Acute coronary syndromes in patients with cancer: Recent advances.

Coronary artery disease is presently one of the leading causes of death among cancer survivors. Due to the number of cancer survivors projected to reach 26 million by 2040 managing coronary disease in this population presents a unique challenge. Cancer patients face an elevated risk of atherosclerotic disease due to shared cardiovascular risk factors and the cardiotoxic effects of cancer therapies, predisposing them to acute coronary syndromes. Challenges in treating cancer patients presenting with acute coronary syndromes include atypical presentations, obscured symptoms, and the impact of cancer-related processes on traditional biomarkers. This review explores the complexities of acute coronary syndrome management in cancer patients, addressing challenges involved, recent advances in percutaneous strategies, pharmacology, and considerations for these high-risk individuals. This review discusses a balance between invasive vs. medical strategy, technical advances in multimodal imaging, intravascular physiology, intracoronary imaging, and evolving stent options, highlighting the need for tailored approaches in this complex patient population.

Artificial Intelligence as a Diagnostic Tool in Non-Invasive Imaging in the Assessment of Coronary Artery Disease.

Coronary artery disease (CAD) remains a leading cause of mortality and morbidity worldwide, and it is associated with considerable economic burden. In an ageing, multimorbid population, it has become increasingly important to develop reliable, consistent, low-risk, non-invasive means of diagnosing CAD. The evolution of multiple cardiac modalities in this field has addressed this dilemma to a large extent, not only in providing information regarding anatomical disease, as is the case with coronary computed tomography angiography (CCTA), but also in contributing critical details about functional assessment, for instance, using stress cardiac magnetic resonance (S-CMR). The field of artificial intelligence (AI) is developing at an astounding pace, especially in healthcare. In healthcare, key milestones have been achieved using AI and machine learning (ML) in various clinical settings, from smartwatches detecting arrhythmias to retinal image analysis and skin cancer prediction. In recent times, we have seen an emerging interest in developing AI-based technology in the field of cardiovascular imaging, as it is felt that ML methods have potential to overcome some limitations of current risk models by applying computer algorithms to large databases with multidimensional variables, thus enabling the inclusion of complex relationships to predict outcomes. In this paper, we review the current literature on the various applications of AI in the assessment of CAD, with a focus on multimodality imaging, followed by a discussion on future perspectives and critical challenges that this field is likely to encounter as it continues to evolve in cardiology.

Percutaneous Coronary Angioplasty in Patients with Cancer: Clinical Challenges and Management Strategies.

The number of cancer survivors in the United States is projected to increase by 31% by 2030. With advances in early screening, diagnosis and therapeutic strategies, a steadily increasing number of patients are surviving cancer. Coronary artery disease (CAD) is now one of the leading causes of death amongst cancer survivors, with the latter group of patients having a higher risk of CAD compared to the general population. Our review covers a range of specific challenges faced by doctors when considering percutaneous coronary interventions (PCI) in cancer patients; clinical outcomes in cancer patients undergoing PCI, as well as some important technical considerations to be made when making decisions regarding the management strategy in this special population of patients.

Outcomes of Percutaneous Coronary Intervention in Patients With Acquired Immunosuppression.

There are limited data on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with acquired immunosuppression who are frequently underrepresented in clinical trials. All PCI procedures between October 2015 and December 2018 in the Nationwide Inpatient Sample were retrospectively analyzed, stratified by immunosuppression status. Multivariable logistic regression models were performed to examine (1) the association between immunosuppression status and in-hospital outcomes, expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CIs) and (2) predictors of mortality among patients with severe acquired immunosuppression. In this contemporary analysis of nearly 1.5 million PCI procedures, approximately 4% of patients who underwent PCI had acquired immunosuppression. Of these, chronic steroid use accounted for approximately half of the cohort who underwent PCI who had acquired immunosuppression, with the remainder divided between hematologic cancer, solid organ active malignancy, and metastatic cancer, with the latter group having the highest rates of composite of in-hospital mortality or stroke (9.3%) (mortality 7.5% and acute ischemic stroke 2.4%). In conclusion, immunosuppression was independently associated with increased adjusted odds of adverse clinical outcomes, specifically mortality or stroke (aOR 1.11, 95% CI 1.06 to 1.15, p <0.001) and in-hospital mortality (aOR 1.21, 95% CI 1.13 to 1.29, p <0.001), with outcomes dependent on the cause of immunosuppression.

The Gerbode defect: a case series.

BACKGROUND: The Gerbode defect is a rare abnormal communication between the left ventricle (LV) and right atrium (RA). The lesion is either congenital or acquired. Acquired defects are largely iatrogenic or infective in origin. We present two cases of acquired Gerbode defects with similar clinical presentations but very different outcomes. CASE SUMMARIES: Patient 1 A 64-year-old male presented with features of decompensated cardiac failure and a low-grade temperature. Dehiscence of a recently implanted bioprosthetic aortic valve and high-velocity LV to RA jet (Gerbode defect) was found on echocardiography. Blood cultures grew Staphylococcus warneri and the diagnosis of infective endocarditis was established. The patient was treated with intravenous antibiotics and the aortic valve and Gerbode defect were successfully surgically repaired.Patient 2 An 81-year-old male presented after being found on the floor at home. On admission, he was clinically septic with evidence of decompensated heart failure. No clear infective focus was initially found. Transthoracic echocardiography revealed severe left ventricular impairment, with a normal bioprosthetic aortic valve. He was treated with intravenous antibiotics, but later deteriorated with evidence of embolic phenomena. Repeat echocardiography revealed a complex infective aortic root lesion with bioprosthetic valve dehiscence and flow demonstrated from the LV to RA. Unfortunately, the patient succumbed to the infection and cardiac complications. DISCUSSION: The Gerbode defect is a rare but important complication of infective endocarditis and valve surgery. Care needs to be taken to assess for Gerbode defect shunts on echocardiogram, especially in the context of previous cardiac surgery.

Fever in a returning traveller: visceral leishmaniasis triggering haemophagocytic lymphohistiocytosis.

We present the case of a 23-year-old student admitted with fever, night sweats and splenomegaly. These non-specific signs and symptoms posed a diagnostic challenge which was further complicated by a history of recent foreign travel. The range of potential diagnoses required a variety of investigations in order to reach the final diagnosis. The incidental finding of an incompetent bicuspid aortic valve and an inflamed gallbladder further clouded the diagnostic process. Despite treatment with broad spectrum antibiotics, the patient continued to deteriorate. Serological testing finally provided a diagnosis of visceral leishmaniasis. The patient subsequently developed haemophagocytic lymphohistiocytosis, a life-threatening immune hyperactivity state that very rarely complicates leishmaniasis infection. With the use of amphotericin B and high-dose steroids, the patient made an excellent recovery.

Septic Cerebral Embolisation in Fulminant Mitral Valve Infective Endocarditis.

A 37-year-old male with known intravenous drug use was admitted with an acute onset of worsening confusion and speech impairment. His vitals and biochemical profile demonstrated severe sepsis, with a brain CT showing several lesions suspicious for cerebral emboli. He then went on to have a bedside transthoracic echocardiogram that was positive for vegetation on the mitral valve, with associated severe mitral regurgitation. Unfortunately, before he was stable enough to be transferred for valve surgery, he suffered an episode of acute pulmonary oedema requiring intubation and ventilation on intensive care unit.

An unusually heavy heart.

A 47-year-old female presented with worsening insidious symptoms of breathlessness and leg swelling over the last 12 months. Whilst her ECG and chest X-ray were relatively unremarkable on admission, an echocardiogram demonstrated a large-sized left atrial myxoma. This tumour was resected by the cardiac surgeons the next day, with very good postoperative results. The ensuing discussion details the anatomy and physiology of myxomas, their epidemiology, clinical features, diagnostic investigations and management.

Intracoronary adenosine versus intravenous adenosine during primary PCI for ST-elevation myocardial infarction: which one offers better outcomes in terms of microvascular obstruction?

Aims. Previous studies have suggested that intravenous administration of adenosine improves myocardial reperfusion and reduces infarct size in ST-elevation myocardial infarction (STEMI) patients. Intracoronary administration of adenosine has shown conflicting results. Methods. In this retrospective, single-centre, blinded clinical study, we assessed whether selective intracoronary administration of adenosine distal to the occlusion site immediately before initial balloon inflation reduces microvascular obstruction (MVO) as assessed with cardiac magnetic resonance imaging (MRI). Using contrast-enhanced sequences, microvascular obstruction (MVO) was calculated. We found 81 patients presenting with STEMI within 12 h from symptom onset who were eligible for the study. In 80/81 (100%) patients receiving the study drug, MRI was performed on Day 1 after primary angioplasty. Results. The prevalence of MVO was reduced in the patients treated with intracoronary adenosine, (45%) compared to 85% of patients who were administered intravenous adenosine (P = 0.0043). We found that the size of MVO in patients receiving intracoronary adenosine was significantly reduced compared to 0.91 g in the intravenous-treated group (P = 0.027). There was no statistically significant difference in TIMI flow and clinical outcomes after primary PCI. Conclusion. We found significant evidence that selective high-dose intracoronary administration of adenosine distal to the occlusion site of the culprit lesion in STEMI patients results in a decrease in microvascular obstruction.

Flexible cystoscopy findings in patients investigated for profound lower urinary tract symptoms, recurrent urinary tract infection, and pain.

BACKGROUND AND PURPOSE: The National Institute of Clinical Excellence published guidelines in 2010 recommending the use of cystoscopy to investigate profound lower urinary tract symptoms (pLUTS), recurrent urinary tract infection (rUTI), and pain in men. Currently, there are no equivalent guidelines for women. We aimed to examine the diagnostic performance of flexible cystoscopy (FC) when it is used in this context in both men and women. PATIENTS AND METHODS: Results of all outpatient FCs undertaken in our department between April 2009 and March 2010 were examined retrospectively. Patients undergoing FC for the investigation of pLUTS, rUTI, or pain were included. Diagnostic performance was calculated, which was defined as the number of patients receiving a diagnosis of a clinically relevant abnormality at FC divided by the total number of patients undergoing FC for this indication. RESULTS: Of the 1809 patients who underwent FC during the study period, 113 underwent FC to investigate pLUTS, rUTI, or pain. Diagnostic performance was 11.5% (n=13), being 11.4%, 19.2%, and 0% in those with pLUTS, rUTI, and pain, respectively. Bladder cancer was diagnosed in one (0.9%) patient who underwent FC to investigate pLUTS but also had nonvisible hematuria. Urethral stricture was diagnosed in nine (8.0%) cases and intravesical calculi in four (3.5%) cases. CONCLUSION: Clinically relevant abnormalities were found in 11.5% of patients with pLUTS, rUTI, or pain, supporting recently published NICE guidelines recommending cystoscopy in patients with pLUTS or rUTI. Of the 17 patients who were investigated for pain, none was found to have clinically relevant abnormalities; further studies are needed to define the clinical utility of FC in these cases.