RESUMO
The EVOLVE Short DAPT study demonstrated the safety of truncated dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) treated with SYNERGY stent(s) (Boston Scientific Company, Marlborough, Massachusetts). In this population, bleeding and ischemic risk prediction may further inform DAPT decisions. This post hoc analysis of the EVOLVE Short DAPT study identified predictors of ischemic and bleeding events up to 15 months using Cox proportional hazard models. The predicted probabilities of bleeding were calculated using the Breslow method. Of 2,009 enrolled patients, 96.9% of the patients met at least 1 HBR criteria. At 15 months, the cumulative incidences of bleeding and ischemic events were 6.3% and 6.0%, respectively. The risk of bleeding was increased in patients who received oral anticoagulants (hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.50 to 3.36, p <0.001) or had peripheral vascular disease (HR 1.61, 95% CI 1.01 to 2.56, p = 0.045). The risk of ischemic events was increased in patients with diabetes (HR 1.86, 95% CI 1.24 to 2.78, p <0.01) or congestive heart failure (HR 2.06, 95% CI 1.39 to 3.04, p <0.001). Renal insufficiency/failure was associated with both endpoints. There was a strong positive correlation between the predicted probability of ischemic and bleeding events (R = 0.77, p <0.001). In 617 patients with a predicted bleeding risk <4%, ischemic events predominated, and the ischemic and bleeding rates were higher in patients with a predicted bleeding risk ≥4%. Within an HBR cohort, specific characteristics identify patients at a higher risk for ischemic and separately, bleeding events. Increased bleeding risk is tied to increased ischemic risk. In conclusion, standardized risk models are needed to inform DAPT decisions in patients with a higher risk. Clinical Trial Registration: NCT02605447.
Assuntos
Terapia Antiplaquetária Dupla , Hemorragia , Humanos , Quimioterapia Combinada , Terapia Antiplaquetária Dupla/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Incidência , Inibidores da Agregação Plaquetária/uso terapêutico , Stents , Resultado do TratamentoRESUMO
We present a case of a 30-year-old female with no pertinent medical history who presented with 4 days of chest pressure, dyspnea and fever. She had hemodynamic compromise and had elevated cardiac and inflammatory markers consistent with cardiogenic shock. ECG demonstrated anterior ST-segment elevations with reciprocal changes. Coronary angiography revealed normal coronaries and echocardiogram showed severe biventricular dysfunction. Endomyocardial biopsy showed signs of lymphocytic myocarditis and viral testing was positive for Coxsackie A. She was initially supported with an intra-aortic balloon pump and later escalated to venoarterial extracorporeal membrane oxygenation due to electromechanical compromise. With supportive care, she was weaned off venoarterial extracorporeal membrane oxygenation and made a full myocardial recovery on follow up echocardiogram and cardiac MRI.
Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Miocardite , Feminino , Humanos , Adulto , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Balão Intra-Aórtico , Miocardite/diagnóstico , Miocardite/etiologia , Miocardite/terapiaRESUMO
[Figure: see text].
Assuntos
Stents Farmacológicos , Implantes Absorvíveis , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/terapia , Quimioterapia Combinada , Everolimo/efeitos adversos , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Polímeros , Resultado do TratamentoAssuntos
Imagem de Perfusão do Miocárdio/métodos , Miocardite/diagnóstico por imagem , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Artefatos , Ecocardiografia/métodos , Feminino , Humanos , Incidência , Imageamento por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Movimento (Física) , Perfusão , Tecnécio Tc 99m SestamibiRESUMO
A 75-year-old man with a history of mechanical aortic valve replacement with aortic conduit for severe aortic insufficiency underwent routine screening computed tomography evaluation revealing right coronary anastomosis endoleak and proximal aortic root pseudoaneurysm.
Assuntos
Falso Aneurisma/complicações , Aneurisma da Aorta Torácica/complicações , Implante de Prótese Vascular/métodos , Oclusão Coronária/etiologia , Idoso , Falso Aneurisma/diagnóstico , Falso Aneurisma/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/cirurgia , Angiografia Coronária , Oclusão Coronária/diagnóstico , Oclusão Coronária/cirurgia , Ecocardiografia , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
A 57-year-old male former smoker presented to the Emergency Department (ED) with blurry vision, headache, and generalized weakness. He was hypoxic on room air and ECG showed sinus tachycardia. A CT pulmonary angiogram was ordered in the ED and revealed no pulmonary embolism but incidentally noted a likely significant stenosis in the proximal LAD. Subsequent cardiac catheterization revealed a 90% stenotic lesion with percutaneous coronary intervention leading to symptom resolution. Unlike coronary CTA, CTPA is performed with non-ECG gated helical scanning and generates motion artifacts associated with myocardial contraction. However, the timing of vascular contrast opacification during CTPA often allows for at least partial evaluation of the coronary arteries, especially ostial and proximal segments. Physicians ordering and evaluating noncardiac-focused CT chest studies, particularly in the ED, should remain cognizant of the radiographic appearance of underlying CAD, particularly life-threatening incidental coronary pathologies to allow for timely management and intervention.
Assuntos
Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Filtered back-projection (FBP) has been a standard in SPECT imaging. Newer iterative reconstruction algorithms have been shown to improve image quality and shorten acquisition time by taking into account statistical nature of raw data and using resolution recovery (RR). Wide-beam reconstruction (WBR) is an iterative algorithm with RR and adaptive noise control. We prospectively investigated outcome of WBR half-time SPECT on diagnostic certainty, accuracy and normalcy by quantitative perfusion analysis in comparison to full-time FBP images. METHODS: 434 patients underwent rest (201)Tl/stress (99m)Tc-sestamibi full-time (20 s/stop, FBP) followed by a half-time (10 s/stop, WBR) SPECT. 34 patients underwent an angiogram within 90 days of SPECT. Diagnostic certainty was based on summed stress scores (SSS, 5-point/17 segments): normal if SSS ≤ 1, equivocal if SSS = 2-3, and abnormal if SSS ≥ 4. Perfusion defects were normalized to a percent of total myocardium, and expressed as %LV = defect SSS/maximal SSS × 100% with maximal SSS of 28 for left anterior descending (LAD), and of 20 for right coronary (RCA) and left circumflex (LCX). Change in %LV (Δ%LV = %LV FBP - %LV WBR) was evaluated for diagnostically discordant versus concordant scans. RESULTS: SSS and %LV demonstrated very good correlation. There were significantly fewer equivocal scans with WBR (38 vs 151 FBP, P < .0001). Most discordant scans were equivocal FBP SPECT becoming normal with WBR (123/151). Δ%LV(LAD) for discordant studies was greater for women (5.4% ± 4.2%, P < .001), while Δ%LV(RCA,LCX) (4.4% ± 5.1%, P < .001; 1.2% ± 5.0%, P = .04) were greater for men. Normalcy rate was 91.4% for FBP and WBR with more definitely normal WBR studies (84.5% vs 43.9% for FBP, P < .0001). There were no differences in sensitivity (FBP 84.2%, WBR 81.6%), specificity (FBP 54.6%, WBR 63.6%), and accuracy (FBP, WBR 77.6%). CONCLUSION: Quantitative perfusion analysis suggests that adaptive noise control with WBR improves uniformity of myocardium comparing to FBP techniques, and results in improved diagnostic certainty while preserving normalcy and accuracy.
Assuntos
Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Aumento da Imagem/métodos , Interpretação de Imagem Assistida por Computador/métodos , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/etiologia , Algoritmos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão do Miocárdio/métodos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
Biventricular pacing for the treatment of congestive heart failure is now one of the forefront therapies for symptomatic heart failure patients who are receiving maximal medical therapy. Recent advances in lead technology and delivery systems have improved the success rates of left ventricular (LV) lead implantation. A major difficulty in LV lead implantation, however, occurs in patients with coronary vein stenoses, insufficient coronary vein caliber, or significant variations in coronary venous anatomy, in terms of left ventricular lead implantation. We sought to examine whether cardiac vein angioplasty and/or stenting would allow for the proper placement of the LV lead in these patients.
Assuntos
Angioplastia Coronária com Balão/métodos , Estimulação Cardíaca Artificial/métodos , Desfibriladores Implantáveis , Insuficiência Cardíaca/terapia , Stents , Taquicardia Ventricular/terapia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/métodos , Terapia Combinada , Ecocardiografia Transesofagiana , Eletrocardiografia , Seguimentos , Insuficiência Cardíaca/diagnóstico , Ventrículos do Coração , Humanos , Masculino , Medição de Risco , Índice de Gravidade de Doença , Taquicardia Ventricular/diagnóstico , Resultado do TratamentoRESUMO
Primary tumors of the heart are rare with an incidence of 0.0017% to 0.19% in unselected patients at autopsy. Of those tumors, cardiac myxomas are the most commonly seen and account for about 50% of primary cardiac tumors. About 75% to 85% of myxomas originate in the left atrium, 15% to 20% in the right atrium, and only rare cases have been reported of myxomas originating in the left and right ventricles (5%). We present 3 cases in which right-sided myxomas were diagnosed echocardiographically and review the literature on primary cardiac myxomas.