ISCHEMIA (Initial Invasive or Conservative Strategy for Stable Coronary artery disease) trial was a large, international, multi center, prospective, randomized controlled clinical trial comparing initial invasive plus optimal medical therapy (OMT) strategy versus conservative management plus OMT strategy in stable coronary artery disease patients with moderate to severe ischemia. It is still too early to describe the overall impact of ISCHEMIA trial partly because the result is still in the process of slowly being digested in the cardiology and general communities, but also because COVID-19 pandemic has greatly altered recent cardiology practices in the US and worldwide. However, one thing is very likely. Based on the result of this trial, cardiologists will be asked more often to be cautious about indications for revascularization. A proof of ischemia alone cannot be justified for initial invasive strategy in a stable coronary artery disease patients who are optimally medically managed and asymptomatic or minimally symptomatic. In the early days of angioplasties, “Oculo-stenotic reflex” was frowned upon as a too premature attitude of angioplasty treatment for an anatomically significant coronary stenosis but otherwise unknown hemodynamic or clinical importance. After the ISCHEMIA trial, cardiologists may be asked to shy away from “Ischemia-invasive reflex” in the appropriate context in stable coronary artery disease patients who are optimally medically treated and asymptomatic or minimally symptomatic. According to the result of this trial, proof of significant ischemia is not a “Carte Blanche” for early invasive management strategy. On the other hand, this trial did show durable improvement of angina symptoms in the invasive arm compared to conservative arm, thus, as long as the goal of the management is clearly stated to reduce angina and to improve quality of life, early invasive strategy for stable coronary artery disease patients is justifiable in the post ISCHEMIA era.

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A major achievement in nuclear cardiology has been the identification of ischemia, and multimodal imaging of coronary artery disease has been pivotal in this process. X-ray computed tomography (CT) is an imaging modality that can reveal information about coronary artery stenosis. Thus, the number of studies has rapidly increased in Japan, where CT is widely available in clinical practice. However, coronary CT angiography is more suitable for visualizing the coronary anatomy of patients with mild to intermediate risk, and nuclear cardiology is more appropriate for detecting stress-induced ischemia among patients with intermediate-to-severe risk. Solid-state SPECT cameras equipped with cadmium-zinc-telluride detectors enable dynamic data acquisition and generate information about myocardial flow reserve, which might offer a new perspective of multi-vessel diseases and the microcirculation. Artificial intelligence is emerging as a possible new strategy for identifying ischemia. The applications of ¹²³I-labeled non-perfusion tracers have expanded in Japan. For example, ¹²³I-BMIPP can visualize ischemic memory, help determine the prognosis of patients with chronic kidney disease or those on hemodialysis, and it has also recently proved useful for diagnosing triglyceride cardiomyovasculopathy. Although ¹²³I-MIBG is indicated for heart failure, model-based approaches to differentially predicting causes of cardiac death are under investigation. Other applications include ^99mTc-pyrophosphate imaging of transthyretin cardiac amyloidosis and ¹⁸F-FDG for cardiac sarcoidosis. Among all multimodal imaging modalities, nuclear cardiology continues to be tracer-based and reflect myocardial perfusion, flow reserve and molecular imaging.

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Background: Coronary artery spasm may lead to the aborted sudden cardiac death (A-SCD). Objectives: We investigated the number of coronary vasodilators, including calcium channel blocker (CCB), implantable cardioverter-defibrillator (ICD) implantation and prognosis in patients with A-SCD due to coronary spasm in the real world. Methods: We recruited 98 patients (82 men, mean age of 59.6±13.3 years old) with A-SCD due to coronary spasm using a questionnaire. Results: Ventricular fibrillation (VF) as a cause of A-SCD was observed in 83 patients (84.7%), while pulseless electrical activity (PEA) was recognized in 12 patients (12.2%). ICD was implanted in 58 patients and appropriate ICD therapies were recognized in 8 patients (13.8%). There were no differences regarding medications between patients with and without ICD or between patients who survived and those who died. Mean follow-up duration was 27.1±19.9 months and three patients died. Mortality during the follow-up period was not different patients with ICD from those without ICD. The mean number of coronary vasodilators including CCB in patients with spasm provocation tests under medications were significantly higher than in those without. VF as an initial cause of A-SCD was recognized in all 3 patients who died, while PEA was a final cause of death in 2 of 3 patients. Conclusions: Clinical outcomes in patients with A-SCD due to coronary spasm is satisfactory under medical and mechanical therapy. Decision of requiring the ICD implantation in patients with A-SCD due to coronary spasm is a challenging clinical problem.

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The anomalous origin of the right coronary artery (RCA) is relatively more frequent with an approximate to 0.25% incidence¹⁾. Localization and adequate visualization of the anomaly are essential for patients undergoing evaluation for complex coronary or valvular interventional and surgical treatments. We report a case of anomalous origin of RCA from intercuspal area of the aortic sinus. Such a variant of anomalous coronary origin is not described before as per our literature search.

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We report an extremely rare case of acute myocardial infarction occurring shortly after a negative exercise stress test (EST). It was highly likely that the shear stress directly increased by the EST caused plaque rupture in this case.

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No-reflow phenomenon is a condition in which blood flow to the ischemic myocardium is significantly reduced despite percutaneous coronary intervention. So far, a standard treatment to improve this condition has not been established. We here report an interesting case that illustrates an effective treatment for no-reflow phenomenon. A 66-year-old male was admitted to our hospital for acute myocardial infarction and underwent emergent catheterization. Coronary angiogram showed total obstruction of the distal right coronary artery (RCA). We used an AL2 guiding catheter and passed a coronary guidewire into the RCA. Coronary flow was then slightly restored, and severe stenosis of the distal RCA with massive thrombus was observed. Intravascular ultrasound revealed that the thrombus was large and diffuse. Firstly, thrombus aspiration was performed. Then, no-reflow phenomenon was observed in the far distal RCA. An infusion catheter (Lumune™) was advanced to the distal RCA and 50 μg nitroprusside was injected. Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 was immediately achieved. Two weeks after the first catheterization, a second catheterization was performed. Coronary angiogram showed no stenosis in the RCA and most of the thrombus disappeared. Left ventriculography showed severe hypokinesis of the inferior wall, but ejection fraction increased to 59%. He was discharged and has been followed as an outpatient at our hospital. We experienced a case of no-reflow phenomenon clearly ameliorated by intracoronary nitroprusside injection with a Lumine™ infusion catheter. This method could be a powerful option to treat no-reflow phenomenon.

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