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The importance of evaluating patients with MINOCA (Myocardial infarction with non-obstructive coronary arteries)
Abstract
136 The importance of evaluating patients with MINOCA (Myocardial infarction with non-obstructive coronary arteries) A. Sheikh 1,3,∗ , S. Sidharta 2,3 , S. Pasupathy 3 , M. Worthley 2,3 , J. Beltrame 1,3 1 The Queen Elizabeth Hospital, Adelaide, Australia 2 Royal Adelaide Hospital, Adelaide, Australia 3 University of Adelaide, Adelaide, Australia
Acute myocardial infarction is associated with obstructive coronary artery disease in over 90% of patients undergoing angiography and the management of such cases is clearly defined. However there are no clear management guidelines for MINOCA. Identifying the responsible mechanism for the infarct should be a key clinical objective since this may impact on management. A 48-year-old man with recurrent angina had “smooth” coronary arteries on angiography but evidence of a mid left anterior descending artery (LAD) myocardial bridge (MB). Following an admission with an inferior non-STEMI and further episodes of angina, he underwent repeat angiography with subsequent invasive coronary haemodynamic testing performed when MINOCA was confirmed. The LAD was interrogated with Volcano Combo (combined Doppler and pressure) wire. The proximal resting Doppler recording showed the characteristic ‘fingertip’ phenomenon associated with MB, which disappeared once the wire tip was advanced beyond the MB. Quantitative measures at maximal hyperaemia showed (i) non-haemodynamically significant MB Fractional Flow Reserve (FFR) of 0.88, (ii) normal vasodilator capacity i.e Coronary flow reserve (CFR) of 3.6, and (iii) hyperaemic microvascular resistance (HMR) 1.2. Similarly, the right coronary artery (RCA) showed normal haemodynamics (FFR=0.93, CFR=4.8 and HMR=1.4) but spasm provocation testing with 25mcg acetylcholine intracoronary (IC) bolus produced occlusive RCA spasm that was resolved with 200mcg of IC nitrate. This case exemplifies the complexity and importance of evaluating patients with MINOCA. Although a MB was evident on angiography, the inducible RCA spasm more likely accounts for the recurrent chest pain and MINOCA findings in this patient. http://dx.doi.org/10.1016/j.hlc.2015.06.137
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137 The role of CT Coronary Angiogram in a Regional setting to improve access to care for Indigenous and non-Indigenous Australians A. Antoo 1,∗ , N. Kangaharan 2 , B. Ko 3 , W. Corkill 4 , I. Agahari 2 , S. Brady 4 1 Western
Hospital, VIC, Australia Darwin Hospital, NT, Australia 3 Monash Heart, VIC, Australia 4 Alice Springs Hospital, NT, Australia 2 Royal
Background: In Central Australia, patients with suspected coronary artery disease (CAD) have limited access to stress testing and no locally available nuclear imaging or invasive angiography (ICA). In August 2013, CT Coronary Angiography (CTCA) became available at Alice Springs Hospital (Aquilion One 320-Detector CT Scanner) supported by a Commonwealth-Northern Territory Government-NT Cardiac scheme. Aim: To describe patient characteristics and results of this inaugural regional CTCA service. Method: All demographic data was prospectively recorded. Stenosis severity on CT and ICA was adjudicated according to clinical report. Significant stenosis is taken as the presence of >50% stenosis. Results: One-hundred-and-forty-nine symptomatic patients (51.3±13.4yrs; 41% Male, 36% Indigenous, 66% intermediate or high risk in accordance with DiamondForrester classification) underwent CTCA with no adverse events. Indigenous patients were younger (43.4 vs. 55.8 yrs, p<0.0001). CTCA identified single, double and triple vessel disease present in 30 (20%), 18 (12%) and 25 (17%) patients respectively. At least 11 of the 36 patients (24%) referred for ICA had ≥1 significant stenosis. Among 80 patients (54%) with abnormal echocardiogram or inconclusive stress testing results; otherwise needing intra/interstate transfer for ICA, CTCA showed 34 normal studies, 23 with non-occlusive disease and only 23 (29%) requiring ICA. Conclusion: The use of CTCA in regional Australia may streamline assessment of patients with suspected CAD and decrease intra/interstate referrals for ICA, particularly in patients with inconclusive stress testing results, reducing costs and associated inconveniences to patients from remote communities. http://dx.doi.org/10.1016/j.hlc.2015.06.138
136 The importance of evaluating patients with MINOCA (Myocardial infarction with non-obstructive coronary arteries) A. Sheikh 1,3,∗ , S. Sidharta 2,3 , S. Pasupathy 3 , M. Worthley 2,3 , J. Beltrame 1,3 1 The Queen Elizabeth Hospital, Adelaide, Australia 2 Royal Adelaide Hospital, Adelaide, Australia 3 University of Adelaide, Adelaide, Australia
Acute myocardial infarction is associated with obstructive coronary artery disease in over 90% of patients undergoing angiography and the management of such cases is clearly defined. However there are no clear management guidelines for MINOCA. Identifying the responsible mechanism for the infarct should be a key clinical objective since this may impact on management. A 48-year-old man with recurrent angina had “smooth” coronary arteries on angiography but evidence of a mid left anterior descending artery (LAD) myocardial bridge (MB). Following an admission with an inferior non-STEMI and further episodes of angina, he underwent repeat angiography with subsequent invasive coronary haemodynamic testing performed when MINOCA was confirmed. The LAD was interrogated with Volcano Combo (combined Doppler and pressure) wire. The proximal resting Doppler recording showed the characteristic ‘fingertip’ phenomenon associated with MB, which disappeared once the wire tip was advanced beyond the MB. Quantitative measures at maximal hyperaemia showed (i) non-haemodynamically significant MB Fractional Flow Reserve (FFR) of 0.88, (ii) normal vasodilator capacity i.e Coronary flow reserve (CFR) of 3.6, and (iii) hyperaemic microvascular resistance (HMR) 1.2. Similarly, the right coronary artery (RCA) showed normal haemodynamics (FFR=0.93, CFR=4.8 and HMR=1.4) but spasm provocation testing with 25mcg acetylcholine intracoronary (IC) bolus produced occlusive RCA spasm that was resolved with 200mcg of IC nitrate. This case exemplifies the complexity and importance of evaluating patients with MINOCA. Although a MB was evident on angiography, the inducible RCA spasm more likely accounts for the recurrent chest pain and MINOCA findings in this patient. http://dx.doi.org/10.1016/j.hlc.2015.06.137
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137 The role of CT Coronary Angiogram in a Regional setting to improve access to care for Indigenous and non-Indigenous Australians A. Antoo 1,∗ , N. Kangaharan 2 , B. Ko 3 , W. Corkill 4 , I. Agahari 2 , S. Brady 4 1 Western
Hospital, VIC, Australia Darwin Hospital, NT, Australia 3 Monash Heart, VIC, Australia 4 Alice Springs Hospital, NT, Australia 2 Royal
Background: In Central Australia, patients with suspected coronary artery disease (CAD) have limited access to stress testing and no locally available nuclear imaging or invasive angiography (ICA). In August 2013, CT Coronary Angiography (CTCA) became available at Alice Springs Hospital (Aquilion One 320-Detector CT Scanner) supported by a Commonwealth-Northern Territory Government-NT Cardiac scheme. Aim: To describe patient characteristics and results of this inaugural regional CTCA service. Method: All demographic data was prospectively recorded. Stenosis severity on CT and ICA was adjudicated according to clinical report. Significant stenosis is taken as the presence of >50% stenosis. Results: One-hundred-and-forty-nine symptomatic patients (51.3±13.4yrs; 41% Male, 36% Indigenous, 66% intermediate or high risk in accordance with DiamondForrester classification) underwent CTCA with no adverse events. Indigenous patients were younger (43.4 vs. 55.8 yrs, p<0.0001). CTCA identified single, double and triple vessel disease present in 30 (20%), 18 (12%) and 25 (17%) patients respectively. At least 11 of the 36 patients (24%) referred for ICA had ≥1 significant stenosis. Among 80 patients (54%) with abnormal echocardiogram or inconclusive stress testing results; otherwise needing intra/interstate transfer for ICA, CTCA showed 34 normal studies, 23 with non-occlusive disease and only 23 (29%) requiring ICA. Conclusion: The use of CTCA in regional Australia may streamline assessment of patients with suspected CAD and decrease intra/interstate referrals for ICA, particularly in patients with inconclusive stress testing results, reducing costs and associated inconveniences to patients from remote communities. http://dx.doi.org/10.1016/j.hlc.2015.06.138