Methods
This is a
descriptive, and a retrospective review study which was conducted at Queen Alia
Heart Institute in Amman – Jordan, during January 2006 to January 2011, on 5000
adult patients (>18 years) who underwent diagnostic coronary angiography
during that period because of the main complaint of chest pain.
The angiograms
reports were reviewed for the presence of coronary
artery ectasia and its clinical features
as mentioned in their medical records. Ectasia was considered present when the
area of dilatation was more than 1.5 times the diameter of the normal portion
of the coronary artery. Patients known to have congenital structural heart
disease were excluded from the study.
A
specially designed medical record abstract form was used to record the
following data: Gender, type of coronary ectasia (diffuse or localized),
affected coronaries and association with stenotic coronary rtery disease. The
frequency of coronary ectasia was calculated.
Simple descriptive statistics (frequency, mean, percentage) were used to
describe the study variables.
Results
Table I
presents the frequency of CAE among the study group which was 140 patients (2.8%).
Males were the majority (87.1%) of patients with CAE.
Table II
shows the distribution of CAE according to the involved vessel. The commonest was the right coronary artery
(36.4%), followed by the left anterior descending
artery (15.0%).
Isolated left main
artery ectasia was present in 2.1%. Two vessels ectasia and three vessels ectasia
had equal frequencies with 19.3% of cases for each category.
Table III
demonstrated the pattern of ectasia in the involved coronary artery, the
diffuse pattern was the commonest (61.4%) followed by proximal ectasia in 34.3%
of cases, whereas localized distal ectasia being the lowest (4.3%).
As illustrated
in Table IV, Stenotic Coronary Artery Disease was found in 56.4% of the ectatic
coronaries, which was almost similar to the ratio of stenotic
coronary artery disease among the non ectatic coronaries in patients with CAE (54.3%)
– as shown in Table V.
Discussion
Coronary Artery
Ectasia is a well-recognized, albeit uncommon, finding in diagnostic coronary
angiography and is defined as an abnormal dilatation of a segment of the
coronary artery to a diameter of at least 1.5 times that of the normal adjacent
segment. It was first described by Bourgon in 1812,(12) while
the term "ectasia" was first coined by Bjork in 1966.(13)
Its
prevalence varies from 0.3-4.7%. Its clinical significance is unclear, there is
some dispute regarding its relation to occlusive coronary heart disease. The mechanism
behind dilatation in some, with stenosis in other, individuals with
atherosclerotic heart disease remains obscure. In various reports, ectasia has
been described either as an isolated congenital lesion, or in association
with coronary atherosclerosis,
syphilis, congenital heart disease.(8) scleroderma,
polyaretritis nodosa, Ehlers Danlos Syndrome,
bacterial infections and Kawasaki
disease.(5,6,7)
Cardiac
catheterization and coronary arteriography is the main diagnostic technique for
the diagnosis of CAE. However; other valuable non invasive tools have been
proposed like Magnetic Resonance Angiography (MRA) and Computed
Tomography (CT) scan, before going to the invasive coronary arteriography. Such
modalities proved their usefulness in demonstrating the presence and the extent
of CAE.(9-11) in addition to allow a great accuracy in
the diagnosis of atherosclerosis and stenosis in those vessels although there
is no universal agreement regarding that.
Ectasia
is classified according to the extent of involvement of the coronary vessels,
with type I representing diffuse ectasia of two or more major vessels; type II
diffuse ectasia in one vessel and localized disease in another; type III
diffuse ectasia of one vessel only and type IV localized involvement (Markis et
al).(14)
The clinical importance of CAE should be stressed
on as it may cause Acute Coronary Syndrome including acute myocardial
infarction even without associated stenotic lesions so there is growing body of
the literature which suggests that ectasia is not an innocent condition, but a
risk factor for accelerated atherosclerosis and acute
myocardial infarction as ecstatic vessels appear to be prone, beside thrombus formation
and dissection, to spasm despite the fact that vascular medial damage was seen
in histology.(2)
The frequency
of CAE in our study was 2.8%, and although it is within the wide range reported
in other angiographic studies, it is relatively lower than the ratios found in
these studies, for example; Sharma et al reported a frequency
of about 10% and Swaye et al reported a frequency of 4.9%. Nevertheless,
others reported a lower frequency than what was obtained in our Study, for
example; Hartnell et al reported an overall frequency of 1.4% and Lam et
al showed even a lower frequency of CAE (only 1.2%).(3,15-18)
CAE
certainly appears to be more common in males than in females in our study,
which is similar to other reports.(19-21) This may
reflect the selectivity and prejudice of female referrals for cardiac
catheterization and coronary angiography.
The
incidence of CAE is probably higher than the percentage found in this study,
because the study included only symptomatic individuals with chest pain
subjected to diagnostic coronary angiograms, while asymptomatic people with CAE
remain undiagnosed as is a descriptive, and a retrospective review study.
The
variable frequency of CAE can be explained partly by geographical and racial
differences, for example; Sharma et al reported a higher This is a
descriptive, and a retrospective non-randomized review study of CAE in Indian
people with coronary artery disease, and Lam et al documented a
variation in the frequency of ectasia among Chinese, Malays and Indians.(15,18)
Besides,
few reports attributed the high frequency of CAE in certain specific areas to
the high exposure to certain chemicals like pesticides.(22)
and fluorosis.(23) Our
angiographic results were consistent with what was reported in the medical literature(3,21,24)
where the right coronary artery (RCA) is the most commonly ectatic vessel found
while the Left Main Artery (LMA) is the least commonly affected.
However,
in one report the distribution of ectasia in different coronary arteries did
not confirm with the pattern reported in the medical literature where coronary
ectasia was most frequently observed in the Left Anterior Descending (LAD)
artery.(25)
Diffuse
pattern CAE was found in 61.4% of cases, and involvement of all coronary
arteries was present in 19.3% of medical records which is relatively high. This
raises the question of the progressive nature of the disease and people with a
single vessel and focal ectasia, if restudied later, will have all coronaries and
diffuse ectasia or not.
CAE was
associated with coronary atherosclerosis in more than the half of our patients,
which was in agreement with the statement that coronary ectasia is a form or a
variant of Coronary Artery Disease.(26-29) Literature is unclear with regard
to prognosis of this condition. In some reports the long term prognosis of
patients with isolated CAE was no better than in individuals with isolated
obstructive coronary artery disease.(30-33)
Another
unanswered question is about the treatment of CAE; the use of warfarin,
aspirin, diltiazem and beta blockers have been suggested in the literature.
However,
the supporting literature is scant, with many recommendations based on
anecdotal evidence.
Finally,
the authors recommend that recognition of CAE at angiography is essential in
order to plan proper follow-up and appropriate medical therapy as we realize
its exact clinical consequences and plan the precise timing of therapeutic
measures application to prevent acute coronary syndrome and myocardial
infarction.
Limitations for this Study
The study
was based on review of angiograms reports and not on reviewing the angiograms
per se, which seems to be more realistic. However, the angiograms reporter in
this study is a senior consultant cardiologist who is absolutely aware of the
definition of coronary ectasia reporting.
There was
underreporting of CAE in the study, because it was designed to study only
symptomatic patients.
The
authors could not show the etiology or the conditions associated with CAE in
the included patients, because in this retrospective review study,the
medical files were deficient in that regard.
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