ABSTRACT
BACKGROUND: Acute myocardial infarction (AMI) is considered a major cause of death and disability. Myocardial perfusion scintigraphy (MPS) as a non-invasive diagnostic imaging procedure and certain biomarkers associated with myocardial ischemia (ISCH), such as ischemia-modified albumin (IMA), neuropeptide Y (NPY), N-terminal pro b-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hsTnT) could probably aid in the detection of myocardial infarction. METHODS: Between December 2011 and June 2012, we prospectively analyzed patients who underwent a MPS study with the clinical question of myocardial ISCH. An exercise test was performed along with a MPS. Blood was drawn from the patients before exercise and the within 3 minutes from achieving maximum load and was analyzed for the aforementioned biomarkers. RESULTS: A total of 71 patients (56 men and 15 women) were enrolled with a mean age of 61 ± 12 years. Twenty-six patients (36.6%) showed reduced uptake on stress MPS images that normalized at rest, a finding consistent with ISCH. Between ISCH and non-ISCH groups, only hsTnT levels showed a significant difference with the highest levels pertaining to the former group both before (0.0075 ng/ml vs 0.0050 ng/ml, P = 0.023) and after stress exercise (0.0085 vs 0.0050, P = 0.015). The most prominent differences were seen in higher stages of the Bruce protocol (stress duration > 9.05 minutes - P < 0.017). None of the IMA, NPY, and NP-pro BNP showed significant differences in time between the two groups. CONCLUSIONS: Although IMA, NPY, and NT-pro BNP may not detect minor ischemic myocardial insults, serum hsTnT holds a greater ability of detecting not only myocardial infarction but also less severe ischemia. Further studies with larger cohorts of patients are warranted in order to better define the role of hsTnT as a screening tool for myocardial ischemia.
Subject(s)
Biomarkers/blood , Myocardial Ischemia/diagnostic imaging , Troponin T/blood , Aged , Area Under Curve , Exercise , Female , Humans , Male , Middle Aged , Myocardial Infarction , Natriuretic Peptide, Brain/blood , Neuropeptide Y/blood , Peptide Fragments/blood , Probability , Prospective Studies , Sensitivity and Specificity , Serum Albumin, HumanABSTRACT
Pulmonary embolism (PE) is a frequently encountered clinical condition with a high mortality rate that is affected by various factors such as age, hemodynamics, and other comorbidities. Early diagnosis and risk stratification are crucial to achieving a favorable clinical outcome. New risk stratification algorithms have been proposed in order to identify high-risk patients who will benefit from early thrombolytic treatment. Among the various validated diagnostic methods, the role of echocardiography is increasingly accepted. Recent advances in studying right ventricular function have made echocardiography an attractive tool for establishing or excluding the diagnosis of acute PE in the emergency setting and initiating optimal therapy.
Subject(s)
Echocardiography, Doppler, Color , Echocardiography, Transesophageal , Pulmonary Embolism/diagnostic imaging , Acute Disease , Algorithms , Decision Support Techniques , Humans , Predictive Value of Tests , Prognosis , Pulmonary Embolism/mortality , Pulmonary Embolism/physiopathology , Pulmonary Embolism/therapy , Risk Assessment , Risk Factors , Thrombolytic Therapy , Ventricular Function, Left , Ventricular Function, RightABSTRACT
Chronic total occlusions (CTOs) represent the most complex subset of coronary artery disease and therefore careful planning of CTO percutaneous coronary recanalization (PCI) strategy is of paramount importance aiming to achieve procedural success, and improve patient's safety and post CTO PCI outcomes. Intravascular imaging has an essential role in facilitating CTO PCΙ. First, intravascular ultrasound (IVUS), due to its higher penetration depth compared to optical coherence tomography (OCT), and the additional capacity of real-time imaging without need for contrast injection is considered the preferred imaging modality for CTO PCI. Secondly, IVUS can be used to resolve proximal cap ambiguity, facilitate wire re-entry when dissection and re-entry strategies are applied and most importantly to guide stent deployment and optimization post implantation. The role of OCT during CTO PCI is currently limited to stent sizing and optimization, however, due to its high spatial resolution, OCT is ideal for detecting stent edge dissections and strut malapposition. In this review, we describe the use of intravascular imaging for lesion crossing, plaque characterization and wire tracking, extra- or intra-plaque, and stent sizing and optimization during CTO PCI and summarize the findings of the major studies in this field.
ABSTRACT
Percutaneous transluminal coronary angioplasty balloon fracture, retention, and embolization are rare complications of percutaneous coronary intervention. The incidence has historically been estimated at <0.8%, which is likely an underestimate given the increasing quantity and complexity of percutaneous procedures. We demonstrate how to avoid emergency surgery by using basic balloon trapping techniques and a snare in the more distal arterial bed.
Subject(s)
Angioplasty, Balloon, Coronary , Percutaneous Coronary Intervention , Vascular Access Devices , Angioplasty, Balloon, Coronary/adverse effects , Device Removal/methods , Humans , Percutaneous Coronary Intervention/adverse effects , Urinary CathetersABSTRACT
Application of the hybrid algorithm for the treatment of coronary chronic total occlusions requires the operator to readily deploy complex techniques and advanced technologies to achieve successful revascularization. Patient-specific factors and limitations in torquability and material strength of low-profile equipment such as microcatheters can result in procedural complications due to device fracture. Using a mini-series of 2 cases to demonstrate the successful application of antegrade dissection re-entry techniques to overcome such challenges, we highlight procedural complexities and risk, and review prior approaches and literature.
Subject(s)
Coronary Occlusion , Percutaneous Coronary Intervention , Humans , Coronary Occlusion/diagnosis , Coronary Occlusion/surgery , Percutaneous Coronary Intervention/adverse effectsABSTRACT
BACKGROUND: Guidelines endorse a heart team (HT) approach to standardize the decision-making process for patients with complex coronary artery disease (CAD). With percutaneous treatment options for complex CAD increasing, we hypothesized that practice had changed over the past decade-and that more individuals, previously deemed too high risk for intervention, would now be referred for either surgical or percutaneous revascularization. METHODS: This observational study was conducted at St Thomas' Hospital (London, United Kingdom). All patients discussed at HT meetings were recorded and treatment recommendations audited. A subset of historic cases was selected for blinded, repeat discussion. RESULTS: From April 2018 to 2019, a total of 52 HT meetings discussing 375 cases were held. Patients tended to be male, with a majority demonstrating multivessel CAD in the context of preserved left ventricular function. SYNTAX scores were balanced across the tertiles. Thirty-five percent of patients had at least 1 chronic total occlusion (mean J-CTO, 3 [interquartile range, 2-3]), affecting the right coronary artery in 60%. Fifteen historic patients with isolated CTOs were re-presented an average of 8 years later; only 3 patients received the same outcome, with 80% now receiving a recommendation for revascularization over medical therapy. CONCLUSIONS: A dedicated program supporting complex coronary intervention is associated with a change in treatment recommendations issued by the local HT. In line with international guidelines, this might indicate that any complex or multivessel CAD should be discussed at HT meetings with, ideally, the presence of CTO operators.
Subject(s)
Coronary Artery Disease , Coronary Occlusion , Percutaneous Coronary Intervention , Chronic Disease , Coronary Artery Bypass , Coronary Artery Disease/diagnosis , Coronary Artery Disease/surgery , Coronary Occlusion/diagnosis , Coronary Occlusion/surgery , Decision Making , Humans , Male , Percutaneous Coronary Intervention/adverse effects , Risk Factors , Treatment Outcome , United KingdomABSTRACT
Diabetic patients are considered to be at high risk for the development of atherosclerotic disease. Management of hypercholesterolemia is of paramount importance to optimize cardiovascular outcomes in this subset of patients and statins are regarded as the mainstay of treatment. However, the recent advent of PCSK-9 inhibitors has provided a useful alternative in the management of dyslipidemia, especially when statins cannot be tolerated or when hypolipidemic targets cannot be achieved. In this review, we discuss current trends in their use, and we focus on their role in the management of diabetic dyslipidemia.
Subject(s)
Anticholesteremic Agents , Diabetes Mellitus, Type 2 , Dyslipidemias , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Diabetes Mellitus, Type 2/drug therapy , Dyslipidemias/drug therapy , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Proprotein Convertase 9ABSTRACT
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new class of glucose-lowering agents which have changed the landscape of diabetes therapy, due to their remarkable cardiorenal protective properties. The attack of severe acute respiratory syndrome coronavirus 2 on the heart and kidneys shares similarities with diabetes; therefore, the notion that SGLT2i might have a role in the future management of Coronavirus Disease 2019 (COVID-19) is based on a solid pathophysiological hypothesis. SGLT2i have been proved to decrease the expression of proinflammatory cytokines, ameliorate oxidative stress and reduce sympathetic activity, thus resulting in downregulation of both systemic and adipose tissue inflammation. On the other hand, they have been linked to an increased risk of euglycemic diabetic ketoacidosis. Therefore, the efficacy and safety of SGLT2i in COVID-19 are still debatable and remain to be clarified by ongoing randomized trials, to assess whether the benefits of treatment with these drugs outweigh the potential risks.
Subject(s)
COVID-19/complications , Diabetes Mellitus, Type 2/complications , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Diabetes Mellitus, Type 2/drug therapy , Diabetes Mellitus, Type 2/virology , Humans , Risk Assessment , Sodium-Glucose Transporter 2 Inhibitors/adverse effects , COVID-19 Drug TreatmentABSTRACT
Cardiac Troponin (hs-TnT) elevation has been reported in unselected patients hospitalized with COVID-19 however the mechanism and relationship with mortality remain unclear. Consecutive patients admitted to a high-volume intensive care unit (ICU) in London with severe COVID-19 pneumonitis were included if hs-TnT concentration at admission was known. Kaplan-Meier survival analysis performed, with cohorts classified a priori by multiples of the upper limit of normal (ULN). 277 patients were admitted during a 7-week period in 2020; 176 were included (90% received invasive ventilation). hs-TnT at admission was 16.5 (9.0 to 49.3) ng/L, 56% had concentrations >ULN. 56 patients (31.8%) died during the index admission. Admission hs-TnT level was lower in survivors (12.0 (8.0-27.8) vs 28.5 (14.0 to 81.0) ng/L, pâ¯=â¯0.001). Univariate predictors of mortality were age, APACHE-II Score and admission hs-TnT (HR 1.73, pâ¯=â¯0.007). By multivariate regression, only age (HR 1.33, CI: 1.16.to 1.51, p < 0.01) and admission hs-TnT (HR 1.94, CI: 1.22 to 3.10, pâ¯=â¯0.006) remained predictive. Survival was significantly lower when admission hs-TnT was >ULN (log-rank p-value<0.001). Peak hs-TnT was higher in those who died but was not predictive of death after adjustment for other factors. In conclusion, in critically ill patients with COVID-19 pneumonitis, the hs-TnT level at admission is a powerful independent predictor of the likelihood of surviving to discharge from ICU. In most cases, hs-TnT elevation does not represent major myocardial injury but acts as a sensitive integrated biomarker of global stress. Whether stratification based on admission Troponin level could be used to guide prognostication and management warrants further evaluation.
Subject(s)
COVID-19/epidemiology , Critical Care , Hospitalization/statistics & numerical data , Myocardial Infarction/blood , Troponin T/blood , Biomarkers/blood , Comorbidity , Female , Humans , London/epidemiology , Male , Middle Aged , Myocardial Infarction/epidemiology , Prognosis , SARS-CoV-2ABSTRACT
Treatment of chronic total occlusions poses a specific set of challenges above and beyond those encountered in conventional percutaneous coronary intervention. Antegrade dissection and re-entry (ADR) is an established and safe technique with high success rates in experienced centers. CTO techniques frequently require greater-than-usual guide-catheter support and rapid-exchange technologies. Either can be achieved with separate guide extension and a trapping balloon; in this case series of guide-extension facilitated ADR, we highlight the technical advantages gleaned from the use of combined devices such as the TrapLiner guide-extension catheter (Teleflex).
Subject(s)
Coronary Occlusion , Chronic Disease , Coronary Angiography , Coronary Occlusion/diagnosis , Coronary Occlusion/surgery , Dissection , Humans , Percutaneous Coronary Intervention , Treatment OutcomeABSTRACT
We report an unusual case of post-procedural spontaneous spinal epidural hematoma in a 65â¯year old man who presented with an acute coronary syndrome and underwent complex coronary intervention with adjunct use of a GPIIb/IIIa inhibitor. Although spontaneous spinal epidural hematoma (SSEH) following coronary intervention is extremely rare, clinicians should be aware of this unusual diagnosis. Prompt investigation with MRI and early referral for neurosurgical input are recommended to prevent potentially significant sequelae.
Subject(s)
Acute Coronary Syndrome/therapy , Hematoma, Epidural, Spinal/etiology , Percutaneous Coronary Intervention/adverse effects , Acute Coronary Syndrome/diagnostic imaging , Aged , Drug-Eluting Stents , Hematoma, Epidural, Spinal/diagnostic imaging , Hematoma, Epidural, Spinal/drug therapy , Humans , Magnetic Resonance Imaging , Male , Percutaneous Coronary Intervention/instrumentation , Platelet Aggregation Inhibitors/therapeutic use , Treatment OutcomeABSTRACT
Background The Heart Team ( HT ) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease ( CAD ). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion. Methods and Results This observational study was conducted at St Thomas' Hospital (London, UK). Case mixture included unprotected left main, 2-vessel (including proximal left anterior descending artery) CAD , 3-vessel CAD , or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy ( OMT ) alone, OMT +percutaneous coronary intervention ( PCI ), or OMT +coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23-39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3-vessel CAD . Three-year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT + PCI cohort, and 90.2% in the OMT +coronary artery bypass grafting cohort (92 of 102). Conclusions In our experience, the HT approach involved a careful selection process resulting in appropriate patient-specific decision making and good long-term outcomes in patients with complex CAD .
Subject(s)
Cardiology , Cardiovascular Agents/therapeutic use , Clinical Decision-Making/methods , Coronary Artery Bypass , Coronary Artery Disease/therapy , Patient Care Team , Percutaneous Coronary Intervention , Thoracic Surgery , Age Factors , Aged , Aged, 80 and over , Cooperative Behavior , Coronary Artery Disease/epidemiology , Female , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Prospective Studies , Severity of Illness Index , Shock, Cardiogenic/epidemiology , Survival Rate , United Kingdom , Ventricular Dysfunction, Left/epidemiologyABSTRACT
Heavily calcified lesions are encountered with increasing frequency during percutaneous coronary interventions (PCI). This poses a significant problem as it often leads to suboptimal stent expansion, which in turn is a major cause for stent restenosis and thrombosis. Various technologies have been developed to tackle this. The high-pressure balloon (OPN) seems to be a promising adjunct in treating undilatable lesions. In this concise mini review we highlight the use of HPB and we present the current status of technology implemented in complex PCI cases.
Subject(s)
Angioplasty, Balloon, Coronary/instrumentation , Cardiac Catheters , Coronary Artery Disease/surgery , Vascular Calcification/surgery , Aged , Angioplasty, Balloon, Coronary/adverse effects , Atherectomy, Coronary , Coronary Artery Disease/diagnostic imaging , Drug-Eluting Stents , Equipment Design , Female , Humans , Male , Middle Aged , Pressure , Risk Factors , Severity of Illness Index , Treatment Outcome , Vascular Calcification/diagnostic imagingABSTRACT
AIM: The balloon assisted tracking (BAT) technique is utilised to overcome various anatomical difficulties during radial procedures when standard measures such as adequate sedation, pain relief, vasodilators and use of hydrophilic guidewires, fail. The aim of this study was to evaluate the success rates of the BAT technique in overcoming anatomical difficulties during radial coronary interventional procedures. METHODS: We retrospectively reviewed 1100 consecutive patients undergoing coronary procedures from the transradial approach (TRA) between May 2015 and May 2017. Anatomic variations and equipment used were recorded from procedure logs. RESULTS: Overall 30 patients (2.72%) required the use of BAT. Mean age was 66.7years, with a range from 48 to 90years (53.3% female). Out of these 30 cases, 86.7% patients underwent percutaneous coronary intervention (PCI) while the remaining patients underwent coronary angiography alone. Acute coronary syndrome cases represented 63.3% of the cases while the remaining patients were elective procedures. Anatomical difficulties included severe, non-resolving radial spasm (66.6%), catheter induced radial or brachial perforation (16.6%), small calibre and/or diseased radial artery (10.0%), severe radial, branchial and/or subclavian tortuosity (3.0%) and radial loops (3.0%). Anatomical difficulties were overcome in all cases (100%). Coronary angiography and/or PCI were successfully completed in all 30 cases without the need for obtaining alternative arterial access. Mean added procedural time was 131s. There were no procedure related complications. CONCLUSION: Balloon assisted tracking is a highly successful and safe technique for overcoming various anatomical difficulties at the level of the radial, brachial or subclavian arteries, which minimises the need for alternative arterial access.
Subject(s)
Acute Coronary Syndrome/therapy , Angioplasty, Balloon , Cardiac Catheterization , Catheterization, Peripheral/methods , Peripheral Arterial Disease/therapy , Radial Artery , Acute Coronary Syndrome/diagnostic imaging , Aged , Aged, 80 and over , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/instrumentation , Cardiac Catheterization/adverse effects , Catheterization, Peripheral/adverse effects , Coronary Angiography , Feasibility Studies , Female , Humans , Male , Middle Aged , Percutaneous Coronary Intervention , Peripheral Arterial Disease/diagnostic imaging , Radial Artery/diagnostic imaging , Radiography, Interventional , Retrospective Studies , Treatment Outcome , Vascular Access DevicesABSTRACT
BACKGROUND: Chronic total occlusions (CTO) are commonly encountered in patients undergoing coronary angiography; however, percutaneous coronary intervention (PCI) is infrequently performed owing to technical difficulty, the perceived risk of complications and a lack of randomized data. The aim of this study was to analyse the frequency and outcomes of CTO-PCI procedures in a large contemporary cohort of successive patients. PATIENTS AND METHODS: We undertook an observational cohort study of 48 234 patients with stable angina of which 5496 (11.4%) procedures were performed for CTOs between 2005 and 2015 at nine tertiary cardiac centres across London, UK. Outcome was assessed by in-hospital major adverse cardiac events and all-cause mortality at a median follow-up of 4.8 years (interquartile range: 2.2-6.4 years). RESULTS: Over time, there was an increase in the proportion of elective PCI procedures performed for CTOs, but no increase in the absolute number. Overall success rates increased over time (74.3% in 2005 to 81.5% in 2015; P=0.0003) despite an increase in case complexity (previous myocardial infarction, diabetes, renal failure, previous coronary artery bypass grafting, peripheral vascular disease and left ventricular impairment) that correlated with procedural advancements. Successful CTO PCI was associated with lower mortality [9.5%, 95% confidence interval (CI): 8.1-11.6 vs. 15.3%, 95% CI: 13.7-20.6, P<0.0001] that persisted after multivariate cox analysis (hazard ratio: 0.37, 95% CI: 0.25-0.62) and propensity matching (hazard ratio=0.36, 95% CI: 0.18-0.73, P=0.0005). CONCLUSION: Successful procedures were associated with lower mortality suggesting that the greater uptake of CTO PCI may improve clinical outcomes in a wider population than are currently being offered therapy.
Subject(s)
Coronary Occlusion/therapy , Percutaneous Coronary Intervention , Aged , Chronic Disease , Coronary Angiography , Coronary Occlusion/diagnostic imaging , Coronary Occlusion/mortality , Female , Humans , London , Male , Middle Aged , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/mortality , Registries , Retrospective Studies , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: The metabolic syndrome (MetS) is associated with an increased incidence of coronary heart disease (CHD). Postprandial hypertriglyceridaemia is also associated with CHD. The aim of this study was to evaluate the postprandial lipaemia after an oral fat tolerance test (OFTT) in women with MetS. METHODS: OFTT, was given to 21 menopausal women with MetS (defined by the Adult Treatment Panel III) and to 12 healthy menopausal women. Triglyceride (TG) levels were measured before and 2, 4, 6 and 8h after the OFTT. The postprandial response was quantified by the areas under the curve (AUC) of TG levels. MetS women were subdivided according to body mass index (BMI) < or > or =30kg/m(2), and to fasting TG levels < or > or =150mg/dl. RESULTS: The response to the OFTT was significantly higher in the MetS group compared to healthy [AUC(S.D.), in mg/dl/h; 2014(933) versus 732(197), p<0.001]. The subjects with BMI < or > or =30kg/m(2) had similar fasting TG levels [157(60)mg/dl versus 158(67) mg/dl] and AUC [1975(898) versus 2072(1044), respectively]. The MetS women with TG> or =150mg/dl had higher AUC compared to those with TG<150mg/dl [2502(854) versus 1281(441), p=0.002]. In linear regression analysis, where BMI, high-density lipoprotein cholesterol, fasting TG, HOMA-IR and QUICKI were the independent variables, only fasting TGs significantly predicted the AUC (coefficient B=11.866, p=0.008). CONCLUSIONS: The fasting TG concentration is the main determinant of postprandial lipaemia. The obesity state was not an additional determinant for exaggerated postprandial response in MetS women. The abnormal postprandial lipaemia could be added as an important metabolic disturbance to the MetS.
Subject(s)
Dietary Fats/pharmacokinetics , Menopause , Metabolic Syndrome/blood , Postprandial Period/physiology , Triglycerides/metabolism , Area Under Curve , Cholesterol/blood , Cholesterol, HDL/blood , Cholesterol, LDL/blood , Female , Humans , Middle Aged , Triglycerides/bloodABSTRACT
The field of percutaneous intervention for chronic total occlusion (CTO) has enjoyed significant innovations in the recent years. Novel techniques and technologies have revolutionized the field and have resulted in considerably higher success rates even in patients with high anatomical complexity. Successful CTO recanalization is associated with significant clinical benefits, such as the improvement of angina and quality of life, reduced rates of surgical revascularization, improvement of left ventricular function and decreased mortality rates. However, complex CTO procedures often require prolonged x-ray exposure which have been associated with adverse long term outcomes.