulation. The coronary vascular resistance was measured at rest and during pacing. Mean RR and autonomic indexes did not differ between patients with a positive exercise test and controls (831/884 mθ 24 h SD 125/134 mθ pNN6% 6.715.4%, respectively). Patients with a normal exercise test had shorter mean RR (758 ms vs 844 mθ P<0.05) and significantly reduced 24-h SD (103 ms vs 134 mθ P<0.05) than controls, whereas values for vagal index (6.5% vs 5.4%) did not differ from healthy controls. Mean RR wake-sleep also tended to be lower in patients with a normal exercise test (− θ125 ms vs − θ173 ms) compared to controls (P<0.1). Patients with a positive exercise test had a significantly attenuated reduction in coronary vascular resistance during pacing in comparison to patients with a normal exercise test (− θ0.131− θ0.26mmHg × θ min. ml; P<0.05). The findings suggest the occurrence of general elevated sympathetic activation in angina patients with a normal exercise test. Patients with a positive exercise test exhibited no signs of autonomic dysfunction although these patients had altered coronary vascular resistance indicating microvascular angina. This supports the suggestion that patients with a normal exercise test constitute an independent pathophysiological entity. [ABSTRACT FROM PUBLISHER]

We investigated nocturnal secretion pattern of melatonin in patients with cardiac syndrome X and healthy subjects. The present study performed in five patients with cardiac syndrome X and in nine healthy controls. Blood samples from all subjects were collected every 2 h intervals between 22:00 and 08:00 h. Melatonin levels were measured with a radioimmunoassay kit. Patients with cardiac syndrome X secreted less nocturnal melatonin at 02:00 h than control subjects (P=0.04). Peak and Δ melatonin (peak–lowest melatonin) were found lower in patients with cardiac syndrome X (P=0.039 and P=0.028, respectively). In conclusion patients with cardiac syndrome X show a markedly decreased nocturnal melatonin synthesis. Our study provides useful information about melatonin synthesis and release in patients with cardiac syndrome X might help physicians in managing these patients. [Copyright &y& Elsevier]