2. METHODS2.1. Patient PopulationPatients diagnosed with CEA according to CAG in Peking Union Medical College Hospital (PUMCH) from April 2003 to October 2009, were enrolled.
2.2. DefinitionsCoronary artery ectasia: >1.5 times of the diameter of adjacent normal vessels. Coronary artery aneurysm: >2 times of the diameter of adjacent normal vessel [1]. Two experienced investigators reviewed the patients’ CAG films and made the diagnosis.
2.3. Classification of CEAThe classification of CEA was according to Markis criteria, 4 types were made.
Type 1: Diffuse ectasia of two or three vessels;
Type 2: Diffuse ectasia in one vessel and localized in another;
Type 3: Diffuse ectasia of a single vessel;
Type 4: Localized or segmental ectasia.
2.4. Data CollectionPatient variables including gender, age, blood pressure, history of coronary artery disease, smoking history, hyperlipidemia, diabetes mellitus, body mass index, clinical presentation, coronary angiography results and medications at discharge, were collected.
2.5. Primary OutcomeThe primary outcome was all-cause mortality or cardiovascular readmission.
2.6. Statistical AnalysisAll data were analyzed by SPSS software, version 17.0 for Windows, using spearman’s correlation analysis to explore the relationship of various medications and the primary outcome. p value ≤ 0.05 was considered statistically significant.
3. RESULTS3.1. Patients and PrevalenceA total of 39 patients (69% male, mean age: 59.5 ± 12.6 years) with CEA were diagnosed, 3 patients were lost of follow-up, therefore, 36 patients constituted the study population, including coronary artery ectasia in 32 patients and coronary artery aneurysm in 4 patients. A total of 6130 patients underwent CAG in PUMCH during the same period, therefore, the prevalence of CEA in the patients referred for CAG was 0.6%. All the patients with CEA suffered from angina pectoris, and 10 patients accompanied with atherosclerotic stenosis, the remaining 26 patients (72%) were isolated CEA. The median follow-up was 27 months (1 - 76). Table 1 summarized the clinical characteristics of the study patients.
3.2. Coronary FeaturesThe majority of CEA patients were presented with multiple coronary ectasia or aneurysm, the left anterior descending branch (LAD) was the most commonly involved vessel. According to the classification made by Markis, type 1, 2, 3 and 4 were seen in 13, 12, 2 and 9 patients, respectively. Table 2 summarized the coronary features of the study patients.
3.3. Primary OutcomeNo death was observed. Cardiovascular readmission occurred in 8 patients, including acute myocardial infarction in 3 patients, unstable angina pectoris in 3 patients, acute heart failure in 1 patient and atrial fibrillation in 1 patient, respectively.
Table 1. Clinical characteristics.
Table 2. Coronary features.
LAD = left anterior descending branch; RCA = right coronary artery; LCX = left circumflex branch; LM = left main branch.
3.4. Relationship between Primary Outcomes and MedicationsThere was negative correlation between cardiovascular readmission and the current use of clopidogrel (R = −0.316, p = 0.050) and statins (R = −0.371, p = 0.026). The negative correlation between cardiovascular readmission and the current use of clopidogrel and statins still remained after adjustment of the distribution and classification of CEA. Table 3 summarized the relationship between medications and primary outcome.
4. DISCUSSIONSeveral studies reported the morbidity and cardiovascular risk factors of CEA [2-6]. Coronary Artery Surgery Study reported the largest cohort of CEA patients with a
Table 3. Correlations between medications and primary outcome.
ARB = angiotensin 1 receptor blockers; ACEI = Angiotensin-Converting Enzyme Inhibitors; CCB = calcium channel blockers.
incidence of 4.9% among 20,087 patients referred for CAG [2]. In Asian, database containing the largest number of CEA patients is from Singapore, which reporting an incidence of 1.2% (n = 8641) [3]. Our study showed a lower prevalence (0.6%) of CEA, which may be attributed to a lower atherosclerotic risk in Chinese population.
All of CEA patients in the present study complained of clinical presentations of angina pectoris, with a male dominance (69%), similar with previous reports [3,5]. Although atherosclerosis [6], dyslipidemia [5], smoking [5], diabetes mellitus [5], hypertension [7] and abodominal artery aneurysm [5,8] were considered as possible CEA risk factors, there were no significant correlation between these variables and the severity of CEA in the present study.
There were some striking features observed in the present study. The previous study showed that 50% of patients with CEA also have concomitant atherosclerosis [9], with a most frequently involved branches of RCA, followed by LAD and LCX [2,4], while ectasia of multivessels and LM were rare [9]. However, CEA with atherosclerosis only occurred in 28% of the present study, while isolated CEA were observed in more than 70% patients, strongly supporting a recent viewpoint that CEA was not a simple variant of atherosclerosis [10]. Moreover, LAD is the most commonly involved artery, multiple coronaries and LM involvement observed in about 2/3 and 1/4 patients in the present study, respectively.
The appropriate therapeutic strategy is still controversial. Considering that thrombus formation and distal embolization play crucial roles in pathogenesis of CEA [5,11-13], anticoagulation and antiplatelet therapy should be beneficial to reduce cardiovascular events. In case series of Rath [14], 5 patients without obstructive coronary aneurysms developed acute myocardial infarction and complete occlusion of aneurysmal vessels without any anticoagulation and antiplatelet medications. Alloul [15] reported a case with isolated coronary aneurysm, who developed acute myocardial infarction when withdrawal of warfarin after 6 months of preventive anticoagulation. Although many researchers suggested application of platelet inhibitors in all forms of CEA to prevent myocardial ischemia [11,16], long-term follow-up data was limited about the impact of antiplatelet therapy on clinical outcomes of CEAs. Meanwhile, clinical study of anticoagulant medications on CEAs is lack. Our results revealed a significant correlation between clinical improvement and application of aspirin and clopidogrel. In particular, the clopidogrel, which is a strong platelet ADP receptor antagonist, may not only decrease attacks of angina pectoris, but also reduce the readmission event rate. Otherwise, we couldn’t find any association between anticoagulation drugs and reduced risks of cardiovascular events, indicating that prophylactic use of low-molecular-weight heparin or warfarin may be not necessary in patients with CEAs.
Statins, which are generally accepted as lipid-lowing and anti-inflammatory agents to protect AS patients from coronary ischemic events, are negative correlation with primary outcomes in the present study. Tokgozoglu et al. [17] reported elevated plasma levels of inflammatory markers such as interleukin-6 and C-reactive protein (CRP) in CEA patients comparing with those with normal coronary. In another study from Ozbay [18], significantly elevated hs-CRP levels in CEA patients than that in AS patients, and significant decreased hs-CRP levels after a 3-month statins therapy, also showing CEA patients may benefit from statins. Aronow [19] and Saratzis et al. [20] reported that patients with abdominal aortic aneurysm could benefit from statins.
