RESUMEN
Stimulant medications like amphetamines have been associated with various cardiovascular complications like coronary artery spasm, coronary dissections and thrombus formation, the pathophysiology of which is theorized to be the endothelial damage induced by the medication and the inflammatory cascade that follows. We report a case of 52-year-old male on lisdexamfetamine, a newer stimulant agent used for attention deficit hyperactivity disorder (ADHD) who presented with sudden chest pain and ECG changes concerning for myocardial infarction and mildly elevated troponins. However, coronary angiogram showed no obstructive coronary artery disease and there was spontaneous resolution of his symptoms and ECG changes.
Asunto(s)
Enfermedad de la Arteria Coronaria , Infarto del Miocardio , Angiografía Coronaria , Vasos Coronarios/diagnóstico por imagen , Humanos , Dimesilato de Lisdexanfetamina/efectos adversos , MINOCA , Masculino , Persona de Mediana Edad , Infarto del Miocardio/inducido químicamente , Infarto del Miocardio/diagnóstico , Factores de RiesgoRESUMEN
Contemporary medicine saw rapid development of artificial valves, as well as evolution of surgical techniques allowing their implantation in a growing number of patients. Primary care and cardiology offices are providing ongoing care for an increasing number of patients post valve surgery. One of the most crucial aspects of this ongoing care is prevention of prosthetic valve thrombosis (PVT). Our case report illustrates the importance of maintaining effective anticoagulation at all times by presenting a case of massive prosthetic valve thrombosis of a mechanical mitral valve.
Asunto(s)
Anticoagulantes , Enfermedades de las Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anticoagulantes/uso terapéutico , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Válvula Mitral , Trombosis/prevención & controlRESUMEN
OBJECTIVES: To analyze clinical factors associated with operator's preference in selection of femoral versus radial access for angiography and percutaneous intervention (PCI) procedures. BACKGROUND: There has been an increase in radial access in cardiac catheterization and PCI in the last few decades. METHODS: Data from 11 226 consecutive cardiac catheterization procedures were collected from Sanford University Medical Center (University of South Dakota, Sanford School of Medicine) from 2011 to 2015. RESULTS: In the overall cases, clinical factors that favored upfront femoral access include patients presenting as ST-elevation myocardial infarction (STEMI) or emergent, coronary artery bypass graft, body mass index (BMI) <30 kg/m2 and age ≥70 years, whereas morbidly obese patients (BMI ≥35) and age <70 favored upfront radial access. Radial access in the overall group had lower fluoroscopy time (6.5 vs 8.4 min, P < 0.0001) and lower contrast use (68.8 vs 80.6 cc, P < 0.0001). In the PCI group, efficacy of upfront radial access is less evident with radial fluoroscopy time (10.1 vs 11.0 min, P < 0.0028) and contrast use being higher in radial group (113.8 vs 108.2 cc, P < 0.037). Interventional cardiologists were more efficient in diagnostic cases than non-interventional cardiologists. CONCLUSION: STEMI or emergent cases and elderly patients favor upfront femoral access. As BMI increases and age decreases, radial access is progressively favored. In diagnostic cases, radial access appears to be superior to femoral access in efficacy, but the distinction is less obvious in PCI and STEMI or emergent cases.
Asunto(s)
Cateterismo Periférico , Angiografía Coronaria , Arteria Femoral/cirugía , Arteria Radial/cirugía , Factores de Edad , Anciano , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Toma de Decisiones Clínicas , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/métodos , Puente de Arteria Coronaria/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/epidemiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Medición de Riesgo , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Paradoxical embolism is a known complication with intra-cardiac shunts. It should be considered in the differential as the pathophysiologic mechanism of simultaneous thromboembolism in the venous and systemic vasculature. We present a case of simultaneous deep venous thrombosis, pulmonary embolism and myocardial infarction in the presence of a confirmed patent foramen ovale on echocardiography. Thrombolytic therapy was administered. Subsequent concerns of intracranial hemorrhage on imaging of the brain complicated the management and added to the challenge of co-managing the clot burden in our patient. This rare presentation highlights the importance of multisystem evaluation in making the best medical decision for the patient.
Asunto(s)
Infarto Cerebral/complicaciones , Foramen Oval Permeable/complicaciones , Infarto del Miocardio/complicaciones , Embolia Pulmonar/complicaciones , Trombosis de la Vena/complicaciones , HumanosRESUMEN
Aspirin, the first antiplatelet agent, has been around since the 19th century, and is one of the most established drugs in history. With the improvement of coronary interventions in the past few decades, there has been more reliance on oral antiplatelet agents to reduce complications of in-stent restenosis/thrombosis. Clopidogrel was initially introduced in 1997, and within the past seven years, two additional oral antiplatelet agents have been approved by the U.S. Food and Drug Administration. With more potent antiplatelet agents comes increased risks of adverse effects. Physicians of all fields should be aware of the common antiplatelet agents used today, and the basic landmark trials that allowed them to be on the market today. The focus of this review article is to evaluate each oral antiplatelet drug, its brief history, relevant trials, indications and management of complications through evidence based guidelines.
Asunto(s)
Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/prevención & control , Hemorragia Gastrointestinal/inducido químicamente , Inhibidores de Agregación Plaquetaria/efectos adversos , Trombosis/prevención & control , Adenosina/efectos adversos , Adenosina/análogos & derivados , Adenosina/uso terapéutico , Administración Oral , Aspirina/efectos adversos , Aspirina/uso terapéutico , Clopidogrel , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel/efectos adversos , Clorhidrato de Prasugrel/uso terapéutico , Factores de Riesgo , Ticagrelor , Ticlopidina/efectos adversos , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéuticoRESUMEN
Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome (ACS) that tends to affect young females. Diagnosis is confirmed by a dissection flap that is seen on coronary angiogram in the absence of underlying coronary atherosclerosis. New techniques in intra-coronary imaging such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are useful in diagnosing SCAD. These techniques are helpful because SCAD is often associated with intra-mural hematoma within the vessel wall that would not be visualized on coronary angiography. Given the lack of randomized trials, most data on treatment of this relatively uncommon condition is controversial and based on expert opinion. Postpartum SCAD comprises a small subgroup of all patients presenting with SCAD.
Asunto(s)
Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/etiología , Anomalías de los Vasos Coronarios/complicaciones , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Periodo Posparto , Enfermedades Vasculares/congénito , Síndrome Coronario Agudo/cirugía , Adulto , Angiografía Coronaria , Anomalías de los Vasos Coronarios/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Stents , Enfermedades Vasculares/complicaciones , Enfermedades Vasculares/diagnóstico por imagen , Enfermedades Vasculares/cirugíaRESUMEN
Coronary artery stent fracture is a recognized complication of drug eluting stents. It has been reported more commonly with the use of Cypher stent. Currently, there are no specific recommendations regarding the management of this entity. Routine screening for stent fractures should be avoided as not all stent fractures lead to clinically significant outcomes.
Asunto(s)
Aneurisma Coronario/diagnóstico por imagen , Reestenosis Coronaria/diagnóstico por imagen , Stents Liberadores de Fármacos , Oclusión de Injerto Vascular/diagnóstico por imagen , Falla de Prótesis , Angiografía Coronaria , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Although a reduction in atherosclerotic cardiovascular disease (ASCVD) events remains the ultimate goal in cholesterol management, there has been a change in recommended cholesterol management in patients with increased risk. The objective in cholesterol management is no longer reducing low-density lipoprotein (LDL) to a particular target value, but ensuring that patients with the highest ASCVD risk are treated with the most potent statin therapy. The previous practice of statin therapy cessation and routine monitoring for adverse events has also been scrutinized by the recent American Heart Association (AHA)/American College of Cardiology (ACC) guidelines. Identifying patients who are at risk now requires the utilization of a novel tool called the ASCVD pooled cohort calculator. The following article will guide the clinician on implementing the current AHA/ACC guidelines into clinical practice.
Asunto(s)
Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Hipercolesterolemia/prevención & control , Guías de Práctica Clínica como Asunto , Humanos , Hipertensión/prevención & control , Estilo de Vida , Obesidad/prevención & control , Prevención Primaria , Medición de Riesgo , Estados UnidosRESUMEN
The Joint National Committee (JNC 8) hypertension guidelines have modified the blood pressure goals across the spectrum of disease processes and patient characteristics. This article will elucidate these changes and help clinicians improve the clinical care of patients with hypertension. Patients are now conceptually categorized into two different patient populations: those who are at a low- or high-risk of developing atherosclerotic cardiovascular disease (ASCVD) or chronic kidney disease (CKD). A low-risk population comprises patients aged 60 or older who do not have disease processes that enhance ASCVD or CKD disease development. High-risk patients are those with CKD and/or diabetes, and patients less than 60 years of age who remain at risk of future development. The current recommendation for blood-pressure goals in the low- and high-risk population is 150/90 mmHg and 140/90 mmHg, respectively. In all patients considered for antihypertensive therapy, the first line antihypertensive pharmacotherapy should include either a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or an angiotensin receptor blocker (ARB). Beta blockers no longer have a role as standalone therapy. Thiazide- type diuretics and CCB continue to demonstrate benefit in the African American population and should continue to be considered as first line agents. CKD patients with concomitant hypertension should be treated with an ACE inhibitor or ARB.
Asunto(s)
Hipertensión/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Factores de Edad , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Diuréticos/uso terapéutico , Humanos , Estados UnidosRESUMEN
Coronary artery disease (CAD) involving the left main (LM) artery has traditionally been considered an indication for coronary artery bypass surgery (CABG). With recent advances in the field of percutaneous coronary interventions (PCI), angioplasty and stenting of the unprotected' LM has been performed in patients at high surgical risk. This is a challenging intervention as a large area of myocardium is at risk during the procedure. Features that make it especially high risk are distal stenosis of this vessel and presence of coronary disease in other territories. Left ventricular assist devices need to be considered in these situations so as to minimize the risk involved. We present a case of a 90-year-old female with myocardial infarction who underwent complex angioplasty involving the distal LM and proximal left anterior descending (LAD) coronary artery, without left ventricular assist device or balloon pump support.
Asunto(s)
Vasos Coronarios/cirugía , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea/métodos , Anciano de 80 o más Años , Femenino , Humanos , Infarto del Miocardio/fisiopatologíaRESUMEN
A nulligravid woman in her mid-20s with colchicine-intolerant, steroid-dependent recurrent idiopathic pericarditis was in remission for 2 years on anakinra monotherapy when she had an unplanned pregnancy. Due to very limited and conflicting data, European Alliance of Associations for Rheumatology and American College of Rheumatology guidelines are equivocal on the use of anakinra in pregnancy, emphasising an individualised approach. Anakinra was discontinued but a month later, in the second month of gestation, the patient had an acute pericarditis flare. A multidisciplinary, patient-centred discussion about the competing risks of infection, obstetric complications and fetal malformations with anakinra versus suboptimally managed recurrent acute pericarditis guided the patient to choosing improved symptom control. Chest pain resolved and CRP normalised after daily anakinra injections were resumed. In the second trimester, the patient had mild COVID-19 infection and streptococcal pharyngitis on anakinra. At 34 weeks gestation, the patient went into preterm labour and had a spontaneous vaginal delivery of a healthy neonate.
Asunto(s)
COVID-19 , Pericarditis , Femenino , Recién Nacido , Embarazo , Humanos , Proteína Antagonista del Receptor de Interleucina 1/efectos adversos , Corticoesteroides , Enfermedad Crónica , Colchicina/efectos adversos , Pericarditis/tratamiento farmacológico , RecurrenciaAsunto(s)
Anticoagulantes/administración & dosificación , Warfarina/administración & dosificación , Administración Oral , Anticoagulantes/efectos adversos , Dabigatrán/administración & dosificación , Dabigatrán/efectos adversos , Dieta , Humanos , Pirazoles/administración & dosificación , Pirazoles/efectos adversos , Piridinas/administración & dosificación , Piridinas/efectos adversos , Piridonas/administración & dosificación , Piridonas/efectos adversos , Rivaroxabán/administración & dosificación , Rivaroxabán/efectos adversos , Tiazoles/administración & dosificación , Tiazoles/efectos adversos , Warfarina/efectos adversosRESUMEN
OBJECTIVE: To study the use of CYP2C19 genotyping to guide P2Y12 inhibitor selection to maximize efficacy, and attenuate risk in appropriate patients who underwent PCI for CAD. METHODS: We performed a retrospective analysis of 868 patients with CAD who received CYP2C19 genotyping after PCI and changed P2Y12 inhibitor based on the results. Patients were divided into two groups based on clopidogrel metabolizer status. Group I: Intermediate (IM) and poor metabolizers (PM). Group II: Ultra-rapid (UM), rapid (RM) and normal metabolizers (NM). Each group was then categorized to one of two treatment arms guided by CYP2C19 genotype. Category 1: IM/PM started on clopidogrel, switched to ticagrelor or prasugrel; 2:IM/PM started on ticagrelor/prasugrel, continued these medications; 3: UM/RM/NM started on ticagrelor/prasugrel, switched to clopidogrel; 4: UM/RM/NM started on clopidogrel, continued clopidogrel. Death due to cardiac causes, bleeding events, non-fatal MI, target vessel revascularization (TVR), and MACE in all four categories were considered at 1, 6 and 12 months. RESULTS: We did not observe significant difference between phenotypes for MACE at 1 (p = 0.274), 6 (p = 0.387), and 12 months (p = 0.083). Death due to cardiac causes, MI, and bleeding events were not significant at 1, 6, and 12 months. There was no significant difference in TVR at 6 (p = 0.491), and 12 months (p = 0.423) except at 1 month (p = 0.012). CONCLUSION: CYP2C19 genotype-based intervention can be implemented effectively and reliably to guide selection of P2Y12 inhibitor to optimize patient quality and safety when appropriate in post PCI patients.
Asunto(s)
Intervención Coronaria Percutánea , Síndrome Coronario Agudo , Citocromo P-450 CYP2C19/genética , Genotipo , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y , Estudios RetrospectivosRESUMEN
Robotic-assisted percutaneous coronary intervention can reduce the exposure of interventional cardiologists to radiation and minimize the risk of occupational orthopedic injuries from wearing heavy protective aprons. The PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) study showed the efficacy and safety of robotic-assisted procedures for relatively low-risk lesions in single coronary arteries. Several reports have described robotic-assisted treatment of complex high-risk lesions, mostly through the transfemoral approach. We report 4 cases of patients in whom we used the transradial approach to treat complex lesions in the left anterior descending coronary artery with bifurcation balloon angioplasty reconstruction (2 cases), in the ostium of the first diagonal branch, and in the right coronary artery.
Asunto(s)
Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Intervención Coronaria Percutánea/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Anciano de 80 o más Años , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana EdadAsunto(s)
Enfermedades Cardiovasculares/prevención & control , Colesterol/sangre , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Hipercolesterolemia/tratamiento farmacológico , Factores de Edad , Presión Sanguínea , Complicaciones de la Diabetes , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Hipercolesterolemia/epidemiología , Guías de Práctica Clínica como Asunto , Grupos Raciales , Factores de Riesgo , Factores Sexuales , Fumar , Sociedades MédicasRESUMEN
The prevalence of chronic total occlusion (CTO) lesions in coronary arteries is notably high in patients with significant coronary artery disease. However, only a relatively small fraction of observed CTOs classically go for revascularization. Recent advances in techniques and equipment has greatly improved the success rates of CTO revascularization while reducing complications. There has also been an increasing body of evidence regarding clinical benefit of CTO revascularization. However, until recently majority of the evidence was observational and based on data from large multicenter registries. Recent randomized studies have reported on clinical benefits of CTO revascularization particularly with relief of angina. However, there is heterogeneity of results among different studies and the magnitude of benefit is not consistently seen in all studies. This article reviews the existing literature on the current evidence regarding clinical benefits and other rationale for CTO revascularization.
Asunto(s)
Oclusión Coronaria/cirugía , Vasos Coronarios/cirugía , Intervención Coronaria Percutánea/métodos , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , HumanosRESUMEN
The entrapment of coronary intervention devices within the coronary vasculature is a rare but potentially devastating procedural complication. We report a case of an entrapped balloon and broken shaft that had to be retrieved by an open surgical approach. When device extraction is indicated and the use of snaring equipment is unsuccessful or inappropriate, a number of alternative percutaneous maneuvers can be attempted. These include (1) simple advancement and withdrawal of a trapped balloon, (2) use of a "buddy" wire to straighten the vessel and free the trapped device, (3) inflation of a buddy balloon adjacent to a trapped primary balloon to free the device, (4) partial inflation of a buddy balloon distal to a trapped device followed by gentle withdrawal, (5) use of an in-guide secondary balloon to trap the lost device, (6) advancement and twisting of guidewires to entwine the lost device, (7) saline dilution of trapped balloons, and (8) anchoring balloon and reverse-wire puncture of an undeflated and entrapped primary balloon. Careful consideration of various device retrieval strategies is indicated before resorting to open surgical retrieval in the rare instance of intracoronary device entrapment.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/instrumentación , Catéteres Cardíacos , Enfermedad de la Arteria Coronaria/cirugía , Reestenosis Coronaria/cirugía , Remoción de Dispositivos , Cuerpos Extraños/cirugía , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Stents Liberadores de Fármacos , Urgencias Médicas , Falla de Equipo , Cuerpos Extraños/diagnóstico por imagen , Humanos , Masculino , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: We aimed to assess the decrease in contrast media volume (CMV) with ultra-low contrast delivery technique (ULCD) developed at our institution versus the usual automated contrast injector system (ACIS) contrast delivery in coronary procedures. METHODS: We analyzed the amount of contrast given in the consecutive 204 patients of the operators who use ULCD technique versus consecutive 200 patients of the other operators who use ACIS without ULCD technique for coronary angiograms and/or percutaneous coronary interventions (PCIs) from May 2017 to July 2018 at our center. We calculated the mean CMV between these groups. RESULTS: We observed a significant reduction in mean CMV with ULCD technique versus standard ACIS, respectively: angiogram 24.8 ± 15.8 mL (n = 194) vs 42.3 ± 25.1 mL (n = 200) (p < 0.0001); PCI 23.5 ± 19.7 mL (n = 52) vs 48.2 ± 30.8 mL (n = 16) (p < 0.0070); angiogram with ad hoc PCI 53.4 ± 32.1 mL (n = 23) vs 89.7 ± 35.6 mL (n = 16) (p < 0.0024); and overall angiogram and PCI 27.4 ± 20.5 mL (n = 204) vs 44.9 ± 28.0 mL (n = 181) (p < 0.0001). CONCLUSION: Our study showed a highly significant reduction in CMV using ULCD technique compared to standard ACIS contrast delivery in coronary invasive procedures. Even in the standard ACIS arm, CMV was significantly lower than values reported in literature, possibly due to operators' bias toward contrast preservation.
Asunto(s)
Medios de Contraste/administración & dosificación , Angiografía Coronaria , Intervención Coronaria Percutánea , Ácidos Triyodobenzoicos/administración & dosificación , Anciano , Algoritmos , Femenino , Humanos , Inyecciones , Masculino , Estudios Prospectivos , South DakotaRESUMEN
Alport syndrome (AS) is a genetic disorder due to inheritance of genetic mutations which lead to production of abnormal type IV collagen. AS has been associated with renal, auditory, and ocular diseases due to the presence of abnormal alpha chains of type IV collagen in the glomerulus, cochlea, cornea, lens, and retina. The resulting disorder includes hereditary nephritis, corneal opacities, anterior lenticonus, fleck retinopathy, temporal retinal thinning, and sensorineural deafness. Aortic and aortic valve pathologies have been described as extrarenal manifestations of AS in multiple case reports. One case report described intramural hematoma of the coronary artery. We report the first case of true spontaneous coronary artery dissection (SCAD) with an intimal flap as a very rare manifestation of AS. The patient is a 36-year-old female with history of AS with chronic kidney disease, hypertension, and obesity who presented to the emergency room with acute onset of substernal chest pain radiating to her neck and arms. Troponin was elevated, and ECG showed transient 1 mm ST-segment elevation in the inferior leads. Subsequent coronary angiography revealed localized dissection of the left circumflex artery. Percutaneous coronary angioplasty was performed and her symptoms improved. This case illustrates that SCAD may be a manifestation of AS patients with chest pain.