Resolution of left ventricular postinfarction thrombi in patients undergoing percutaneous coronary intervention using rivaroxaban in addition to dual antiplatelet therapy.

Left ventricular (LV) thrombus is usually seen in situations with reduced LV function, and is mostly seen in patients with large anterior ST-elevation myocardial infarction (MI). Most embolic events, in patients with LV thrombus formation, occur within the first 3-4 months, thus the recommendations regarding the duration of anticoagulant therapy. According to guidelines, an oral vitamin K antagonist, warfarin, is being used as an anticoagulant for this period. Novel oral anticoagulants were found to be either non-inferior or superior compared with warfarin in prevention of thromboembolism in patients with non-valvular atrial fibrillation. However, the data about their role in the management of LV thrombus are limited to case reports. Here, we report on the dissolution of LV apical thrombus in 3 patients with anterior ST-elevation MI receiving dual antiplatelet therapy and rivaroxaban on a reduced dose for 3 months.

The association of the coronary thrombus burden with all-cause mortality and major cardiac events in ST-segment elevation myocardial infarction patients treated with tirofiban.

BACKGROUND: The aim of this study was to investigate the association of the coronary thrombus burden with all-cause mortality and major adverse cardiac events (MACE) in ST-segment elevation myocardial infarction (STEMI) patients treated with 'in-cath lab' (downstream) high-dose bolus tirofiban. METHODS: This study included 2452 patients with STEMI treated with a primary percutaneous coronary intervention. All glycoprotein IIb/IIIa receptor inhibitor (GPI) (tirofiban) infusions were started in the catheterization laboratory according to the coronary thrombus burden; tirofiban was not administered to patients who did not have coronary thrombus burden. All patients with small, moderate, or large thrombus burden received tirofiban therapy. The primary study endpoint was the incidence of all-cause mortality. The secondary study endpoints were major bleeding and MACE, which included all-cause death, nonfatal acute coronary syndrome, and target lesion revascularization. RESULTS: The patients were followed up for a mean period of 28.3±10.4 months. The groups showed similar in-hospital and long-term event rates (MACE, major bleeding, and all-cause mortality). The 3-year Kaplan-Meier overall survivals for no thrombus, small thrombus, moderate thrombus, and large thrombus were 91.9, 92.6, 92.3, and 89.5%, respectively. CONCLUSION: Despite the fact that the large coronary thrombus was found to be a predictor of MACE and mortality in many previous studies, we found that the large thrombus was not associated with MACE or in-hospital mortality or long-term mortality. This can be an effect of downstream GPI therapy. We suggest the use of downstream GPI therapy for STEMI patients with large coronary thrombus without an increased risk of bleeding.

Homocysteine and arterial thrombosis: Challenge and opportunity.

The correlation between homocysteine and vascular disease has been assessed in several clinical studies that demonstrated that elevation of plasma total homocysteine (tHcy) was an independent risk factor for atheriosclerotic disease. Major advances of homocysteine metabolism disorders have been made during the last few years, encompassing the rare homozygous enzyme deficiencies, as well as more common milder abnormalities. In experimental and clinical studies, a homocysteine-mediated oxidant stress has been shown to trigger platelet activation, in turn leading to a tendency to thrombosis, in patients with severe hyperhomocysteinaemia. Likewise, the hypomethylation hypothesis on acquired hyperhomocysteinaemia (chronic renal disease) and the interrelationship between hyperhomocysteinaemia and impaired fibrinolysis, have added further biological plausibility to the role for hyperhomocysteinaemia in vascular medicine. However, whether hyperhomocysteinaemia is causal or a marker of vascular disease, and whether plasma tHcy is only an indicator of the metabolic status remains to be clarified. The role of the intake of some vitamins (folic acid, vit.B12, vit.B6) on cardiovascular disease (CVD) is poorly understood: in spite of the lowering of homocysteine (Hcy) levels, vitamin supplementation failed to exert significant effects on cardiovascular risk. On the other hand, although some lipid-modifying treatments increase Hcy levels in diabetics, there is no evidence that this attenuates the beneficial effects of such treatments on the cardiovascular risk. Because of these uncertainties in the area, the data available do not provide support for routine screening and treatment for elevated Hcy to prevent CVD.

[Prevention of restenosis and of cardiac events after coronary angioplasty in diabetics]. / Prévention de la resténose et des accidents cardiaques après angioplastie coronaire chez le diabétique.

Various systemic pharmacological approaches have been evaluated to reduce the risk of restenosis and clinical complications after coronary angioplasty, with or without stent, a main objective in the high risk diabetic population. The aim of the present paper is to describe the effects of the main pharmacological classes on the risk of restenosis, the need for new revascularisation procedures and the incidence of major clinical events (MACE: death, myocardial infarction, revascularisation). We will analyse successively the role of antiplatelet agents, omega 3 fatty acids, statins, anti-inflammatory compounds, immunomodulators, anti-oxidants and inhibitors of the renin-angiotensin system. Whenever possible, we will focus our attention on the results obtained in the diabetic population.

[Incidence of restenosis and cardiac events after coronary angioplasty in diabetic patients: reduction by systemic pharmacological approaches]. / Risque de resténose et d'evénements cardiaques après angioplastie coronaire chez le patient diabétique: réduction par des approches pharmacologiques systémiques.

Various systemic pharmacological approaches have been evaluated to reduce the risk of restenosis after coronary angioplasty, with or without stent, in the general population and in diabetic patients who are at increased risk for such complication. The aim of the present paper is to describe the effects of the main pharmacological classes on the risk of restenosis, the need for new revascularisation procedures and the incidence of major clinical events (MACE: death, myocardial infarction, revascularisation). We will analyse the role of antiplatelet agents, omega-3 fatty acids, statins, anti-inflammatory compounds, immunomodulators, anti-oxidants, glitazones and, finally, classical antidiabetic drugs such as metformin and insulin. Whenever possible, we will focus our attention on the results obtained in the diabetic population.

STEMI in a 24-year-old man after use of a synephrine-containing dietary supplement: a case report and review of the literature.

Billions of dollars are spent annually in the United States in the largely unregulated market of dietary supplements. Many of these supplements are marketed as weight-loss and athletic-performance-enhancement products. The association of various ephedra-containing products with adverse cardiovascular events has led to a ban on the sale of these products by the U.S. Food and Drug Administration. The result has been the emergence of new formulations marketed for weight loss and athletic-performance enhancement that are "ephedra-free" but contain other sympathomimetic substances, the safety of which has not been established. We present the case of a previously healthy 24-year-old man who presented with an ST-segment-elevation myocardial infarction (STEMI) within hours of taking the ephedra-free product Nutrex Lipo-6x. Emergent coronary angiography revealed the presence of extensive, diffuse thrombus in the left anterior descending coronary artery. The patient had no risk factors for coronary artery disease or myocardial infarction; this includes the absence of a hypercoagulable state and the absence of a history of illicit drug use. This case of STEMI--associated as it is with the use of a synephrine-containing product by a person without risk factors for coronary artery disease--is to our knowledge the 1st reported in the literature. We discuss the patient's evaluation and clinical course, and we review the literature with respect to synephrine-containing dietary supplements. On the basis of synephrine's chemical composition and mechanism of action, we propose a direct association between this patient's use of Nutrex Lipo-6x and his STEMI.

[Theoretical thinking on relationship between toxic-stasis pathogenicity and atherosclerotic vulnerable plaque].

Vulnerable plaque rupture is the main cause of acute coronary syndrome (ACS), a representative cardiovascular thrombotic disease. Considering that the Western medical pathogenetic recognition on vulnerable plaque inflammatory reaction and thrombus formation is similar to the etiopathogenesis and clinical characteristics of toxin and stasis as well as the clinical manifestation of toxic-stasis in TCM, the authors believe that it is necessary to expand the previous TCM thinking on taking blood stasis as the main etiopathogenesis for ACS to that ACS is caused by the toxic-stasis induced vulnerable plaque rupture. Therefore to make sense, depending evidence-based medical principle, the relationship between toxic-stasis and vulnerable plaque forming and rupturing, and to form the clinical norm for diagnosis and treatment of toxic-stasis should be helpful for the prevention and control of ACS.

Cerebral and coronary air embolism: an intradepartmental suicide attempt.

Uncooperative but alert on arrival, a 21-year-old suicidal man was found suddenly unconscious with agonal respirations 2 h into his Emergency Department evaluation. Initially admitted for ingesting multiple pills and self-inflicting a deep wrist laceration, the patient now had a Glasgow Coma Scale score of 3, a dense left-sided hemiplegia, and an electrocardiogram suggestive of acute myocardial infarction. This constellation of physical findings, together with an echocardiogram revealing bi-ventricular gas artifact, led to a diagnosis of coronary and cerebral air emboli. The patient was urgently resuscitated and then underwent hyperbaric oxygen therapy. Subsequent examination confirmed a full recovery. This article details this unprecedented case, as well as clinically relevant aspects of air embolism.