The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting.

INTRODUCTION: Angioplasty has changed the management of acute coronary syndrome (ACS). However, in patients with previous coronary artery bypass grafting (CABG), the role of angioplasty in the management of ACS is widely debated. Lack of clear guidelines leads to subjective and often stereotypical assessments based on clinician preferences. We sought to investigate if angioplasty affected all cause mortality in ACS patients with previous CABG. METHODS: Completely anonymous information on patients with ACS with a background of previous CABG, co-morbidities and procedures attending three multi-ethnic general hospitals in the North West of England, United Kingdom in the period 2000-2012 was traced using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol using ICD-10 and OPCS-4 coding systems. Predictors of mortality and survival analyses were performed using SPSS version 20.0. RESULTS: Out of 12,227 patients with ACS, there were 1172 (19.0%) cases of ACS in patients with previous coronary artery bypass grafting. Of these 83 (7.1%) patients underwent angioplasty. Multi-nominal logistic regression, accounting for differences in age and co-morbidities, revealed that having angioplasty conferred a 7.96 times improvement in mortality (2.36-26.83 95% CI) compared to not having angioplasty in this patient group. CONCLUSIONS: We have shown that angioplasty confers significantly improved all cause mortality in the management of ACS in patients with previous CABG. The findings of this study highlight the need for clinicians to conscientiously think about the individual benefits and risks of angioplasty for every patient rather than confining to age related stereotypes.

Shellfish allergy and relation to iodinated contrast media: United Kingdom survey.

AIM: To assess current practice of United Kingdom cardiologists with respect to patients with reported shellfish/iodine allergy, and in particular the use of iodinated contrast for elective coronary angiography. Moreover we have reviewed the current evidence-base and guidelines available in this area. METHODS: A questionnaire survey was send to 500 senior United Kingdom cardiologists (almost 50% cardiologists registered with British Cardiovascular Society) using email and first 100 responses used to analyze practise. We involved cardiologists performing coronary angiograms routinely both at secondary and tertiary centres. Three specific questions relating to allergy were asked: (1) History of shellfish/iodine allergy in pre-angiography assessment; (2) Treatments offered for shellfish/iodine allergy individuals; and (3) Any specific treatment protocol for shellfish/iodine allergy cases. We aimed to establish routine practice in United Kingdom for patients undergoing elective coronary angiography. We also performed comprehensive PubMed search for the available evidence of relationship between shellfish/iodine allergy and contrast media. RESULTS: A total of 100 responses were received, representing 20% of all United Kingdom cardiologists. Ninety-three replies were received from consultant cardiologists, 4 from non-consultant grades and 3 from cardiology specialist nurses. Amongst the respondents, 66% routinely asked about a previous history of shellfish/iodine allergy. Fifty-six percent would pre-treat these patients with steroids and anti-histamines. The other 44% do nothing, or do nonspecific testing based on their personal experience as following: (1) Skin test with 1 mL of subcutaneous contrast before intravenous contrast; (2) Test dose 2 mL contrast before coronary injection; (3) Close observation for shellfish allergy patients; and (4) Minimal evidence that the steroid and anti-histamine regime is effective but it makes us feel better. CONCLUSION: There is no evidence that allergy to shellfish alters the risk of reaction to intravenous contrast more than any other allergy and asking about such allergies in pre-angiogram assessment will not provide any additional information except propagating the myth.

Giant cell myocarditis with incessant ventricular arrhythmias treated successfully with methylprednisolone and rat antithymocyte globulin.

Giant cell myocarditis is an aggressive form of this condition that is typically progressive and unresponsive to usual medical treatment. Here, we describe a 34-year-old patient presenting with incessant ventricular arrhythmias with hemodynamic compromise who required prolonged support in intensive care with an intra-aortic balloon pump (IABP). His Coronary arteries were normal and LV endomyocardial biopsy revealed myocyte necrosis with inflammatory infiltrate of lymphocytes, eosinophils, and giant cells suggestive of giant cell myocarditis. He was successfully treated with pulsed intravenous methylprednisolone and rat antithymocyte globulin (RATG). Despite a good functional cardiac recovery, some months later he developed a fluctuant neck swelling which fine needle aspiration confirmed as tuberculosis.