Lucyna Woźnicka-Leśkiewicz

Right coronary artery aneurysm with fistula into the coronary sinus in patient with systemic lupus erythematosus.

A 65-year-old woman was hospitalised in the Department of Hypertensiology, Angiology and Internal Diseases due to occasional chest pain and unsuccessfully treated hypertension. The patient had systemic lupus erythematosus (diagnosed in 2002 and treated with Metypred for 7 years). Physical examination: without deviation. ECG: sinus rhythm 67/min; q in III, aVF; negative T in III, incomplete RBBB. Laboratory tests: ESR 48 mm/h; antibodies ANA > 1:300; anti-Ro (anti-SSA) 8.3; anti-ds DNA < 1:10. Stress ECG: (interrupted in 9 min, 10.8 METs, due to fatigue): 1 mm ST depression in II, III, aVF. Angiography: LM very short, no atherosclerotic lesions; LAD and LCX no atherosclerotic lesions; RCA dilated (aneurysm). Cardiac magnetic resonance imaging (MRI) [cm]: LVIDd 5.1; LA 4.0; RVDd 3.0; LVPWd 0.8; IVSd 1.0; Ao 2.0/3.1/2.5; mild mitral and tricuspid regurgitations; EF 69%; no perfusion myocardial impairment; dilated RCA (6.5 mm) (Fig. 1). Coronary computed tomography angiography: LM and LCX without coronary stenosis, LAD in distal part of proximal segment — atherosclerotic plaque (20–30% narrowing), RCA dilated to 9 mm proximally and 5 mm distally (Fig. 2), winding, length about 40 cm (Fig. 3), in the distal part — the fistula to the coronary sinus (Fig. 4). In the literature data, coronary aneurysms are recognisable in nearly 5% of those undergoing angiography. When large, they may predispose to turbulent blood flow and thrombus formation. Of all the coronary arteries, the RCA is the most commonly dilated and predisposed to fistula formation. The most common aetiologies of an aneurysm are: atherosclerosis (50%), hereditary diseases (20–30%), vasculitis (10–20%) and damage (also iatrogenic). Fistulas between the coronary vessels are usually asymptomatic and discovered incidentally, but they can lead to steal syndromes causing myocardial ischaemia. In this case, due to the coexistence of systemic lupus erythematosus, the inflammatory aetiology of the RCA aneurysm should be recognised. Due to the relief of angina after blood pressure normalisation and the absence of myocardium perfusion impairment, conservative treatment was continued. The MRI failed to show the fistula of dilated RCA. This leads to the conclusion that coronary artery tomography is more accurate for the diagnosis and monitoring of this pathology. The patient remains in clinical observation with effective treatment comprising perindopril (5 mg), indapamide (2.5 mg), amlodipine (10 mg) and aspirin (150 mg).

Gender, subclinical organ damage and cardiovascular risk stratification in hypertensive patients

Abstract Background: The aims of the study were to assess subclinical organ damage in men and women with hypertension and its subsequent effect on cardiovascular risk, and use of new statistical methods for more precise estimation of cardiovascular risk using vascular cardiovascular risk factors: ankle–brachial index (ABI), intima–media thickness (IMT) and pulse wave velocity (PWV). Methods: We studied 200 patients: 100 hypertensive and 100 normotensive. The parameters we evaluated included: patient age, ABI, IMT, PWV, serum uric acid and serum C-reactive protein (CRP). In addition, the cardiovascular risk according to the SCORE and Framingham scales was assessed. Results: In the hypertensive group, there were significant correlations between ABI and the Framingham scale in both sexes. In hypertensive women, there were also significant correlations between IMT and the SCORE scale risk, and IMT and the Framingham scale risk. In normotensive women, there were significant correlations between ABI and the SCORE scale risk, and between ABI and the Framingham scale risk. In normotensive men, there were significant correlations between PWV and the SCORE scale risk, and between PWV and the Framingham scale risk. Lastly, in the group of normotensive men, there were significant correlations between IMT and the SCORE scale risk, and IMT and the Framingham scale risk. The possibility of correctly classifying a patient into the high-risk category by a logistic regression model using synchronous ABI, IMT and PWV was high – 74% for the risk according to the SCORE scale (66% in men, 88% in women), and 98% for the Framingham scale. Conclusions: The addition of recognized subclinical target organ damage tests to the estimation of cardiovascular risk can significantly strengthen the prevention of cardiovascular disease. Cardiovascular risk estimation follow-up with ABI, PWV and IMT increased the probability of correctly classifying people, especially women, into an at least high-risk category according to the SCORE scale, which has valuable therapeutic implications.

Patient with advanced coronary artery disease and psoriasis

A 67-year-old patient was admitted to the hospital due to the retrosternal pain appearing during moderately physical activity. An interview revealed the following: symptomatic angina pectoris, hypertension, diabetes type 2, and psoriasis with psoriatic arthritis for several years (Fig. 1). Laboratory results showed the following: elevated C-reactive protein, total cholesterol, and glycated haemoglobin. Electrocardiogram revealed the following: regular sinus rhythm, 68/min. Echocardiography: enlargement of the left ventricle with hypokinesis of the basal segment of the inferior wall and the septum, and ejection fraction 60%. Coronary angiography revealed the following: left main artery: minor changes; left anterior descending artery (LAD): aneurysmal extended, distally closed (Fig. 2), diagonal branch: closed; left circumflex artery: aneurysmal extended; 90% narrowing in first marginal branch (Fig. 3); right coronary artery: dominant, wide, 90% distally narrowing (Fig. 4); and posterior descending artery: closed. After the heart team consultation, the changes in coronary arteries were treated conservatively. Doppler ultrasound showed unobstructed both carotid arteries and intima–media thickness of 0.6 mm. An inflammatory process and hyperlipidaemia play roles in the development of atherosclerosis. Psoriasis is a chronic inflammatory disease that belongs to the dermatosis group. Its aetiology includes: genetic factors, vascular changes, and immunological phenomena, as well as environmental factors. The pathophysiology is associated with the inflammatory pathway response of cytokines released by Th1 and Th17 lymphocytes. Patients with psoriasis have increased risk of coronary artery disease (CAD); in this group the probability of myocardial infarction is significantly increased. Moreover, in coronary angiography up to 84% of patients had atherosclerotic lesions vs. 75% observed in the control group. Atherosclerotic lesions in LAD were observed more frequently compared with the general population, and their intensity correlated with the duration of the psoriasis. The inflammatory process is the connecting element between these two diseases. In the pathogenesis of psoriasis one of the main roles is played by the immune processes with the cascade of cytokines released by Th1 and Th17 lymphocytes (TNF-a, IFN-g, IL-17, IL-12, IL-2, and IL-23). The activation of Th1 and its mediators (INF-g, TNF-a, IL-1, IL-12, and IL-18) play a role in the pathogenesis of atherosclerosis. IL-12 and IFN-g are the elements connecting these diseases. European Society of Cardiology guidelines list psoriasis as an independent risk factor for CAD. A key role is attributed to the immune process, especially T-helper response. Patients with concomitant psoriasis and CAD represent an uncommon and complicated group of patients who require significant cardiovascular prevention. It is also worth noting that such patients are good candidates for omega-3 fatty acids supplementation, which is known for both cardiovascular prevention and improvement of psoriasis symptoms. Figure 1. Psoriasis in the joints and nails of both hands

Patient with disseminated atherosclerosis, resistant hypertension and quadruple left renal artery

Lucyna Woźnicka-Leśkiewicz, Anna Posadzy-Małaczyńska, Anna Wolska-Bułach, Maciej Frankiewicz, Robert Juszkat 1Department of Hypertensiology, Angiology and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland 2Department of Family Medicine, Poznan University of Medical Sciences, Poznan, Poland 3Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland

Stenosis in proximal LAD in a 34-year-old female with essential thrombocythemia treated with novel bioabsorbable scaffold.

A 34-year-old woman was hospitalised in the Department of Hypertensiology due to chest pain that had occurred after a few minutes of exercise and stopped quickly at rest. Past history: Preterm delivery because of maternity gestosis and hypertension (2007), glomerulonephritis (2008), tonsillectomy (2008), appendectomy, miscarriage (2009), delivery by caesarean section (2011). Laboratory results: Elevated levels of: PLT, total and LDL cholesterol, RBC, potassium, granulocyte-alkaline phosphatase; negative troponin; positive antibodies ANA (1:160 — speckled light type), V617F JAK2 mutation gene by PCR; low level of erythropoietin. Bone marrow biopsy revealed an increased number of megakaryocytes without evidence of fibrosis. Essential thrombocythemia (ET) was diagnosed. ECG: The sinus rhythm with negative T-waves in V2–V4. Echocardiography: Hypokinesis of basal segment of intraventricular septum with ejection fraction 65%. The ECG stress test was electrocardiographically (ST-segment depression in the inferior and lateral walls) and clinically (chest pain) positive. The coronarography revealed critical stenosis (95%) in the ostium of left anterior descending coronary artery (LAD) (Fig. 1), a circuit filled with a delay, without changes in other coronary arteries. The intravascular ultrasound (IVUS) confirmed very small minimal luminal area (2.1 mm2) (Fig. 2). The patient was qualified by the heart team for percutaneous coronary intervention (PCI) of LAD. The implantation of an everolimus-eluting bioresorbable vascular scaffold (BVS) Absorb 3.5 × 18 mm was successfully performed (Fig. 3). After the PCI, the patient was discharged with the regimen to take: acetylic acid, ticagrelol for 12 months (90 mg twice a day), metoprolol, pantoprazol and atorvastatin. At 5-month follow up, control coronarography showed no signs of stenosis in LAD. Optical coherence tomography (OCT) confirmed the proper neointimal response without scaffold area obstruction (Fig. 4). The ECG and echocardiography revealed no abnormalities. Critical stenosis of coronary arteries or myocardial infarction (MI) is a rare complication of ET in young patients. According to the literature, approximately 13% of patients younger than 40 years at diagnosis experience thrombotic events such as: transient ischaemic attack, MI, stroke, peripheral arterial and venous thrombosis. ET treatment is always a challenge, due to the high risk of recurrent thrombosis. BVS resorption is completed within 3 years after device implantation, thus allowing the artery to restore its physiological vasomotor response as well as reduce chronic inflammation and late stent thrombosis. We assumed that the novel BVS Absorb and antiplatelet drug as ticagrerol used in our case should improve the outcomes of treatment due to better protection against restenosis.