Invasive versus Conservative Management in Coronary Artery Disease.

Background: In patients with ST-elevation myocardial infarction, immediate coronary angiography and intervention is the best practice, if an experienced laboratory is available. In non-Q-wave infarction most, but not all, studies suggest that early invasive strategy is superior to conservative management. Complete revascularization is preferred.Methods: A literature search regarding management of coronary artery disease was conducted in PubMed between January 1985 to January 2021. Articles published in English were reviewed, and those relevant were selected by both authors. Special focus was on the ISCHEMIA trial and related articles.Results: The utility of coronary angiography in patients with stable coronary artery disease is challenging. All patients should undergo optimal medical therapy. Patients with angina should not only receive approved anti-anginal agents but should also receive lifestyle modifications and pharmacologic therapy to control risk factors such as diabetes, hypertension, dyslipidemia, and smoking; and should consider organized physical activity programs. Low density lipoprotein should be reduced to 70 mg/dL or less. Non-invasive studies such as coronary computed tomography angiography (CCTA) are preferred. If expert CCTA is not available, then stress test, preferably with imaging, is recommended. If the results of CCTA show high risk, then coronary angiography and intervention are usually indicated. In patients with left main disease, left ventricular dysfunction, or symptoms of congestive heart failure, early invasive strategy is recommended. If none of these conditions exist, then initial medical therapy may be initiated, and invasive therapy should be utilized only if clinically indicated. In patients with chronic stable angina, continue with medical therapy and risk factor modification. If the frequency or severity of angina episodes change, coronary angiography and revascularization should be considered, as appropriate. In patients with significant renal dysfunction, angiogram may be indicated only if there is complete failure of medical therapy.Conclusion: Optimal medical therapy should be initially utilized in all patients. Early invasive management and revascularization should be utilized in patients with left ventricular dysfunction, congestive heart failure, and failure of medical therapy. A shared decision-making process should always be utilized.

ST Segment Elevation Myocardial Infarction in the COVID-19 Era: Appraisal of the Evidence.

The COVID-19 pandemic continues to present a public health challenge and has had a significant impact on the presentation, time-dependent management, and clinical outcomes of ST elevation myocardial infarction (STEMI). Patients with COVID-19 and pre-disposing cardiovascular risk factors like hypertension, hyperlipidemia, and diabetes mellitus are at a higher risk of developing STEMI, and global trends have highlighted delayed management of STEMI, which may contribute to worse clinical outcomes. Prolonged time to intervention has also resulted in an increased rate of no reflow, which is an independent risk factor for worse outcomes in these patients. Timely primary percutaneous coronary intervention (PCI) remains standard of care for STEMI and can be attained within the recommended 90 minutes timeline from hospital presentation. A coordinated, safe, standardized, algorithmic approach among emergency medical services, emergency departments, and cardiac catheterization laboratory is needed to ensure optimal patient outcome during and after the COVID-19 pandemic. The focus of this case report is to highlight the challenges of PCI for ST elevation myocardial infarction in the COVID-19 era.

Aspirin in Primary Prevention of Cardiovascular Events.

Aspirin has demonstrated a clear benefit in secondary prevention of coronary syndrome, while aspirin's effect in primary prevention is unclear. This report will explore the role of aspirin as primary prevention for various vascular events. It strives to provide a clear guide for clinicians on whether or not to prescribe aspirin for their patients for primary prevention. Current guidelines and recent trials failed to show clear benefit against primary prevention, with risks outweighing benefits in moderate to high risk patients. A thoughtful discussion between patients and their doctors should be conducted before beginning aspirin use. More studies are needed to gain a better understanding of aspirin use in primary prevention.

Outcome of early revascularization surgery in patients with ST-elevation myocardial infarction.

OBJECTIVES: To compare morbidity and mortality of patients with ST-elevation myocardial infarction (MI) undergoing coronary artery bypass graft (CABG) surgery within 24 hours with those who had surgery delayed >24 hours. BACKGROUND: Patients with ST-elevation MI are currently managed by emergency percutaneous coronary intervention (PCI). If PCI is unsuccessful, or if there is severe coronary artery disease not amenable to PCI, CABG is considered. If the patient is clinically stable, surgeons wait several days before performing surgery, as very early surgery carries a prohibitive risk. METHODS: One hundred and eighty-four patients with acute ST elevation MI (STEMI) who had undergone CABG were divided into two groups based on their surgery timing (<24 hours vs. >24 hours). Mortality and complication rates were studied between the two groups by Fischer test. Time-to-event analyses were performed for five primary variables: all-cause mortality, cardiac events, congestive heart failure, stroke, and renal failure. RESULTS: At one month post-CABC, all-cause mortality was noted in 10.6% of patients who had CABG within 24 hours of STEMI diagnosis, compared with 8.9% in patients who had CABG after 24 hours (P = 0.3). Cardiac events including re-exploration, atrial fibrillation, graft occlusion, and arrhythmias requiring shock occurred in 17.1% versus 13.9% between the two groups, respectively (P = 0.68). One year post-coronary artery bypass surgery, there was no difference in individual or combined events between the two groups. CONCLUSIONS: In patients with ST-elevation myocardial infarction who required emergency coronary artery bypass surgery, there was no difference in procedure complications or mortality between early (within 24 hours) or later (more than 24 hours). That was noted at one month and one year after the index myocardial infarction.

The role of aspirin in the prevention of cardiovascular disease.

Aspirin therapy is well-accepted as an agent for the secondary prevention of cardiovascular events and current guidelines also define a role for aspirin in primary prevention. In this review, we describe the seminal trials of aspirin use in the context of current guidelines, discuss factors that may influence the effectiveness of aspirin therapy for cardiovascular disease prevention, and briefly examine patterns of use. The body of evidence supports a role for aspirin in both secondary and primary prevention of cardiovascular events in selected population groups, but practice patterns may be suboptimal. As a simple and inexpensive prophylactic measure for cardiovascular disease, aspirin use should be carefully considered in all at-risk adult patients, and further measures, including patient education, are necessary to ensure its proper use.

An Urgent Call for Studies That Address the Cardiovascular Consequences of Legalization of Marijuana.

In about a decade, half of the United States has legalized marijuana for recreational use. The drug has been associated with acute myocardial infarction, acute stroke, congestive heart failure, and various cardiac arrythmias. Data have shown that legalization of the drug led to an increase of its use as well as an increase in tetra hydro cannabinoid positive tests in patients admitted to emergency departments. In Colorado, one of the earlier states to implement legalization, there was an increase in traffic accidents, suicide rates, and even total mortality. However, there is a paucity of data on the effect of marijuana legalization on various cardiovascular events. It is prudent to have well-designed studies with enough power to provide consumers and health care providers the information they need to decide whether the risks of marijuana, especially on the cardiovascular front, are worth the "high" or potential benefits that have been described for other medical conditions.

Swallow syncope: a case report and review of the literature.

Swallow or deglutition syncope is a relatively rare syndrome. It is a vagally mediated syncope induced by swallowing. Swallow syncope may occur in all age groups and, when diagnosed, is treatable. A woman, aged 60 years, presented with an episode of a syncopal attack associated with swallowing a sandwich. She had a 6-month history of recurrent episodes of lightheadedness while eating solid foods. Telemetry monitoring demonstrated several episodes of severe bradycardia and complete atrioventricular block with up to a 7.0 second pause associated with meals. Computed tomography of the head and neck revealed no significant findings, and barium esophagram was normal. Echocardiogram was within normal limits. Her symptoms resolved after permanent pacemaker placement. Herein, we review the diagnosis, mechanism, and management of swallow syncope.

Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics.

Myocarditis is common during viral infection with cases described as early as the influenza pandemic of 1917, and the current COVID-19 pandemic is no exception. The hallmark is elevated troponin, which occurs in 36% of COVID patients, with electrocardiogram, echocardiogram, and cardiac magnetic resonance being valuable tools to assist in diagnosis. Cardiac inflammation may occur secondary to direct cardiac invasion with the virus, or to intense cytokine storm, often encountered during the course of the disease. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis. Corticosteroids may be avoided during the very early phase of viral replication, but can be of clear benefit in hospitalized, critically ill patients. Statins are beneficial to shorten the course of the disease and may decrease mortality.

Post-Acute Sequelae of SARS-COVID-2 Syndrome: Just the Beginning.

Viral diseases are some of the most common infections affecting humans. Despite the unpleasant symptoms, most people return to their normal lives without residual symptoms. Following the acute infectious phase of some viruses, however, in some individuals symptoms may linger to the extent they are unable to return to a normal lifestyle. Following coronavirus disease 2019 infection, significant numbers of patients continued to have symptoms that persisted for months after hospital discharge. Symptoms spanned many organ systems and were prominent in the pulmonary and cardiovascular systems. The exact mechanism is not clear. This group of patients represents a new challenge to our health care systems. An organized, multi-disciplinary approach and further research are warranted to be ready to deliver better care to these patients.

No-reflow phenomenon following percutaneous coronary intervention for acute myocardial infarction: incidence, outcome, and effect of pharmacologic therapy.

BACKGROUND: No-reflow (NR) phenomenon is a well-known problem, often accompanying percutaneous coronary intervention for acute ST elevation myocardial infarction (STEMI). There are little data on effects of pharmacologic therapy on the resolution, outcome, and long-term natural history of NR. OBJECTIVE: Retrospectively assess incidence, management, and prognosis of NR in a tertiary referral hospital. METHODS: Study included patients with STEMI, treated with percutaneous coronary intervention (PCI). Effect of pharmacologic therapy and long-term outcome were assessed. NR was defined by thrombolysis in myocardial infarction (TIMI) < 3 or myocardial blush grade (MBG) < 3. RESULTS: Of 347 identified subjects, NR occurred in 110 (32%) by TIMI and 198 (57%) by MBG. Higher incidence was identified in men versus women (34% vs. 25% by TIMI, P = 0.08; and 60% vs. 48% by MBG, P = 0.04). Pharmacologic therapy was equally effective in restoring normal flow, increasing TIMI score from 1.62 ± 0.07 to 2.78 ± 0.06 (P < 0.0001) and MBG score from 0.43 ± 0.08 to 2.09 ± 0.11 (P < 0.0001). Twenty-three percent who did not receive pharmacologic therapy developed clinical composite of congestive heart failure, cardiogenic shock, and/or death; only 9% of patients who received pharmacologic therapy developed this composite. Patients with severe NR despite treatment had poorer prognosis. Sixty-five percent of patients who survived and had repeat angiogram about 1.5 years later had spontaneous improvement in coronary flow by MBG. CONCLUSION: NR is common in STEMI. Treatment with nicardipine, nitroprusside, and verapamil are equally effective in improving flow. If not treated, prognosis is poor.

Influenza-related viral myocarditis.

Seasonal influenza outbreak is responsible for significant morbidity and mortality around the world. The disease can be severe, leading to rapid worsening of breathing and culminating in death. The pulmonary manifestations are prominent and may mask the involvement of other organs, such as the heart. This paper will discuss the incidence, clinical manifestations, and management of viral myocarditis in a modest attempt to heighten awareness of acute viral myocarditis for early recognition and prompt management during seasonal episodes of influenza infection.

To drink or not to drink? That is the question.

Numerous studies have used a J-shaped or U-shaped curve to describe the relationship between alcohol use and total mortality. The nadir of the curves based on recent meta-analysis suggested optimal benefit at approximately half a drink per day. Fewer than 4 drinks per day in men and fewer than 2 per day in women appeared to confer benefit. Reductions in cardiovascular death and nonfatal myocardial infarction were also associated with light to moderate alcohol intake. Although some studies suggested that wine had an advantage over other types of alcoholic beverages, other studies suggested that the type of drink was not important. Heavy drinking was associated with an increase in mortality, hypertension, alcoholic cardiomyopathy, cancer, and cerebrovascular events, including cerebrovascular hemorrhage. Paradoxically, light-to-moderate alcohol use actually reduced the development of heart failure and did not appear to exacerbate it in most patients who had underlying heart failure. Numerous mechanisms have been proposed to explain the benefit that light-to-moderate alcohol intake has on the heart, including an increase of high-density lipoprotein cholesterol, reduction in plasma viscosity and fibrinogen concentration, increase in fibrinolysis, decrease in platelet aggregation, improvement in endothelial function, reduction of inflammation, and promotion of antioxidant effects. Controversy exists on whether alcohol has a direct cardioprotective effect on ischemic myocardium. Studies from our laboratory do not support the concept that alcohol has a direct cardioprotective effect on ischemic/reperfused myocardium. Perhaps the time has come for a prospectively randomized trial to determine whether 1 drink per day (or perhaps 1 drink every other day) reduces mortality and major cardiovascular events.

Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory.

Coronary no-reflow occurs commonly during acute percutaneous coronary intervention, particularly in patients with acute myocardial infarction and those with degenerated vein grafts. It is associated with a guarded prognosis, and thus needs to be recognized and treated promptly. The pathophysiology originates during the ischemic phase and is characterized by localized and diffuse capillary swelling and arteriolar endothelial dysfunction. In addition, leukocytes become activated and are attracted to the lumen of the capillaries, exhibit diapedesis and may contribute to cellular and intracellular edema and clogging of vessels. At the moment of perfusion, the sudden rush of leukocytes and distal atheroemboli further contributes to impaired tissue perfusion. Shortening the door-to-balloon time, use of glycoprotein IIb/IIIa platelet receptor inhibitors and distal protection devices are predicted to limit the development of no-reflow during percutaneous interventions. Distal intracoronary injection of verapamil, nicardipine, adenosine, and nitroprusside may improve coronary flow in the majority of patients. Hemodynamic support of the patient may be needed in some cases until coronary flow improves.

Cocaine-induced acute myocardial infarction.

Acute myocardial infarction may occur following cocaine use. Cocaine-induced infarction is particularly common in younger patients aged 18 to 45 years old. Patients may or may not have angiographic evidence of coronary artery disease at the time of their acute event. Previous studies have shown that coronary artery spasm occurs with cocaine use, and perhaps platelet activation, both contributing to a process that may culminate in coronary artery occlusion. Primary coronary intervention should be the preferred revascularization modality by an experienced team. Thrombolytic therapy needs to be instituted if this intervention is unavailable. Beta blockers should be utilized with caution since they may increase coronary spasm or cause a paradoxical rise in blood pressure. They should be avoided in the early hours of the infarction, but be instituted prior to patient discharge. Interruption of cocaine abuse is the cornerstone of secondary prevention in cocaine-related myocardial infarction.

Management strategies for ST-elevation myocardial infarction in the emergency department.

Review of existing evidence supports that percutaneous coronary intervention (PCI) is superior to thrombolytic therapy in patients with acute myocardial infarction. If, however, a dedicated intervention team is not available onsite, transfer to another facility should be considered if reperfusion could be achieved within 90 minutes. If that goal cannot be achieved within 120 minutes, thrombolytic therapy should be administered with a planned transfer to a facility with PCI capability. In patients with cardiogenic shock or recurrence of anginal chest pain, PCI should be immediately considered. The value of administering full or modified dose thrombolytic therapy and then transferring for immediate PCI has not been demonstrated yet. Development of dedicated protocols for management of ST-elevation myocardial infarction developed by a community-based emergency medical service, emergency department, and cardiovascular service is highly recommended.

Preconditioning, postconditioning and their application to clinical cardiology.

Ischemic preconditioning is a well-established phenomenon first described in experimental preparations in which brief episodes of ischemia/reperfusion applied prior to a longer coronary artery occlusion reduce myocardial infarct size. There are ample correlates of ischemic preconditioning in the clinical realm. Preconditioning mimetic agents that stimulate the biochemical pathways of ischemic preconditioning and protect the heart without inducing ischemia have been examined in numerous experimental studies. However, despite the effectiveness of ischemic preconditioning and preconditioning mimetics for protecting ischemic myocardium, there are no preconditioning-based therapies that are routinely used in clinical medicine at the current time. Part of the problem is the need to administer therapy prior to the known ischemic event. Other issues are that percutaneous coronary intervention technology has advanced so far (with the development of stents and drug-eluting stents) that ischemic preconditioning or preconditioning mimetics have not been needed in most interventional cases. Recent clinical trials such as AMISTAD I and II (Acute Myocardial Infarction STudy of ADenosine) suggest that some preconditioning mimetics may reduce myocardial infarct size when given along with reperfusion or, as in the IONA trial, have benefit on clinical events when administered chronically in patients with known coronary artery disease. It is possible that some of the benefit described for adenosine in the AMISTAD 1 and 2 trials represents a manifestation of the recently described postconditioning phenomenon. It is probable that postconditioning--in which reperfusion is interrupted with brief coronary occlusions and reperfusion sequences--is more likely than preconditioning to be feasible as a clinical application to patients undergoing percutaneous coronary intervention for acute myocardial infarction.

The Cardiovascular Effects of Cocaine.

Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.

Management of No-Reflow Phenomenon in the Catheterization Laboratory.

At the conclusion of a primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, and after the cardiologist makes certain that there is no residual stenosis following stenting, assessment of coronary flow becomes the top priority. The presence of no-reflow is a serious prognostic sign. No-reflow can result in poor healing of the infarct and adverse left ventricular remodeling, increasing the risk for major adverse cardiac events, including congestive heart failure and death. To achieve normal flow, features associated with a high incidence of no-reflow must be anticipated, and measures must be undertaken to prevent its occurrence. In this review, the authors discuss various preventive strategies for no-reflow as well as pharmacological and nonpharmacological interventions that improve coronary blood flow, such as intracoronary adenosine and nitroprusside. Nonpharmacological therapies, such as induced hypothermia, were successful in animal studies, but their effectiveness in reducing no-reflow in humans remains to be determined.

Suspected clopidogrel resistance in a patient with acute stent thrombosis.

BACKGROUND: A 67-year-old man with supraventricular tachycardia associated with angina underwent coronary angiographic assessment. This investigation revealed mild coronary artery disease in his left main coronary artery and significant stenosis of the ramus medianus (left intermediate artery). A drug-eluting stent was deployed and treatment with clopidogrel and eptifibatide started. The patient subsequently developed chest pain accompanied by hypotension, hypoxemia and electrocardiographic changes that indicated acute myocardial infarction. Emergency angiography revealed occlusion of the ramus medianus despite clopidogrel therapy. INVESTIGATIONS: Coronary angiography, hypercoagulable work up and platelet function tests. DIAGNOSIS: Acute stent thrombosis and suspected clopidogrel resistance, culminating in ST-segment elevation myocardial infarction after percutaneous coronary intervention. MANAGEMENT: Warfarin, aspirin and clopidogrel drug therapy.