Microvascular Coronary Artery Embolism Presenting as an OHCA STEMI Call Detected by CMRI.

We describe a case of coronary artery embolism leading to an out-of-hospital cardiac arrest (OHCA) in which the diagnosis was achieved with utilisation of cardiac magnetic resonance imaging. The patient was otherwise well prior to this episode. Emergency diagnostic coronary angiography revealed patent arteries with TIMI 3 flow. Subsequent cardiac magnetic resonance imaging demonstrated myocardial infarction and focal microvascular obstruction in the infarcted territory. This report describes an uncommon case presentation, highlights areas for improvement in diagnostic criteria, and briefly discusses the currently available data regarding coronary artery embolism. LEARNING POINTS: Coronary artery embolism is uncommon but it is important to accurately diagnose it given the associated poor prognosis.Currently proposed scoring systems for the diagnosis of coronary artery embolism do not include the use of cardiac magnetic resonance imaging to identify intra-coronary emboli.Consideration should be given to including cardiac magnetic resonance imaging for the detection of intra-coronary emboli as an alternative to angiography in scoring criteria used to diagnose coronary artery embolism.

Outcomes of nurse-led clinic for patients treated with percutaneous coronary intervention: A retrospective analysis.

BACKGROUND: With an increasing prevalence of coronary heart disease, secondary prevention forms a major cornerstone of management. A dedicated nurse-led clinic for patients post percutaneous coronary intervention (PCI) offers a great opportunity to address risk factors in order to reduce cardiovascular events. PURPOSE: To determine the impact of a nurse-led clinic follow up of patients post PCI in relation to the 30 day mortality rate and re-admission, and patient satisfaction. Risk factor assessment, compliance with dual antiplatelet therapy (DAPT), and interventions at the clinic visit were also assessed. METHODS: A retrospective review of parameters recorded at clinic appointments from January 2015-December 2017. The data of patients were examined for baseline characteristics, risk factor assessment, and interventions at the clinic visit. Thirty day mortality and re-admission rates and patient satisfaction were major outcomes. RESULTS: 1325 individual patient records were retrospectively reviewed in our clinic. Mean age was 64 and 78% were males. The indications for PCI were STEMI (22.7%), NSTEMI (21.9%), and unstable and stable angina (43.1%). 5 patients (0.4%) died and 132 patients (10%) were re-admitted within 30 days after the follow-up visit. However, only 24 (1.8%) of the re-admissions were due to cardiac reasons. At the clinic appointment, 852 (64.3%) patients had non-pharmacological intervention and 473 (35.7%) patients had a pharmacological intervention. 712 (53.7%) patients had LDL-C above target and their statin therapy was amended accordingly. CONCLUSION: Nurse-led PCI clinics provide satisfactory assessment and management of risk factors achieving high patient satisfaction rates without increased risk of poor outcomes.

Streptococcus bovis Endocarditis after Colonic Polypectomy.

We describe a case of Streptococcus lutetiensis infective endocarditis occurring in a patient following colonic polypectomy. The patient had multiple risk factors for infective endocarditis including pre-existing mitral valve prolapse and regurgitation. Transoesophageal echocardiography revealed a friable mass on the posterior mitral valve leaflet, confirming the diagnosis. The patient was treated with intravenous antibiotics, successfully underwent mitral valve surgery and was discharged home for outpatient follow-up. This report details an uncommon case presentation, highlights areas for improvement in clinical practice, and summarises the current knowledge available in the literature regarding Streptococcus bovis infective endocarditis. LEARNING POINTS: Infective endocarditis occurring in association with gastrointestinal endoscopy is rare.Clinical suspicion of infective endocarditis after colonic polypectomy or biopsy should be maintained, especially in those with risk factors for infective endocarditis.Antibiotic prophylaxis against infective endocarditis is not recommended for routine gastrointestinal endoscopic procedures.

Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis.

Purpose: We sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy. Background: Direct oral anticoagulants have become a popular choice for the prevention of thromboembolism. Risk factors for thromboembolism are common among cardiovascular conditions and indications for direct oral anticoagulant therapy as well as coronary angiography often overlap in patients. It has been hypothesised that uninterrupted direct oral anticoagulant therapy would increase haemorrhagic and access site complications, however data in this area is limited. Methods: This was a prospective observational analysis of 49 patients undergoing elective diagnostic coronary angiography while receiving uninterrupted anticoagulation with direct oral anticoagulants. This population was compared with a control group of 49 unselected patients presenting to the cardiology service for elective diagnostic coronary angiography. Continuous variables were analysed using the independent samples t-test and categorical variables using Pearson's χ2 test. Results: The mean duration of radial compression for the control group was 235.8±62.8 min and for the uninterrupted direct oral anticoagulant group was 258.4±56.5 min. There was no significant difference in mean duration of radial compression (p=0.07; 95% CI=-1.4 to 46.5). There was also no difference in the complication rate between the two groups (p=1). Conclusions: We observed similar complication rates and radial artery compression time postangiography in both groups. This small prospective observational study suggests that uninterrupted continuation of direct oral anticoagulants during coronary angiography is safe. Larger randomised control studies in this area would be beneficial.

Chronic spontaneous coronary artery dissection in association with antiphospholipid syndrome presenting as stable angina.

A 52-year-old man presented to our cardiology service for an elective diagnostic coronary angiogram for risk stratification in the context of stable angina. He was diagnosed with antiphospholipid syndrome 2 years prior and had three known thrombotic episodes in the form of a stroke, retinal artery occlusion and deep vein thrombosis. Our initial differential was atherosclerotic coronary artery disease, however, coronary angiography demonstrated a dominant right coronary artery with a long segment of chronic spontaneous dissection distally but with thrombolysis in myocardial infarction III flow. He was treated medically with antianginals which rendered him asymptomatic and is currently on regular follow-up in the cardiology outpatient department.

Circadian and seasonal variations in patients with acute STEMI: A retrospective, single PPCI center study.

This was a retrospective observational analysis of all (n = 876) ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) at University Hospital Limerick (UHL) from 2012 to 2016 to determine whether chronological patterns existed in incidence and mortality at our center. Data were obtained from the electronic Cardiology STEMI database in UHL. Statistical analysis was performed using the Independent Samples t Test, ANOVA and Pearson's Chi-Squared test. The rate of STEMI from 0800 and 2259 hours (46.9/hr) was greater than 2300 to 0759 hours (19.1/hr) (p < 0.001). No association was found between 30-day mortality and weekend/weekdays presentation (p = 0.81) or off/in hour presentation (p = 0.86). No seasonal variation was found in STEMI incidence at our center using international (p = 0.29) or Celtic (p = 0.82) seasonal calendars. 30-Day mortality is equivalent whether STEMI patients treated with PPCI present during "normal working hours" or during the "out of hours"/weekend period at our center. The majority of STEMIs occur during the hours 0800 to 2259, but no further chronological relationship was observed in incidence.

Revascularisation of left main stem disease: a prospective analysis of modern practice and outcomes in a non-surgical centre.

Purpose: In this study, we sought to prospectively analyse the management and long term outcomes associated with revascularisation of left main stem disease via percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in our centre. Methods: This prospective study enrolled all patients with unprotected left main stem disease undergoing revascularisation from January 2013 to June 2014. Baseline characteristics, hospital presentation and hospital stay length were collected. Patients were followed up at 1, 2 and 3 years. Primary outcomes of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) were defined as death, Q wave myocardial infarction, stroke, repeat revascularisation and readmission within 30 days. Results: 56 patients with significant left main stem coronary artery disease were identified from the clinical registry. 27 patients underwent PCI (median age 67.7) and 29 CABG (median age 68.6). PCI patients had a higher surgical risk as measured by mean euroSCORE (4.95±5.8 vs 3.11±3.85). At 3 years, total MACCE occurred in 29.6% of the PCI cohort and 27.5% of the CABG cohort. Death occurred in three patients in the PCI group within the first 6 months. Death occurred in one patient in the CABG group over 2 years postprocedure. Two patients in the CABG cohort presented with Transient Ischemic Attacks (TIAs) at 2-year follow-up. At 3 years, revascularisation occurred in three patients in the PCI cohort. There were no revascularisation events in the CABG cohort. Conclusions: PCI with modern drug eluting stents is a reasonable treatment option for unprotected left main stem disease in a non surgical centre.