Myocardial ischemia is known to occur even in the absence of coronary artery stenosis. Ischemia with nonobstructive coronary artery disease (INOCA) was first defined in 2017. Since then, several studies have been conducted, and consensuses and guidelines have been reported on the treatment and management of INOCA. Numerous studies have examined coronary spasm/vasospastic angina (CSA/VSA) and coronary microvascular dysfunction (CMD), resulting in the current consensus concerning the management and treatment of INOCA. However, several unsolved problems still exist. We herein review the definition, pathology, epidemiology, diagnosis, treatment, management, and perspectives of INOCA.

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Recent advancements in the medical field have significantly improved the diagnosis and treatment of ischemic heart disease. Furthermore, myocardial infarction without coronary artery obstruction, known as myocardial infarction with non-obstructive coronary arteries (MINOCA), has gained recognition. The etiology of MINOCA as a “working diagnosis” can be attributed to coronary, myocardial, and non-cardiac disorders. Understanding the “working diagnosis” of MINOCA, comprehending its underlying conditions, and carrying out appropriate diagnostic methods for each etiology to provide cause-specific treatment is necessary. We present a clinical overview of MINOCA, including its diagnosis, and a detailed review of each underlying condition.

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Objective: To evaluate the utility of a comprehensive risk assessment system for cardiovascular surgery.
Materials and methods: Among 438 patients who underwent elective cardiovascular surgery between 2020 and 2021, 199 underwent a comprehensive preoperative risk assessment using the Japanese version of the Cardiovascular Health Study (J-CHS) criteria, Short Physical Performance Battery (SPPB), Mini-Mental State Examination (MMSE), and Barthel Index. The patients were divided into 3 groups according to the J-CHS classification: robust (n = 50), prefrail (n = 110), and frail (n = 39). The in-hospital mortality, transfer to rehabilitation, and length of hospital stay were compared between the groups. Predictors of in-hospital mortality or transfer for rehabilitation were identified using a multivariate analysis.
Results: The J-CHS class correlated with other risk assessment tools (all p < 0.001). Male sex (robust vs. prefrail vs. frail; median: 74% vs. 54.5% vs. 38.5%), albumin concentration (4.0 vs. 4.0 vs. 3.6 g/dL), and hemoglobin concentration (12.9 vs. 12.7 vs. 11.4 g/dL) were significantly different between the groups (p < 0.01), while age was not. Transfer for rehabilitation (6% vs. 9.1% vs. 23.1%, p = 0.038) and hospital stay (15 vs. 16 vs. 22 days, p < 0.001) were significantly different between the groups, whereas the in-hospital mortality was not markedly different. An MMSE score of < 4 points (odds ratio [OR] 4.67, p = 0.029) and SPPB score of < 9 points (OR 3.66, p = 0.032) predicted in-hospital mortality and transfer for rehabilitation.
Conclusion: The length of hospital stay and transfer for rehabilitation increased in the J-CHS frailty group. The SPPB and MMSE scores may predict in-hospital outcomes in older patients.

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Objective: To evaluate the triglyceride-lowering effect and safety of pemafibrate in secondary prevention of coronary artery disease (CAD).
Patients and methods: Forty-six patients (male, n = 38; female, n = 8; mean age, 68 years) with CAD and a triglyceride (TG) concentration of 150 mg/dl or higher according to an ambulatory blood draw were included. Other coronary risk factors included diabetes mellitus in 24 patients (52%) and hypertension in 36 patients (78%). Forty-four patients had undergone previous coronary revascularization procedures, 86% by percutaneous coronary intervention (PCI) and 14% by coronary artery bypass grafting (CABG). All patients were taking statins. All patients were ambulatory, and blood was drawn before the administration of pemafibrate and at approximately 3, 6, 12, and 24 months after the initiation of pemafibrate treatment. Blood samples were obtained in a nonfasting state, 2–4 hours after breakfast.
Results: In comparison to previous values, TG levels were significantly lower at all time points, with similar reductions up to 24 months (pretreatment, 223 mg/dl; 3 months, 136 mg/dl; 6 months, 117 mg/dl; 12 months, 131 mg/dl, and 24 months, 124 mg/dl). Mildly elevated low-density lipoprotein cholesterol levels were observed in the early stages of pemafibrate treatment, and statin use increased or ezetimibe was added to 15 patients. Significant increases in high-density lipoprotein cholesterol levels were observed at 3 and 6 months. There were no significant changes in the estimated glomerular filtration rate, aspartate aminotransferase or alanine aminotransferase levels during the treatment period.
Conclusions: Pemafibrate effectively reduced TG levels for up to 2 years, without side effects, in patients with a history of PCI or CABG.

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In this case series, we report our experience with three surgical cases of anomalous origin of the coronary artery from the opposite sinus of Valsalva. Case 1: A 16-year-old boy complained of chest pain during physical education. The patient was diagnosed with an anomalous origin of the left coronary artery from the right sinus of Valsalva and underwent re-implantation into the left sinus of Valsalva. Case 2: A 51-year-old man had complained of a sensation of chest strangulation upon exertion since his 30s. He was diagnosed with anomalous origin of the right coronary artery from the left sinus of Valsalva and underwent reimplantation into the right sinus of Valsalva. Case 3: A 14-year-old girl complained of chest pain during a physical education class. The patient was urgently transferred to our hospital due to cardiogenic shock. The patient was placed on extracorporeal membrane oxygenation and diagnosed with an anomalous origin of the left coronary artery from the right sinus of Valsalva. Owing to widespread myocardial ischemia, an Impella and intra-aortic balloon pump were inserted for mechanical circulatory support. Unroofing was performed in the acute phase. A left ventricular assist device was fitted because of the persistent low cardiac function caused by ischemic cardiomyopathy.

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Performing percutaneous coronary intervention in the presence of previous femoral arterial grafts can be difficult. A 68-year-old man who had been resuscitated from cardiac arrest was admitted to our hospital with an electrocardiogram showing acute myocardial infarction. An ultrasound-guided puncture of the femoral artery was performed due to the absence of radial/ulnar and brachial pulses. The wire was advanced through an axillobifemoral bypass. The patient was successfully treated using a combination of long catheters, extension catheters, and high-support wires.

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A 73-year-old woman underwent percutaneous coronary intervention of a diagonal branch. While removing an intravascular ultrasonography (IVUS) catheter, the outer tube was torn off, leaving only the outer tube, including the marker, in the guiding sheath. The tip of the IVUS remnant was identified by fluoroscopy and epicardial echocardiography. An incision of 5 mm in length was made in the distal part of the stent on the diagonal branch using a stabilizer. The IVUS remnant was pulled out distally. The IVUS catheter of approximately 30 cm in length was removed without resistance. Since there was no blood coming from the proximal side of the incision, an off-pump aorto-coronary artery bypass using a saphenous vein graft was performed. The patient was discharged from the hospital on postoperative day 8 without any complications.

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