Short-term dual antiplatelet therapy for 1-3 months after percutaneous coronary intervention using drug eluting stents: A systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: The optimal dual antiplatelet therapy (DAPT) duration and regimen in patients undergoing percutaneous coronary intervention (PCI) using current generation drug eluting stents (DES) is still unclear. AIMS: To compare the safety and efficacy of short-term DAPT (S-DAPT) with longer duration DAPT (l-DAPT) after contemporary PCI. METHODS: We searched for studies comparing S-DAPT (≤3 months) followed by single antiplatelet therapy (SAPT) with aspirin or a P2Y12 inhibitor against L-DAPT (6-12 months) after PCI with current generation DES. Primary end-points of interest were major bleeding and stent thrombosis (ST) at 1 year. Random-effects meta-analyses were performed to calculate odds ratios with 95% CIs. RESULTS: Eleven RCTs (n = 48,946) were included in the primary analysis. Major bleeding was significantly lower with S-DAPT (n = 24,424) (odd ratio [OR 0.65; 95% confidence interval, CI 0.52-0.80]) compared with L-DAPT (n = 24,486). There were no differences in ST between the two groups [OR 1.26; 95% CI 0.97-1.63]. There were no significant differences in risks of all-cause death, cardiovascular death or myocardial infarction between S-DAPT and L-DAPT groups. In a subgroup analysis, there was borderline significantly higher ST with 1 month S-DAPT [1.39; 1.0-1.92], but not with 3 months S-DAPT [1.07; 0.70-1.64], when compared to L-DAPT. Finally, there were no significant treatment interactions observed when trials using SAPT with aspirin were compared with those using P2Y12 inhibitor monotherapy. CONCLUSION: Among patients undergoing current generation DES implantation, S-DAPT for 1-3 months reduces major bleeding without an increase in ischemic events compared with L-DAPT. Three months S-DAPT might provide a better risk-benefit profile based on current analysis. Further study is needed to define the SAPT of choice after 1-3 months DAPT.

Dual Left Main Coronary Arteries With Ischemia and Coronary Steal.

A 59-year-old man had angina and an abnormal perfusion scan. Work-up revealed 2 left main coronary arteries: the anomalous artery originated from the right coronary cusp and took an aberrant interventricular septal course; the other artery was atretic. He underwent surgical unroofing, with resolution of symptoms. (Level of Difficulty: Intermediate.).

Gigantic arteriovenous fistula between left coronary cusp and coronary sinus draining into the right atrium.

Coronary arteriovenous fistulas (CAF) are infrequent anatomic anomalies that establish a direct connection between coronary arteries and cardiac chambers. The reported incidence is extremely low and estimated at 0.002% in the general population. We report a rare case of CAF in a middle-aged man, who was asymptomatic but incidentally found to have a gigantic CAF on a low-dose Computed Tomography scan of his chest. The case was presented to cardiothoracic surgeons. Since the patient was asymptomatic, they recommended medical management and continued close surveillance. The Left Coronary Artery or its branches are extremely uncommon site for CAF. With the advances in technology, the network of veins including coronary sinus has gained further clinical relevance. While technology has helped elucidate many aspects of these rare anomalies, mysteries still remain. With continued research, we can expect more cost-effective and less invasive interventional therapies to be developed in the near future.

A Phase II study of autologous mesenchymal stromal cells and c-kit positive cardiac cells, alone or in combination, in patients with ischaemic heart failure: the CCTRN CONCERT-HF trial.

AIMS: CONCERT-HF is an NHLBI-sponsored, double-blind, placebo-controlled, Phase II trial designed to determine whether treatment with autologous bone marrow-derived mesenchymal stromal cells (MSCs) and c-kit positive cardiac cells (CPCs), given alone or in combination, is feasible, safe, and beneficial in patients with heart failure (HF) caused by ischaemic cardiomyopathy. METHODS AND RESULTS: Patients were randomized (1:1:1:1) to transendocardial injection of MSCs combined with CPCs, MSCs alone, CPCs alone, or placebo, and followed for 12 months. Seven centres enrolled 125 participants with left ventricular ejection fraction of 28.6 ± 6.1% and scar size 19.4 ± 5.8%, in New York Heart Association class II or III. The proportion of major adverse cardiac events (MACE) was significantly decreased by CPCs alone (-22% vs. placebo, P = 0.043). Quality of life (Minnesota Living with Heart Failure Questionnaire score) was significantly improved by MSCs alone (P = 0.050) and MSCs + CPCs (P = 0.023) vs. placebo. Left ventricular ejection fraction, left ventricular volumes, scar size, 6-min walking distance, and peak oxygen consumption did not differ significantly among groups. CONCLUSIONS: This is the first multicentre trial assessing CPCs and a combination of two cell types from different tissues in HF patients. The results show that treatment is safe and feasible. Even with maximal guideline-directed therapy, both CPCs and MSCs were associated with improved clinical outcomes (MACE and quality of life, respectively) in ischaemic HF without affecting left ventricular function or structure, suggesting possible systemic or paracrine cellular mechanisms. Combining MSCs with CPCs was associated with improvement in both these outcomes. These results suggest potential important beneficial effects of CPCs and MSCs and support further investigation in HF patients.

Cardiac Lymphoma Presenting with Recurrent STEMI.

The incidence of primary cardiac tumors is exceedingly rare, whereas secondary cardiac tumors are more common in the global population. Cardiac involvement is seen in approximately 18% of patients with non-Hodgkin's lymphoma at the time of autopsy. Clinical manifestations of cardiac involvement are subtle and often go unrecognized until advanced stages of the disease. We present a rare case of metastatic cardiac lymphoma that presented as an ST-segment elevation myocardial infarction complicated by left ventricular free wall rupture and cardiogenic shock due to transmural myocardial necrosis from malignant cell infiltration.

Comparison of revascularization strategies in patients with acute coronary syndrome and multivessel coronary disease: A systematic review and network meta-analysis.

BACKGROUND: Whether revascularization should be performed as multivessel intervention at the time of index procedure (MV-index), staged procedure (MV-staged), or culprit only intervention (COI) in patients with multivessel disease (MVD) presenting with acute coronary syndrome (ACS) is unclear. We performed a systematic review and network meta-analysis of randomized controlled trials to assess the optimal revascularization strategy in this patient population. METHODS: PubMed, Embase, and Cochrane Central databases were systematically searched to identify all relevant studies. The outcomes assessed were major cardiac adverse events (MACE), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and revascularization. A Bayesian random-effects network meta-analysis was used to calculate odds ratio (OR) with credible interval (CrI). RESULTS: Thirteen studies with 8,066 patients were included in the analysis. There was a decreased risk of MACE (MV-index vs. COI: OR, 0.35; 95% CrI, 0.23-0.55; MV-staged vs COI: OR, 0.52; 95% CrI, 0.31-0.81) and revascularization (MV-index vs. COI: OR, 0.27; 95% CrI, 0.15-0.49; MV-staged vs. COI: OR, 0.38; 95% CrI, 0.19-0.70) with MV-index intervention and MV-staged intervention compared with COI. However, MV-index intervention and not MV-staged intervention was associated with a decreased risk of MI (MV-index vs. COI: OR, 0.35; 95% CrI, 0.12-0.93; MV-staged vs. COI: OR, 0.65; 95% CrI, 0.24-1.59) compared with COI. CONCLUSIONS: Our analysis suggests that multivessel intervention either at index procedure or as staged intervention may be more efficacious compared to COI in patients with MVD presenting with ACS.

Allogeneic Mesenchymal Cell Therapy in Anthracycline-Induced Cardiomyopathy Heart Failure Patients: The CCTRN SENECA Trial.

BACKGROUND: Anthracycline-induced cardiomyopathy (AIC) may be irreversible with a poor prognosis, disproportionately affecting women and young adults. Administration of allogeneic bone marrow-derived mesenchymal stromal cells (allo-MSCs) is a promising approach to heart failure (HF) treatment. OBJECTIVES: SENECA (Stem Cell Injection in Cancer Survivors) was a phase 1 study of allo-MSCs in AIC. METHODS: Cancer survivors with chronic AIC (mean age 56.6 years; 68% women; NT-proBNP 1,426 pg/ml; 6 enrolled in an open-label, lead-in phase and 31 subjects randomized 1:1) received 1 × 108 allo-MSCs or vehicle transendocardially. Primary objectives were safety and feasibility. Secondary efficacy measures included cardiac function and structure measured by cardiac magnetic resonance imaging (CMR), functional capacity, quality of life (Minnesota Living with Heart Failure Questionnaire), and biomarkers. RESULTS: A total of 97% of subjects underwent successful study product injections; all allo-MSC-assigned subjects received the target dose of cells. Follow-up visits were well-attended (92%) with successful collection of endpoints in 94% at the 1-year visit. Although 58% of subjects had non-CMR compatible devices, CMR endpoints were successfully collected in 84% of subjects imaged at 1 year. No new tumors were reported. There were no significant differences between allo-MSC and vehicle groups with regard to clinical outcomes. Secondary measures included 6-min walk test (p = 0.056) and Minnesota Living with Heart Failure Questionnaire score (p = 0.048), which tended to favor the allo-MSC group. CONCLUSIONS: In this first-in-human study of cell therapy in patients with AIC, transendocardial administration of allo-MSCs appears safe and feasible, and CMR was successfully performed in the majority of the HF patients with devices. This study lays the groundwork for phase 2 trials aimed at assessing efficacy of cell therapy in patients with AIC.

Anomalous Origin of the Right Coronary Artery from the Left Main Coronary Artery in the Setting of Critical Bicuspid Aortic Valve Stenosis.

Anomalous origin of the right coronary artery (ARCA) is an extremely rare cardiac pathology. The coronary artery can potentially course between the aorta and the pulmonary artery, putting the patient at risk for sudden cardiac death. Even rarer is an ARCA that arises from the left main coronary artery (LMCA). To our knowledge, this is the first case where an ARCA arising entirely from the LMCA is associated with critical bicuspid aortic valve stenosis.

Single-Center Retrospective Study of Risk Factors and Predictive Value of Framingham Risk Score of Patients with ST Elevation Myocardial Infarction.

OBJECTIVES: The objective of this study was to identify risk factors and clinical profile of the patients presenting with ST elevation myocardial infarction (STEMI). We further evaluated the utility of the Framingham Risk Score (FRS) in the accurate identification of these patients if used before their coronary event. METHODS: We evaluated the demographic, clinical, and angiographic characteristics of patients admitted with STEMI. We also calculated cardiovascular event risk using the FRS in a subset of patients without prior known coronary artery disease and diabetes mellitus. RESULTS: A total of 44 patients, predominantly men (75%) and white (80%), with a mean age of 56 ± 10 years, were included in our analysis. Cigarette smoking was the predominant risk factor (83%) followed by hypertension (77%) and dyslipidemia (68%). The calculated FRS in a subset of patients without prior coronary artery disease or diabetes mellitus was 14.1% ± 5.8%. Based on the FRS, 8 (36%) patients had a 10-year risk >20% and 14 (63%) patients had a 10-year risk between 10% and 20%. CONCLUSIONS: In a series of consecutive patients with STEMI, we observed that high FRS was inadequate in correct identification and risk stratification of the majority of patients who had STEMI. Our study underlines the importance of being familiar with multiple risk scores and choosing the most applicable risk score based on the patient's individual characteristics. In addition, it is important to take into consideration the nontraditional risk factors or measurement of coronary artery calcium as a part of the risk assessment algorithm.

Thirty-Day Readmission Rate and Costs After Percutaneous Coronary Intervention in the United States: A National Readmission Database Analysis.

BACKGROUND: The association of short-term readmissions after percutaneous coronary intervention (PCI) on healthcare costs has not been well studied. METHODS AND RESULTS: The Healthcare Cost and Utilization Project National Readmission Database encompassing 722 US hospitals was used to identify index PCI cases in patients ≥18 years old. Hierarchical regression analyses were used to examine the factors associated with risk of 30-day readmission and higher cumulative costs. We evaluated 206 869 hospitalized patients who survived to discharge after PCI from January through November 2013 and analyzed readmissions over 30 days after discharge. A total of 24 889 patients (12%) were readmitted within 30 days, with rates ranging from 6% to 17% across hospitals. Among the readmitted patients, 13% had PCI, 2% had coronary artery bypass surgery, and 3% died during the readmission. The most common reasons for readmission included nonspecific chest pain/angina (24%) and heart failure (11%). Mean cumulative costs were higher for those with readmissions ($39 634 versus $22 058; P<0.001). The multivariable analyses showed that readmission increased the log10 cumulative costs by 45% (ß: 0.445; P<0.001). There was no significant difference in cumulative costs by the type of insurance. CONCLUSIONS: In a national sample of inpatient PCI cases, 30-day readmissions were associated with a significant increase in cumulative costs. The majority of readmissions were because of low-risk chest pain that did not require any intervention. Ongoing effort is warranted to recognize and mitigate potentially preventable post-PCI readmissions.

Increased Risk of Adverse Neurocognitive Outcomes With Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors.

BACKGROUND: There is encouraging evidence of the efficacy of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors; however, their long-term safety remains unclear. We performed a meta-analysis of studies to evaluate the long-term safety of PCSK9 inhibitors. METHODS AND RESULTS: Our search strategy yielded 11 studies (9 smaller early-phase and 2 larger outcome trials). The outcomes assessed were cumulative serious adverse events, musculoskeletal adverse events, neurocognitive adverse events, and stroke. Odds ratio (OR) was calculated using the Mantel-Haenszel method. Subgroup analysis was done to assess the difference in safety between the smaller early-phase studies and the larger outcome studies. Our meta-analysis suggested no difference in the incidence of serious adverse events (OR, 1.00; 95% confidence interval [CI], 0.88-1.15), musculoskeletal adverse events (OR, 1.01; 95% CI, 0.87-1.13), neurocognitive adverse events (OR, 1.29; 95% CI, 0.64-2.59), or stroke (OR, 1.44; 95% CI, 0.57-3.65) with the use of PCSK9 inhibitors. Subgroup analysis of the 2 large outcome studies did suggest an increased incidence of neurocognitive adverse events (OR, 2.85; 95% CI, 1.34-6.06) with the use of PCSK9 inhibitors. However, the overall incidence of neurocognitive adverse events and stroke was <1%, whereas the cumulative incidence of serious adverse events and musculoskeletal events was >10% in both the groups. CONCLUSIONS: Our analysis suggests that PCSK9 inhibitors are not associated with an increased risk of cumulative severe adverse effects, musculoskeletal effects, or stroke. There is a signal toward adverse neurocognitive effects, seen in the outcome studies with a larger sample size and longer follow-up. There should be close monitoring, for the increased risk of neurocognitive events in the ongoing outcome studies and post-marketing surveillance.

Ticagrelor-induced Sweet Syndrome: an unusual dermatologic complication after percutaneous coronary intervention.

A 73-year-old male underwent cardiac catheterization and received two Everolimus drug eluting stents for 80 % stenotic lesions in the left anterior descending and right coronary arteries. He was discharged on aspirin and ticagrelor. He started noticing progressive multiple painful hemorrhagic bullae on the palms of both hands. Biopsy showed lesions consistent with Sweet Syndrome (SS). He was started on steroids and ticagrelor was switched to Clopidogrel with improvement in rash without recurrence. SS is an inflammatory disorder characterized by the abrupt appearance of painful, edematous, and erythematous lesions on the skin. This is the first reported case of SS associated with ticagrelor.

Eptifibatide-Induced Profound Thrombocytopenia After Percutaneous Intervention for Acute Coronary Syndrome: A Challenging Clinical Scenario.

Eptifibatide is a glycoprotein (GP) IIb/IIIa inhibitor used mostly in the treatment of acute coronary syndrome (ACS). The GP IIb/IIIa antagonists occupy the fibrinogen binding site at the GP IIb/IIIa and block thrombocyte aggregation independent of the initial activation pathway. Severe thrombocytopenia has been reported with eptifibatide use. Thrombocytopenia after ACS can have multiple etiologies. Human immunodeficiency virus (HIV) infection has also been implicated in immune-mediated thrombocytopenia. In this manuscript, we report a case of acute severe thrombocytopenia secondary to eptifibatide use in a patient with a history of HIV infection who presented with an ST elevation myocardial infarction. We also review the differential diagnosis and suggest management strategies in this challenging clinical scenario.

Acute left ventricle failure on induction of anesthesia: a case report of reverse stress cardiomyopathy-presentation, diagnosis and treatment.

Reverse takotsubo cardiomyopathy (TCM) is a less common variant of classic TCM that presents within a different patient profile and with its own hemodynamic considerations. A 46-year-old woman was admitted to our hospital for laryngoscopy and possible balloon dilatation for tracheal stenosis under general anesthesia. One year prior to this admission, the patient was admitted after a motor vehicle accident with subdural hematoma, subarachnoid hemorrhage, and fracture of the eighth thoracic vertebra. She underwent uneventful anesthesia for thoracic spine surgery and tracheostomy to help her wean from the ventilator during that admission. Since her previous admission, she developed posttraumatic anxiety and depression (a neuropsychiatric disorder triggered by subdural hematoma and subarachnoid hemorrhage) and was treated with antianxiety and antidepressant medication. At this admission, the patient developed acute left ventricle failure on induction of anesthesia secondary to reverse TCM. We report a case of reverse TCM, where posttraumatic emotional stress of a neuropsychiatric disorder combined with physical stress from anesthesia and laryngoscopy triggered TCM in a patient with previous uneventful anesthesia 1 year earlier.

Fluoroscopy-guided thrombolysis of mechanical mitral valve thrombosis in a young female with antiphospholipid antibody syndrome.

Prosthetic valve thrombosis (PVT) is a rare but potentially fatal complication of mechanical valve prosthesis. The differential diagnoses for prosthetic valve obstruction includes pannus formation, prosthetic valve dehiscence, prosthetic valve endocarditis, chordae entrapment, patient-prosthesis mismatch and primary device failure. Establishing a diagnosis requires an understanding of prosthetic valve haemodynamics and careful correlation of clinical and imaging findings. Definitive therapy must be individualised based on various patient-specific factors. We present a case of mechanical mitral PVT in a young woman with antiphospholipid antibody syndrome, and outline the diagnostic and therapeutic approach utilised for successful treatment. The success and complication rates of various therapeutic strategies are also discussed, and highlight the need for individualised decision-making rather than a one-size-fits-all approach to PVT.