Extended dual antiplatelet therapy for Asian patients with acute coronary syndrome: expert recommendations.

BACKGROUND: Recently, new evidence from large scale trials and updated guidelines have emerged on the risks and benefits of extended dual antiplatelet therapy (DAPT) for patients with acute coronary syndrome (ACS). AIMS: To discuss, clarify and advise on the application of the evidences and guidelines on individual patient selection for extended DAPT, with regard to balancing risk factors, particularly in Asian populations. METHODS: A total of 14 local cardiologists from Hong Kong with extensive experience in cardiology and cardiac interventions convened in a series of 3 advisory board meetings from October 2016 to September 2017, which included reviews of new evidence in the literature and discussions of the latest clinical trends, using an anonymous, electronic voting system for arriving at consensuses. RESULTS: Recommendations were produced for the following nine risk factors: old age (>65), chronic kidney disease (CKD), diabetes mellitus (DM), recurrent myocardial infarction (MI), multi-vessel disease (MVD), multiple stents, bioresorbable vascular scaffold (BVS) stent, left main stenting and peripheral artery disease (PAD). Strong ischaemic risk factors include DM, recurrent MI, MVD and/or >3 stents; less-strong ischaemic factors include CKD, left main stenting, BVS stent and PAD. Old age can be an unclear risk factor due to variations in physical fitness even among patients of identical age. DISCUSSION: The strengths and limitations of the results were acknowledged. CONCLUSION: ACS patients with ischaemic risk factors could be considered for extended DAPT beyond 12 months, while balancing the risk of bleeding.

Venous access and long-term pacemaker lead failure: comparing contrast-guided axillary vein puncture with subclavian puncture and cephalic cutdown.

AIMS: Existing data on the relationship between venous access and long-term pacemaker lead failure (PLF) are scarce and inconsistent. We aim to study the hypothesis that contrast-guided axillary vein puncture (AP) is better than subclavian puncture (SP) and similar to cephalic vein cutdown (CV) in the incidence of PLF and the success rate of AP is higher than CV. METHODS AND RESULTS: The case records of 409 patients with 681 implantable pacemaker leads were reviewed. Two hundred and fifty-two, 217, and 212 leads were implanted via AP, CV, and SP, respectively. With a mean follow-up of 73.6 ± 33.1 months, 20 (2.9%) PLF occurred. Three (1.2%), 5 (2.3%), and 12 (5.6%) PLF occurred in the AP, CV, and SP groups, respectively. On multivariate Cox regression analysis, the only independent predictor for PLF was the use of SP instead of AP (AP vs. SP; hazard ratio: 0.261; 95% confidence interval: 0.071-0.954, P = 0.042). The success rate of CV (78.2%) was significantly lower than those of AP (97.6%) and SP (96.8%) (P < 0.001). CONCLUSION: Compared with SP, the use of AP but not CV independently predicted a lower risk of PLF. The success rates in achieving venous accesses were similar between AP and SP, but significantly lower for CV. Axillary vein puncture may thus be considered the venous access of choice for pacemaker lead implantation.

Valve-in-valve-in-valve: Treating endocarditis of a transcatheter heart valve.

Transcatheter heart valve endocarditis is a rare, but life threatening complication. We describe the case of a patient who was successfully treated by transcatheter aortic valve-in-valve-in-valve replacement with a favorable 1-year outcome, despite severe early complications.

Hemodynamic Effects of Noninvasive Positive-Pressure Ventilation Assessed Using Transthoracic Echocardiography.

AIMS: The aim of this study is to measure the effect of positive-pressure ventilation on heart chamber dimensions, left ventricular (LV) systolic function, LV diastolic function, right ventricular (RV) systolic function, and RV pressure using transthoracic echocardiography. SETTINGS AND DESIGN: This is a prospective study in a single secondary health-care center. MATERIALS AND METHODS: A total of 107 patients with obstructive sleep apnea on continuous positive airway pressure (CPAP) therapy were recruited as participants between April and September 2016. Transthoracic echocardiography was performed twice on each participant, before and 15 min after, they used their own CPAP machines, and the echocardiography parameters of both scans were compared. STATISTICAL ANALYSIS USED: The parametric paired t-test was used to compare heart chamber dimensions, left heart diastolic function, left heart systolic function, right heart systolic function, and right heart pressure effect, without and with CPAP. These data were further examined among several subgroups defined by CPAP when the cutoff point was set at 8 cmH2O and 10 cmH2O. The level of significance was set at 0.05. Statistical analyses were performed using IBM SPSS version 22 (IBM, Armonk, NY, USA). RESULTS: There were statistically significant reductions, after the application of CPAP, in the heart dimensions, and LV and RV systolic function. There were no significant changes in diastolic function. Concerning right heart pressure, with CPAP, there was a significant increase in the inferior vena cava (IVC) diameter and there was also a significant decrease in IVC variability from 44.56% ± 14.86% to 36.12% ± 11.42%. The maximum velocity of tricuspid regurgitation (TR) decreased significantly from 180.66 ± 6.95 cm/s to 142.30 ± 52.73 cm/s. Such changes were observed in both low and high CPAP subgroups. CONCLUSIONS: When placed on positive pressure, the clinically significant change in IVC diameter and variability and change in trans-TR velocity mean that it would be inaccurate to predict right heart chamber pressure through echocardiogram. Alternative methods for predicting right heart pressure are recommended.

Clinical outcomes in patients with stable coronary artery disease with vs. without a history of myocardial revascularization.

AIMS: The aim was to describe outcomes among patients with stable coronary artery disease (CAD) with or without a history of myocardial revascularization in a large contemporary cohort. METHODS AND RESULTS: Patients with stable CAD were selected from the Reduction of Atherothrombosis for Continued Health (REACH) registry. The cohort was divided into patients with ( n = 25 583) and without ( n = 13 133) a history of myocardial revascularization. Crude outcomes were described according to the use and type of revascularization: percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). The primary outcome was cardiovascular (CV) death. At baseline, the non-revascularized group was older and had more CV risk factors. At 36-month median follow-up, previous revascularization was associated with a lower risk of CV death [crude incidence rate (CIR): 6.82 vs. 9.08%, hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.66-0.80]; P < 0.01]. This association was seen for patients with a history of PCI (CIR 5.78 vs. 8.88%, HR 0.64 [0.58-0.71]; P ≤ 0.01), but not with CABG (HR 1.26 [1.14-1.49]; P < 0.01), and was consistent regardless of prior MI and the timing of prior revascularization. CONCLUSION: Among patients with stable CAD, a history of myocardial revascularization was associated with lower CV mortality, particularly when PCI was the mode of revascularization. Coronary artery disease patients managed non-invasively represent a high-risk group.

Measuring health related quality of life in coronary heart disease: the importance of feeling well.

Health related quality of life (HRQoL) is used increasingly as a measure of the outcome of CHD. As an improvement in survival of CHD continues, assessment of HRQoL has become an important and useful outcome measure complementing the traditional "hard outcomes" such as mortality for evaluating benefits of medical interventions. Increasing number of clinical trials is applying HRQoL as an outcome measure of CHD therapy. Assessment of HRQoL in CHD should comprise a disease-specific measure in addition to a generic measure. This review aims to provide an overview of generic, disease-specific, and utility measures used in the assessment of HRQoL in CHD.