Andrea Cuculo

Coronary artery ectasia is related to coronary slow flow and inflammatory activation

AIM To evaluate possible links between coronary flow anomalies, inflammatory activation and coronary artery ectasia (CAE). METHODS Fourteen consecutive patients with CAE diagnosed at coronary angiography were enrolled in the study and compared with 17 patients with coronary atherosclerosis without CAE and 15 controls with normal coronary angiography. All patients underwent blood assay with evaluation of circulating levels of interleukin (IL)-1b, IL-2, IL-8, IL-10 and tumor-necrosis-factor(TNF)-α. The number of coronary segments showing CAE at coronary angiography, the Markis class, and coronary flow assessed with TIMI frame count (TFC) were also assessed. RESULTS Subjects with CAE showed higher levels of IL-1b, TNF-α, and IL-10 (p<0.05). The number of coronary segments showing CAE was related to TFC both in left anterior descending (LAD) coronary artery (p<0.01) and in right coronary artery (RCA) (p<0.001), and to circulating levels of IL-1b and IL-10 (p<0.01). TFC on LAD (p<0.05) and on RCA (p<0.001), circulating IL-1b levels (p<0.01), IL-8 (p<0.05), and IL-10 (p<0.01) were proportionally increased comparing controls, subjects with coronary atherosclerosis without CAE, and with decreasing Markis class. In subjects with CAE involving LAD, TFC on LAD was related to IL-8 and TNF-α levels (p<0.05); subjects with IL-1b levels above median showed higher TFC values on LAD (p<0.01), CONCLUSIONS: In subjects with CAE, the extension of disease is related to the impairment of coronary circulation and to inflammatory activation. The inflammatory response is also related to an impaired coronary circulation.

Inflammatory activation and carbohydrate antigen‐125 levels in subjects with atrial fibrillation

Eur J Clin Invest 2012; 42 (4): 371–375

Systemic inflammation in nonischemic dilated cardiomyopathy

We investigated links between inflammatory systemic activation and clinical presentation of nonischemic dilated cardiomyopathy (NIDC). Thirty-one consecutive patients with NIDC (age 57 ± 10 years, left ventricular ejection fraction 32% ± 7%) were enrolled in the study: subjects with ischemic heart disease, valvular heart disease, congenital malformations, pulmonary, renal, inflammatory, or metabolic diseases were excluded. All patients underwent physical examination, electrocardiography, chest radiology, echocardiography, and coronary angiography. Plasma levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fibrinogen were ascertained. New York Heart Association (NYHA) functional class was significantly correlated with concentrations of fibrinogen (r = 0.42, P < 0.05) and CRP (r = 0.52, P < 0.01), and with ESR (r = 0.46, P < 0.05). Left ventricular ejection fraction was inversely related to fibrinogen (r = −0.41, P < 0.05) and ln CRP (r = −0.46, P < 0.05). Correlations between NYHA class and markers of inflammation remained significant also after correction for age, sex, and cardiovascular risk factors. Ongoing treatment with statins was associated with reduced CRP levels. Inflammatory markers are increased in patients with NIDC proportionally with severity of symptoms and systolic impairment. Systemic inflammation might be related to deterioration of NYHA class.

Acute phase proteins activation in subjects with coronary atherosclerosis and micro-vessel coronary circulation impairment

Aim To investigate possible correlations between acute phase proteins (APPs) activation and coronary flow in subjects with coronary artery disease (CAD) undergoing coronary angiography. Methods Fifty-nine consecutive patients with CAD who underwent coronary angiography were enrolled in the study: blood samples were taken in order to evaluate plasmatic concentrations of C-reactive protein (CRP) and APPs such as alpha-1-anti-trypsin (A1AT), alpha-1-glyco-protein (A1GP) and haptoglobin (HG). Coronary flow on left anterior descending (LAD) was assessed with TIMI frame count (TFC). Patients with TIMI flow 0–1 were excluded from the study. Results Coronary atherosclerosis expressed in terms of number of coronary vessels with severe (>70%) lumen narrowing was related to serum concentrations of all considered APPs (A1GP: r 0.282, P < 0.05; A1AT: r 0.256, P 0.055; HG: r 0.335, P < 0.01). TFC on LAD was related to all considered APPs (A1GP: r 0.24, P 0.06; A1AT: r 0.28, P < 0.05; HG: r 0.43, P < 0.01; log CRP: r 0.57, P < 0.001); correlations remained significant even after correction for age, gender, risk factors, diagnosis and treatment. Among 12 patients who were previously treated with coronary angioplasty, those implanted with a drug eluting stent showed a significantly slower coronary flow on LAD (19.6 ± 2.07 vs. 16.71 ± 2.06, P < 0.05) if compared with those implanted with a bare metal stent. Conclusions An increased inflammatory systemic activation featured by plasmatic concentrations of CRP and APPs might be associated with both coronary atherosclerosis and an impaired coronary micro-circulation.

Carbohydrate antigen-125: additional accuracy in identifying patients at risk of acute heart failure in acute coronary syndrome.

ObjectivesTo evaluate levels of carbohydrate antigen-125 (CA-125) in patients with acute coronary syndrome (ACS), with regard to incidence of acute heart failure (AHF) and levels of brain natriuretic peptide (BNP). MethodsIn 47 consecutive patients with ACS, circulating levels of CA-125 and BNP were ascertained in the first 24 h and after 3 days of hospitalization. Left ventricular function and in-hospital incidence of AHF were also evaluated. ResultsBNP and CA-125 levels were significantly higher in patients with pulmonary oedema (PO) (564.25±500.50 vs. 258.57±284.81 pg/ml, P<0.05; 51.78±54.71 vs. 13.78±12.01 UI/ml, P<0.001) proportionally to Killip class (r=0.44, r=0.47; P<0.01) and were related to LV end-diastolic dimension (r=0.47, P<0.01; r=0.66, P<0.001) and LV ejection fraction (r=−0.63, P<0.001; r=−0.37, P<0.01). CA-125 levels identified patients with PO with higher specificity (97.1 vs. 31.4%), positive predictive value (83.3 vs. 33.3%) and accuracy (83.0 vs. 48.9%) when compared with BNP. ConclusionCA-125 levels are increased in patients with ACS and systolic dysfunction or AHF. Patients with PO are better identified by combined BNP and CA-125 assay rather than by only BNP.

Les liaisons dangereuses: Tako-Tsubo syndrome after an adulterous intercourse in an elderly male.

We report the case of an 81-year-old man who presented with chest pain after an adulterous intercourse with a young woman. At echocardiography a typical apical ballooning phenomenon was detectable and completely reversed after one week. Coronary angiography did not show significant coronary atherosclerosis.

Intra day ECG variation after general anesthesia in Brugada syndrome.

ECG variations of characteristic coved-type patterns are a common finding in subjects with Brugada syndrome. Few data are available about patients with Brugada syndrome undergoing major surgery and requiring general anesthesia. We reported ECG serial variations in a patient with Brugada syndrome who underwent surgery for tibial fracture. Relevant variations of ST patterns in V1–V2 leads over 24-h ECG monitoring were detectable, albeit these modifications were not associated with incidence of arrhythmias.

Blunted inflammatory response in STEMI patients timely reperfused.

Background Acute coronary syndrome is characterized by an acute inflammatory systemic response. We investigated whether timely reperfusion could reduce the inflammatory response in patients with ST-elevation acute myocardial infarction (STEMI). Methods Forty-seven consecutive patients with STEMI eligible for fibrinolysis and admitted to a coronary care unit were enrolled in the study and reperfused with tenecteplase; 33 patients admitted 6 h after the onset of chest pain (late comers), who therefore underwent delayed coronary angioplasty, acted as controls. All patients underwent serial blood sampling in order to evaluate plasma concentrations of C-reactive protein (CRP), fibrinogen and erythrocyte sedimentation rate (ESR) for 4 days. Patients treated with primary (<6 h from symptom onset) or rescue angioplasty were excluded from the study. Results CRP, ESR and fibrinogen in patients who were timely reperfused showed significantly lower values compared to late comer controls (P < 0.05). In a multivariable analysis considering age, sex, diabetes, presence of anterior wall infarction, presence of Q-waves, left-ventricular ejection fraction and peak troponin levels, timely reperfusion was inversely related to CRP peak values (hazard ratio 0.74, 95% confidence interval 0.55–0.98, P < 0.05). Conclusion Timely reperfusion can blunt inflammatory activation in patients with STEMI.

An unusual case of left anterior descending coronary artery occlusion—anterior ST depression and inferior ST elevation

We report a case of a 51-year-old man with chest pain, sweating, and breathlessness for a few hours. He was a smoker, reporting neither history of heart disease nor other cardiovascular risk factors: he was not receiving any drug therapy. At emergency room, an electrocardiogram (ECG) showed an unusual type of ST-segment depression in V2-V6 leads, thus suggesting an involvement of left anterior descending (LAD) coronary artery (Fig. 1). Systolic arterial blood pressure at admission was 90/60 mm Hg, and physical examination was unremarkable. Chest radiography showed no sign of pulmonary congestion, with a normal cardiac transverse diameter. Suddenly, ventricular fibrillation appeared, necessitating a 250 Joule DC shock to restore sinus rhythm. After a while, a second ECG showed ST-segment elevation in V2-V6—DI leads associated with an intraventricular delay of conduction. The patient was immediately transferred into the coronary care unit where a third ECG unexpectedly showed ST-segment elevation in inferior leads (Fig. 2), mimicking an inferior acute myocardial infarction (AMI). The patient immediately underwent systemic fibrinolysis with tenecteplase, able to reverse any sign of ST-segment elevation (Fig. 3). Echocardiography showed anterior, septal, apical, and lateral akinesis, with mild mitral regurgitation and left ventricular ejection fraction b35%. A coronary angiography performed within 24 hours unexpectedly showed a severe narrowing at proximal LAD (Fig. 4): no other signs of severe coronary atherosclerosis were present. After coronary angioplasty with sirolimus-eluting stent, the patient was discharged with aspirin, clopidogrel, statins and β-blockers. Negative V2-V6–DI-aVLTwaves were

“Lambda-wave” ST-elevation is associated with severe prognosis in stress (takotsubo) cardiomyopathy

Persistent ST‐segment elevation in acute coronary syndrome is associated with both short and long‐term complications. By contrast, there is limited information about ST‐elevation and its evolution during takotsubo (stress) cardiomyopathy (TTC).