One-Year Outcomes in Anticoagulated Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights From the Greek Antiplatelet Atrial Fibrillation Registry.

ABSTRACT: GReek-AntiPlatElet Atrial Fibrillation registry is a multicenter, observational, noninterventional study of atrial fibrillation patients undergoing percutaneous coronary intervention. Primary endpoint included clinically significant bleeding rate at 12 months between different antithrombotic regimens prescribed at discharge; secondary endpoints included major adverse cardiovascular events and net adverse clinical events. A total of 647 patients were analyzed. Most (92.9%) were discharged on novel oral anticoagulants with only 7.1% receiving the vitamin K antagonist. A little over half of patients (50.4%) received triple antithrombotic therapy (TAT)-mostly (62.9%) for ≤1 month-whereas the rest (49.6%) received dual antithrombotic therapy (DAT). Clinically significant bleeding risk was similar between TAT and DAT [Hazard ratio (HR) = 1.08; 95% confidence interval (CI), 0.66-1.78], although among TAT-receiving patients, the risk was lower in those receiving TAT for ≤1 month (HR = 0.50; 95% CI, 0.25-0.99). Anticoagulant choice (novel oral anticoagulant vs. vitamin K antagonist) did not significantly affect bleeding rates ( P = 0.258). Age, heart failure, leukemia/myelodysplasia, and acute coronary syndrome were associated with increased bleeding rates. Risk of major adverse cardiovascular events and net adverse clinical events was similar between ΤAT and DAT (HR = 1.73; 95% CI, 0.95-3.18, P = 0.075 and HR = 1.39; 95% CI, 0.93-2.08, P = 0.106, respectively). In conclusion, clinically significant bleeding and ischemic rates were similar between DAT and TAT, although TAT >1 month was associated with higher bleeding risk.

Contrast-induced early repolarization pattern and ventricular fibrillation.

Malignant arrhythmias during coronary angiography consist a complication of the procedure. Clinicians should be aware that intracoronary infusion of contrast medium can lead to physiological changes that lower the ventricular fibrillation threshold.

The Use of Genotoxicity Endpoints as Biomarkers of Low Dose Radiation Exposure in Interventional Cardiology.

The effect of the reportedly low ionizing radiation doses, such as those very often delivered to patients in interventional cardiology, remains ambiguous. As interventional cardiac procedures may have a significant impact on total collective effective dose, there are radiation protection concerns for patients and physicians regarding potential late health effects. Given that very low doses (<100 mSv) are expected to be delivered during these procedures, the purpose of this study was to assess the potency and suitability of current genotoxicity biomarkers to detect and quantitate biological effects essential for risk estimation in interventional cardiology. Specifically, the biomarkers γ-H2AX foci, dicentric chromosomes, and micronuclei, which underpin radiation-induced DNA damage, were studied in blood lymphocytes of 25 adult patients before and after interventional cardiac procedures. Even though the mean values of all patients as a group for all three endpoints tested show increased yields relative to baseline following medical exposure, our results demonstrate that only the γ-H2AX biomarker enables detection of statistically significant differences at the individual level (p < 0.001) for almost all patients (91%). Furthermore, 24 h after exposure, residual γ-H2AX foci were still detectable in irradiated lymphocytes. Their decline was found to vary significantly among the individuals and the repair kinetics of γ-H2AX foci was found to range from 25 to 95.6% of their maximum values obtained.

Prasugrel in the treatment of acute coronary syndrome.

Dual antiplatelet therapy is the mainstay therapy in patients with acute coronary syndrome. The combination of aspirin and a P2Y12 inhibitor in patients who receive a coronary stent reduces the rate of stent thrombosis and the rates of major adverse cardiovascular events. The newer P2Y12 inhibitors (prasugrel and ticagrelor) have better efficacy than clopidogrel. Prasugrel provides greater inhibition of platelet aggregation and has a rapid onset of action. Current acute coronary syndrome guidelines recommend the use of both newer P2Y12 inhibitors. However, emerging data have shown that prasugrel is more efficient than ticagrelor in reducing the incidence of nonfatal myocardial infarction, stroke or cardiovascular death, without increased risk of major bleeding.

The Role of the Endothelium in Premature Atherosclerosis: Molecular Mechanisms.

Atherosclerotic disease is still one of the leading causes of mortality. Atherosclerosis is a complex progressive and systematic artery disease that involves the intima of the large and middle artery vessels. The inflammation has a key role in the pathophysiological process of the disease and the infiltration of the intima from monocytes, macrophages and T-lymphocytes combined with endothelial dysfunction and accumulated oxidized low-density lipoprotein (LDL) are the main findings of atherogenesis. The development of atherosclerosis involves multiple genetic and environmental factors. Although a large number of genes, genetic polymorphisms, and susceptible loci have been identified in chromosomal regions associated with atherosclerosis, it is the epigenetic process that regulates the chromosomal organization and genetic expression that plays a critical role in the pathogenesis of atherosclerosis. Despite the positive progress made in understanding the pathogenesis of atherosclerosis, the knowledge about the disease remains scarce.

Endothelium in Aortic Aneurysm Disease: New Insights.

Inflammation is recognized as a fundamental element in the development and growth of aortic aneurysms. Aortic aneurysm is correlated with aortic wall deformities and injury, as a result of inflammation, matrix metalloproteinases activation, oxidative stress, and apoptosis of vascular smooth muscle cells. The endothelial wall has a critical part in the inflammation of the aorta and endothelial heterogeneity has proven to be significant for modeling aneurysm formation. Endothelial shear stress and blood flow affect the aortic wall through hindrance of cytokines and adhesion molecules excreted by endothelial cells, causing reduction of the inflammation process in the media and adventitia. This pathophysiological process results in the disruption of elastic fibers, degradation of collagen fibers, and destruction of vascular smooth muscle cells. Consequently, the aortic wall is impaired due to reduced thickness, decreased mechanical function, and cannot tolerate the impact of blood flow leading to aortic expansion. Surgery is still considered the mainstay therapy for large aortic aneurysms. The prevention of aortic dilation, though, is based on the hinderance of endothelial dysregulation with drugs, the reduction of reactive oxygen and nitrogen species, and also the reduction of pro-inflammatory molecules and metalloproteinases. Further investigations are required to enlighten the emerging role of endothelial cells in aortic disease.

Transfemoral transcatheter aortic valve replacement in the presence of a mitral prosthesis.

PURPOSE: In the current case series, we present our experience with the self-expanding CoreValve or Evolut R (Medtronic Inc.) in patients with severe symptomatic aortic valve stenosis and concomitant mitral valve prosthesis. METHODS: Twelve patients with previous mitral valve prosthesis underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and/or aortic valve regurgitation. All patients underwent evaluation with an echocardiogram, computed tomography and coronary angiogram. After the index intervention and before discharge all patients underwent transthoracic echocardiography. All outcomes were defined according to the Valve Academic Research Consortium-2 criteria. RESULTS: Eleven patients underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and one patient for severe aortic valve regurgitation. There was immediate improvement of patients' hemodynamic status; no cases of procedural death, stroke, myocardial infarction, or urgent cardiac surgery occurred. There was no 30-day mortality and all patients improved, with 91.6% in functional New York Heart Association class I-II. CONCLUSION: The current study demonstrates that in patients with severe aortic valve stenosis or regurgitation and mitral valve prosthesis, the implantation of a self-expanding aortic valve via the transfemoral route is safe and feasible, with maintained long-term results.

Missed Heparin-Induced Thrombocytopenia (HIT) Diagnosis in a Patient with Acute Stent Thrombosis.

BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin therapy, characterized by thrombocytopenia and high risk for venous and arterial thrombosis. CASE REPORT We report an unusual case of acute stent thrombosis secondary to delayed HIT. A 74-year-old man with non-ST-segment elevation myocardial infarction had a coronary angiography which revealed 2-vessel disease. A bolus of unfractionated heparin (UFH) was administered at admission and he received fondaparinux during his hospitalization. We performed elective percutaneous coronary intervention (PCI) with stents to LAD and LCx. Two hours after PCI, the patient developed acute pulmonary edema, and repeat angiography revealed an occlusive thrombus in the ostial LAD and the LCx. A turbidimetric assay for the rapid detection of plasma anti-PF4/heparin antibodies was negative. After repeated unsuccessful attempts of balloon angioplasty and continuous thrombosis, the patient was transferred for emergency surgical revascularisation and was treated with additional UFH followed by enoxaparin. Platelets decreased gradually to 38 k/µl 7 days after surgery, at which time enoxaparin was replaced with fondaparinux. The subsequent HIT test results were positive. CONCLUSIONS HIT should be considered in patients with multiple recent exposures to anticoagulants, independent of the platelet count, if there are signs and symptoms of thrombosis.

E-cigarette use is strongly associated with recent smoking cessation: an analysis of a representative population sample in Greece.

The purpose was to examine the association between e-cigarette use and smoking cessation according to quit duration in Greece in 2017. A cross-sectional survey of a representative sample of adults living in Attica prefecture was performed in May 2017 through telephone interviews. The present analysis was confined to current and former smokers (n = 2568). Logistic regression analyses were performed with current and current daily e-cigarette use being the dependent variables and demographics and smoking status (current smokers vs smoking cessation for ≤ 12 months, 13-36 months, 36-72 months, and > 72 months) being independent variables. Almost half of former smokers (47.7%) had quit smoking for ≤ 72 months. Current e-cigarette use was more prevalent among former smokers of ≤ 12 months (26.2%) and 13-36 months (27.0%), and was rare among former smokers of > 72 months (1.0%). Current e-cigarette use was strongly associated with smoking cessation for ≤ 12 months (OR 6.12, 95% CI 4.11-9.10, P < 0.001) and 13-36 months (OR 6.28, 95% CI 4.25-9.28, P < 0.001). Current daily e-cigarette use was also strongly associated with smoking cessation for ≤ 12 months (OR 10.41, 95% CI 6.56-16.53, P < 0.001) and 13-36 months (OR 11.18, 95% CI 7.12-17.55, P < 0.001). Current and current daily e-cigarette use were not significantly associated with smoking cessation for 37-72 months, and were negatively associated with smoking cessation for > 72 months. Current and current daily e-cigarette use are strongly associated with recent smoking cessation in Greece, suggesting a positive public health impact in a country with the highest prevalence of smoking in the European Union. E-cigarettes do not appear to promote relapse in long term former smokers. Duration of smoking cessation and frequency of e-cigarette use should be taken into consideration when examining the association between e-cigarette use and smoking cessation in population studies.

Balloon pulmonary angioplasty is a promising option in thalassemic patients with inoperable chronic thromboembolic pulmonary hypertension.

Pulmonary hypertension (PH), a serious disorder with a high morbidity and mortality rate, is known to occur in a number of unrelated systemic diseases. ß-Thalassaemia, among other haematological disorders, develop PH which is not an infrequent finding and worsens the prognosis. Haemolysis, iron overload and hypercoagulable state are among the main pathogenetic mechanisms. Haemoglobinopathies and congenital haemolytic anaemia constitute a unique patients population more predisposed to developing chronic thromboembolic pulmonary hypertension (CTEPH). Although pulmonary endarterectomy is accepted as the best treatment for CTEPH, surgery in these patients poses significant practical challenges given the distinct nature of the disease. As drug therapy is not expected to offer relief from the mechanical obstructions of pulmonary arteries and the use of specific pulmonary arterial hypertension drugs is not established in thalassaemia patients, the novel technique of balloon pulmonary angioplasty (BPA) may emerge as a new therapeutic option for patients with inoperable CTEPH and thalassaemia. We are reporting the case of a thalassaemic patient with a history of splenectomy suffering from progressive severe pulmonary hypertension related to chronic thromboembolic disease, who was successfully treated by BPA with substantial improvement.

Novel approaches for the treatment of ventricular tachycardia.

Ventricular tachycardia (VT) is a crucial cause of sudden cardiac death (SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to life-threatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of research. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.

Carbonyl emissions from a novel heated tobacco product (IQOS): comparison with an e-cigarette and a tobacco cigarette.

AIMS: To measure carbonyl emissions from a heated tobacco product (IQOS) in comparison with an e-cigarette (Nautilus Mini) and a commercial tobacco cigarette (Marlboro Red). DESIGN: Regular and menthol variants of the heated tobacco product were tested. A tank-type atomizer was tested with a tobacco-flavoured liquid at 10 and 14 W. Aerosol and smoke were collected in impingers containing 2,4-dinitrophenylhydrazine. Health Canada Intense and two more intense puffing regimens were used. SETTING: Analytical laboratory in Greece. MEASUREMENTS: Carbonyl levels in the aerosol and smoke. FINDINGS: At the Health Canada Intense regimen, heated tobacco products emitted 5.0-6.4 µg/stick formaldehyde, 144.1-176.7 µg/stick acetaldehyde, 10.4-10.8 µg/stick acrolein, 11.0-12.8 µg/stick propionaldehyde and 1.9-2.0 µg/stick crotonaldehyde. Compared with the tobacco cigarette, levels were on average 91.6% lower for formaldehyde, 84.9% lower for acetaldehyde, 90.6% lower for acrolein, 89.0% lower for propionaldehyde and 95.3% lower for crotonaldehyde. The e-cigarette emitted 0.5-1.0 µg/12 puffs formaldehyde, 0.8-1.5 µg/12 puffs acetaldehyde and 0.3-0.4 µg/12 puffs acrolein, but no propionaldehyde and crotonaldehyde. At more intense puffing regimens, formaldehyde was increased in heated tobacco products, but levels were three-fourfold lower compared with the tobacco cigarette. Based on the findings from Health Canada Intense puffing regimen, use of 20 heated tobacco sticks would result in approximately 85% to 95% reduced carbonyl exposure compared with smoking 20 tobacco cigarettes; the respective reduction in exposure from use of 5 g e-cigarette liquid would be 97% to > 99%. CONCLUSIONS: The IQOS heated tobacco product emits substantially lower levels of carbonyls than a commercial tobacco cigarette (Marlboro Red) but higher levels than a Nautilus Mini e-cigarette.

Platelet to lymphocyte ratio in acute aortic dissection.

BACKGROUND: Inflammation plays an important role in the initiation and progression of acute aortic dissection (AAD). New inflammatory indices derived from full cell blood count and its differential may be associated with increased risk. We evaluated platelet-lymphocyte (PLR), red cell distribution width (RDW) and RDW/PLT's (platelets) (RPR) in AAD. METHODS: We studied 120 consecutive patients with AAD type I admitted for emergency surgery (group I), 121 consecutive patients with aortic aneurysms of the ascending aorta prior to elective repair (group II) and 121 controls (group III), age and sex matched. RESULTS: PLR was significantly higher in group I vs both groups II and III (P < .001). There was an excellent correlation of PLR with neutrophil/lymphocyte ratio (NLR) in all three groups (P < .001 for all). After adjustment for hemoglobin, RDW did not differ but RPR remained significantly higher in group I compared to groups II and III (P < .001). The best cutoff value of PLR to predict dissection was 159 with 53% sensitivity and 86% specificity. No association between PLR, RDW, and RPR and mortality in group I was found. CONCLUSIONS: Indices derived from full cell blood count may provide diagnostic information in patients with AAD; whether these indices may contribute to prognosis assessment should be further investigated.

Electronic cigarette use in Greece: an analysis of a representative population sample in Attica prefecture.

BACKGROUND: The purpose was to assess prevalence and correlates of electronic cigarette (e-cigarette) use in Greece in 2017. METHODS: A cross-sectional survey of a representative sample of 4058 adults living in Attica prefecture (35% of the Greek adult population) was performed in May 2017 through telephone interviews. Prevalence and frequency of e-cigarette use were assessed according to the smoking status, and logistic regression analysis was performed to identify correlates of use. RESULTS: Current smoking was reported by 32.6% of participants. Ever e-cigarette use was reported by 54.1% (51.4-56.8%) of current smokers, 24.1% (21.7-26.5%) of former smokers and 6.5% (5.3-7.7%) of never smokers. Past experimentation was the most prevalent pattern of e-cigarette use among ever users (P < 0.001). Almost 80% of ever and 90% of current e-cigarette users were using nicotine. Extrapolated to the whole Attica population (3.1 million), there were 1 million current smokers, 848,000 ever e-cigarette users and 155,000 current e-cigarette users. The majority of current e-cigarette users (62.2%) were former smokers. Only 0.2% of never smokers were current e-cigarette users. One out of 20 participants considered e-cigarettes a lot less harmful than smoking. Being current or former smoker were the strongest correlates current e-cigarette use (OR 30.82, 95%CI 10. 21-69.33 and OR 69.33, 95%CI 23.12-207.90 respectively). CONCLUSIONS: E-cigarette use in Greece is largely confined to current or former smokers, while current use and nicotine use by never smokers is extremely rare. The majority of current e-cigarette users were former smokers. Most participants overestimate the harmfulness of e-cigarettes relative to smoking.

Do flavouring compounds contribute to aldehyde emissions in e-cigarettes?

INTRODUCTION: A recent study identified up to 10,000-fold higher aldehyde emissions from flavoured compared to unflavoured e-cigarette liquids. We set to replicate this study and also test similar flavourings with a new-generation e-cigarette device. METHODS: Three liquids with the highest levels of aldehyde emissions in the previous study were tested (in standard and sweetened versions) using the same e-cigarette device and puffing patterns. Additionally, similar flavourings from a different manufacturer were tested using a new-generation e-cigarette device. Unflavoured samples were also tested. RESULTS: Low levels of formaldehyde (8.3-62 µg/g), acetaldehyde (12.1-26.0 µg/g) and acrolein (5.4-19.4 µg/g) were detected, lower by up to 589-fold compared to the previous report. Unflavoured liquid emitted 16.1 µg/g formaldehyde, 5.6 µg/g acetaldehyde and 2.4 µg/g acrolein, significantly lower compared to 2 liquids for formaldehyde and 1 for acrolein. Emissions from the new-generation device were even lower. Aldehyde emissions from all flavoured liquids were 79-99.8% lower than smoking and lower than commonly measured indoor levels and occupational and indoor safety limits. CONCLUSIONS: The e-cigarettes tested herein emit very low levels of aldehydes. Some flavourings may contribute to aldehyde emissions, but the absolute levels were minimal. Validated methods should be used when analysing e-cigarette emissions.

Nicotine Delivery to the Aerosol of a Heat-Not-Burn Tobacco Product: Comparison With a Tobacco Cigarette and E-Cigarettes.

Introduction: The purpose was to measure nicotine levels to the tobacco and levels emitted to the aerosol of a heat-not-burn product (HnB, IQOS) compared to e-cigarettes (ECs) and a tobacco cigarette. Methods: The HnB device and regular and menthol sticks were purchased from Italy. Three types of ECs (ciga-like, eGo-style, and variable wattage) and a commercially-available tobacco cigarette were also tested. A custom-made liquid containing 2% nicotine was used with ECs. Products were tested using Health Canada Intense puffing regime while HnB and ECs were additionally tested using a 4-second puff duration regime while maintaining the same puff volume. Results: Nicotine content in HnB regular and menthol tobacco sticks was 15.2 ± 1.1 mg/g and 15.6 ± 1.7 mg/g tobacco respectively. The levels of nicotine to the aerosol were similar for regular and menthol HnB products (1.40 ± 0.16 and 1.38 ± 0.11 mg/12 puffs respectively) and did not change significantly with prolonged puff duration. The tobacco cigarette delivered the highest level of nicotine (1.99 ± 0.20 mg/cigarette), with levels being higher than HnB and ECs under Health Canada Intense regime but similar to eGo-style and variable wattage ECs at prolonged puff duration regime. Conclusions: The HnB product delivers nicotine to the aerosol at levels higher than ECs but lower than a tobacco cigarette when tested using Health Canada Intense puffing regime. No change in HnB nicotine delivery was observed at prolonged puff duration with the same puff volume, unlike ECs which deliver more nicotine with longer puff duration. Implications: Nicotine delivery to the smoker is expected to play an important role in the ability of any harm-reduction product to successfully substitute smoking. This study evaluated the content and nicotine delivery to the aerosol of a heat-not-burn tobacco product (IQOS) in comparison with e-cigarettes and a tobacco cigarette. The main findings were that the heat-not-burn tobacco sticks contained similar nicotine concentration to tobacco cigarettes, and that the levels of nicotine delivered to the aerosol of the heat-not-burn products were lower than tobacco cigarette, higher than e-cigarettes at low puff duration but lower than high-power e-cigarettes at longer puff duration.

Ischemic Stroke in a Patient With Quadricuspid Aortic Valve and Patent Foramen Ovale.

Quadricuspid aortic valve (QAV) is a rare congenital aortic valve abnormality. It is less common as compared to bicuspid or unicuspid aortic valve abnormality. QAV causes aortic regurgitation usually in the fifth to sixth decade of life. We present a rare case of a female patient with cryptogenic stroke due to a QAV and a patent foramen ovale (PFO). The patient underwent transcatheter closure of PFO, as there was no clear indication for surgery for her valve. Surgical removal remains the method of choice for the treatment of the QAV before left ventricular decompensation occurs.

E-cigarettes emit very high formaldehyde levels only in conditions that are aversive to users: A replication study under verified realistic use conditions.

PURPOSE: In 2015, a study identified 5-15-fold higher levels of formaldehyde emissions from an old-generation e-cigarette tested at 5.0 V compared to tobacco cigarettes. We set to replicate this study using the same e-cigarette equipment and e-liquid, while checking for the generation of dry puffs. DESIGN: Experienced e-cigarette users (n = 26) took 4 s puffs at different voltage settings and were asked to report the generation of dry puffs. Formaldehyde emissions were measured at both realistic and dry puff conditions. RESULTS: Dry puffs were detected at ≤4.2 V by 88% of participants; thus, 4.0 V was defined as the upper limit of realistic use. Levels ranged from 3.4 (SE = 2.2) µg/10 puffs at 3.3 V to 718.2 (SE = 58.2) µg/10 puffs at 5.0 V. The levels detected at 4.0 V were 19.8 (SE = 5.6) µg/10 puffs. At 4.0 V, the daily exposure to formaldehyde from consuming 3 g of liquid with the device tested would be 32% lower compared to smoking 20 tobacco cigarettes. CONCLUSIONS: The high levels of formaldehyde emissions that were reported in a previous study were caused by unrealistic use conditions that create the unpleasant taste of dry puffs to e-cigarette users and are thus avoided.