Outcomes of Cardiac Screening in Adolescent Soccer Players.

BACKGROUND: Reports on the incidence and causes of sudden cardiac death among young athletes have relied largely on estimated rates of participation and varied methods of reporting. We sought to investigate the incidence and causes of sudden cardiac death among adolescent soccer players in the United Kingdom. METHODS: From 1996 through 2016, we screened 11,168 adolescent athletes with a mean (±SD) age of 16.4±1.2 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiography, and echocardiography. The FA registry was interrogated to identify sudden cardiac deaths, which were confirmed with autopsy reports. RESULTS: During screening, 42 athletes (0.38%) were found to have cardiac disorders that are associated with sudden cardiac death. A further 225 athletes (2%) with congenital or valvular abnormalities were identified. After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. Cardiomyopathy accounted for 7 of 8 sudden cardiac deaths (88%). Six athletes (75%) with sudden cardiac death had had normal cardiac screening results. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes). CONCLUSIONS: Diseases that are associated with sudden cardiac death were identified in 0.38% of adolescent soccer players in a cohort that underwent cardiovascular screening. The incidence of sudden cardiac death was 1 per 14,794 person-years, or 6.8 per 100,000 athletes; most of these deaths were due to cardiomyopathies that had not been detected on screening. (Funded by the English Football Association and others.).

Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial.

BACKGROUND: Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure. METHODS: In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518. FINDINGS: Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59). INTERPRETATION: Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially. FUNDING: Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK).

Clinical implications of QRS duration and QT peak prolongation in patients with suspected coronary disease referred for elective cardiac catheterization.

BACKGROUND: The electrocardiogram (ECG) remains a simple, universally available, and prognostically powerful investigation in heart failure, and acute coronary syndromes. We sought to assess the prognostic utility of clinical, angiographic, and simple ECG parameters in a large cohort of patients undergoing elective cardiac catheterization (CC) for known or suspected coronary artery disease. METHODS: Consecutive consenting patients undergoing CC for coronary disease were enrolled at a single tertiary center. Patient data, drug therapy, catheter reports, and ECG recordings were prospectively recorded in a validated electronic archive. The primary outcome measure was death or nonfatal myocardial infarction (MI) over 1 year or until percutaneous or cardiac surgical intervention. Independent prognostic markers were identified using the Cox proportional hazard model. RESULTS: A total of 682 individuals were recruited of whom 17(2.5%) died or suffered a nonfatal MI in 1 year. In multivariate analysis QRS duration (ms) (HR 1.03 95% CI 1.01-1.05, P = 0.003), extent of coronary disease (HR 2.01 95% CI 1.24-3.58, P = 0.006), and prolonged corrected QT peak interval in lead I (HR 1.02 95% CI 1.00-1.03, P = 0.044) were independently associated with death or nonfatal MI. Receiver-operator characteristic (ROC) analysis for the multivariate model against the primary end point yielded an area under the curve of 0.759 (95% CI 0.660-0.858), P < 0.001. CONCLUSIONS: QRS duration and QT peak are independently associated with increased risk of death or nonfatal MI in stable patients attending for coronary angiography.

Rotational atherectomy does not reduce recurrent in-stent restenosis: results of the angioplasty versus rotational atherectomy for treatment of diffuse in-stent restenosis trial (ARTIST).

BACKGROUND: Aim of this trial was to compare rotational atherectomy followed by balloon angioplasty (rotablation [ROTA] group) with balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) alone in patients with diffuse in-stent restenosis. METHODS AND RESULTS: The ARTIST study is a multicenter, randomized, prospective European trial with 298 patients with in-stent restenosis>70% (mean lesion length, 14 +/- 8 mm) in stents, implanted in coronary arteries for >/= 3 months. In the PTCA group, angioplasty was performed at the discretion of the local investigator, and rotablation was performed by using a stepped-burr approach followed by adjunctive PTCA with low (/= 50%) rates of 51% (PTCA) and 65% (ROTA) (P=0.039). By intravascular ultrasound, the major difference was the missing stent over-expansion during PTCA after ROTA. Six-month event-free survival was significantly higher after PTCA (91.3%) compared with ROTA (79.6%, P=0.0052). CONCLUSIONS: In terms of the primary objective of the study, PTCA produced a significantly better long-term outcome than ROTA followed by adjunctive low-pressure PTCA.

Mitral valve endocarditis resulting from coagulase-negative Staphylococcus after stent implantation in a saphenous vein graft.

Valvular endocarditis after percutaneous coronary intervention is unusual. We report a new case of mitral valve endocarditis after stent implantation to a saphenous vein graft.

Anomalous origin of left internal mammary artery.

We present a case of a left internal mammary artery (LIMA) originating from the third part of the subclavian artery. Awareness of this possibility is particularly important when considering reintervention after coronary artery bypass surgery and the LIMA appears to be missing rather than obviously occluded.

"Cutting Balloon and the Three Burrs": treatment for ostial left anterior descending artery in-stent restenosis.

A 58-year-old man re-presented with symptoms of angina 3 months after percutaneous transluminal coronary angioplasty (PTCA) and stenting to his proximal left anterior descending artery (LAD). Angiography revealed ostial in-stent restenosis of the LAD, which was treated with rotational atherectomy and a cutting balloon PTCA. Combining two useful technologies for treating in-stent restenosis may prove to yield better results than using either technique alone. Long-term benefit will need to be assessed by randomized studies.

Use of the X-SIXER catheter system in the treatment of acute thrombotic coronary occlusion.

The X-SIZER thromboatherectomy catheter system (EndiCOR Medical, Inc.) was initially developed for the treatment of thrombus in acute coronary syndromes. We present the case of a 64-year-old man with thrombotic occlusion of the left circumflex coronary artery. Antegrade flow was restored by aspiration of platelet thrombus at the point of occlusion, although the catheter was unable to cross the underlying stenosis. Its limited ability to cross severe stenoses or reduce lesion severity suggests that the X-SIZER should not be regarded as an atherectomy device. However, this case report suggests that the X-SIZER device has potential as an adjunct to PTCA and stenting in reducing the risk associated with thrombotic occlusion.

Bacteremia following complex percutaneous coronary intervention.

BACKGROUND AND OBJECTIVE: Complex percutaneous coronary intervention (PCI) often requires introduction of numerous devices into and out of the arterial circulation and this may result in an increased risk of bacteraemia or even septicaemia. This study was undertaken to detect the frequency of bacteraemia that may be associated with such procedures. METHODS: 147 patients undergoing complex PCI had blood culture tests immediately after and 12 hours after the procedure. RESULTS: Of 147 patients, 26 (17.7%) had detectable bacteraemia immediately after PCI. Coagulase-negative staphylococcus was isolated most commonly. An additional 12% of patients yielded positive blood cultures in the next 12 hours with femoral sheaths still in-situ. There were no associated clinical sequelae. CONCLUSIONS: Uncomplicated bacteraemia is not uncommon as a result of complex PCI procedures. Although there are usually no clinical sequelae, these findings are important for those patients who are considered to be at moderate or high risk of infective endocarditis who require an invasive procedure such as PCI. This paper emphasizes the need for maximum sterility during PCI procedures if infective complications and stent infection are to be avoided.

Prophylaxis and treatment of infective endocarditis in adults: a concise guide.

Infective endocarditis (IE) is a life-threatening disease with substantial morbidity and mortality which affects individuals with underlying structural cardiac defects who develop bacteraemia, often as a result of dental, gastrointestinal, genitourinary, respiratory or cardiac invasive/surgical procedures. Prompt recognition of the clinical diagnosis by a wide variety of medical personnel, early involvement of specialist cardiologists, cardiac surgeon and a microbiologist, and prompt treatment with the most appropriate antimicrobial agents offer the greatest chance of improving the outcome for these patients. The guidance given here to clinicians involved in the management of patients with IE briefly covers diagnosis, antibiotic prophylaxis, medical treatment and the indications for surgery.

Acute dissection of the thoracic aorta.

Aortic dissection is an acute medical emergency with a high mortality. Crucial to improving survival is early recognition and appropriate treatment. This review describes the presenting clinical features and imaging techniques used in the diagnosis of aortic dissection and outlines the treatment modalities.

Role of antiischemic agents in the management of non-ST elevation acute coronary syndrome (NSTE-ACS).

Non-ST elevation acute coronary syndrome (NSTE-ACS) is the commonest acute presentation of coronary artery disease (CAD). Mortality and morbidity of the condition has improved substantially over the last few decades as a result of the cumulative effect of multiple interventions acting via different mechanisms. Despite a significant increase in the rate of coronary intervention, medical therapy continues to retain a central role in the treatment of NSTE-ACS particularly in frail patients where revascularization is inappropriate or when it is incomplete. Several antiischemic agents have been used in the treatment of the condition. Beta blockers are often the first-line choice with calcium channel blockers and nitrates being used as an alternative when beta blockers are contraindicated, or as an addition to achieve optimal symptom control. Newer agents, such as nicorandil, ivabradine, and ranolazine have also been used in refractory cases. Although most of these agents have been extensively studied in large randomized controlled trials in patients with stable CAD or ST elevation acute coronary syndrome (STE-ACS), the evidence supporting their use in NSTE-ACS is less clear cut. In this article, we review various drugs available for controlling ischemia and the latest evidence in support of their use in NSTE-ACS.

Tako-tsubo, hypertrophic obstructive cardiomyopathy & muscle bridging--separate disease entities or a single condition?

We report a case of an apical ballooning syndrome using classical and high quality imagery. Co-existing features of asymmetrical septal hypertrophy, outflow tract obstruction, systolic anterior mitral valve motion and LAD myocardial bridging make the underlying patho-physiology difficult to ascertain. In conclusion we believe that this single case will promote discussion and add to an expanding literature base of the tako-tsubo cardiomyopathy syndrome.

How should I treat a spontaneously reperfused acute STEMI that involves the left main stem and proximal LAD?

BACKGROUND: A 41-year-old female with 90 minutes of severe chest pain and ST-elevation in leads V1-V2 underwent emergency coronary angiography with a view to primary angioplasty. INVESTIGATIONS: Physical examination, electrocardiography, coronary angiography. DIAGNOSIS: ST-segment elevation anterior myocardial infarction. MANAGEMENT: Coronary angiography, antiplatelet and antithrombotic therapy, statin, angiotensin-converting enzyme inhibitor, beta blocker, IVUS and percutaneous coronary intervention (PCI)