Direct Oral Anticoagulation Versus Warfarin in Left Ventricular Thrombus: Pooled Analysis of Randomized Controlled Trials.

Patients with impaired left ventricular (LV) function can develop LV thrombus, a potentially life-threatening condition due to risk of stroke and embolization. Conventional treatment with vitamin K antagonists (VKAs; e.g., warfarin) puts patients at risk of bleeding, and the use of direct oral anticoagulants (DOACs) appears promising, although data are scant. We searched the published English language literature for randomized controlled trials (RCTs) comparing DOACs with VKAs in LV thrombus. End points were failure to resolve, thromboembolic events (stroke, embolism), bleeding, or any adverse event (composite of thromboembolism or bleeding), or all-cause death. Data were pooled and analyzed in hierarchical Bayesian models. In three eligible RCTs, 141 patients were studied during an average of 4.6 months (53.8 patient-years; n = 71 assigned to DOAC, n = 70 assigned to VKA). A similar number of patients in each treatment arm demonstrated failure to resolve (DOAC: 14/71 vs. VKA: 15/70) and death events (3/71 vs. 4/70). However, patients on DOACs suffered fewer strokes/thromboembolic events (1/71 vs. 7/70; log odds ratio [OR], -2.02 [95% credible interval (CI95 ), -4.53 to -0.31]) and fewer bleeding events (2/71 vs. 9/70; log OR, -1.62 [CI95 , -3.43 to -0.26]), leading to fewer patients on DOACs with any adverse event versus VKAs (3/71 vs. 16/70; log OR, -1.93 [CI95 , -3.33 to -0.75]). In conclusion, pooled analysis of RCT data favors DOACs over VKAs in patients with LV thrombus in terms of both efficacy and safety.

Patterns of Care and Outcomes of Ambulatory Endovascular Interventions in Lower Extremity Peripheral Arterial Disease.

Lower extremity endovascular intervention (LE-EVI) is gaining popularity as the primary treatment modality for patients with symptomatic peripheral artery disease refractory to noninvasive management. We examined the contemporary patterns of care, regional variation, and outcomes of ambulatory LE-EVI in the United States. The National Ambulatory Surgery Sample was analyzed to identify 266,563 records with peripheral artery disease and LE-EVI between January 1, 2016 and December 31, 2017. The mean age of the study cohort was 68.9 years and 40.5% were women. The majority of the endovascular interventions were performed at large (58.1%), urban teaching (64.1%), private not-for-profit (76.8%) centers, and the southern region accounted for most cases (43%). Periprocedural major adverse renal and cardiovascular events and other complications were 0.5% and 3.3%, respectively. Most patients (97.6%) were discharged home after the procedure. Age, female gender, uncontrolled hypertension, ischemic heart disease, heart failure, arrhythmia, chronic kidney disease, malnutrition, non-Medicare insurance, private for-profit, urban teaching facilities, and southern and midwest regions were associated with higher odds of major adverse renal and cardiovascular events. The mean charges per patient encounter were $56,500, with significant differences across various patient and facility characteristics. In conclusion, our study demonstrates the use, patterns of care, financial aspect, and overall safety of ambulatory LE-EVIs in a real-world setting.

Contemporary Interventional Approach to Calcified Coronary Artery Disease.

Calcific coronary artery disease is an increasingly prevalent entity in the catheterization laboratory which has implications for stenting and expected outcomes. With new interventional techniques and equipment, strategies to favorably modify coronary calcium prior to stenting continue to evolve. This paper sought to review the latest advances in the management of severe coronary artery calcification in the catheterization laboratory and discuss contemporary percutaneous interventional approaches.

Oxymetazoline hydrochloride ophthalmic solution, 0.1%, boosts the effects of botulinum toxin on blepharospasm: a case series.

BACKGROUND: Oxymetazoline hydrochloride ophthalmic solution (0.1%) is a medication used to treat blepharoptosis. Patients who suffer from blepharoptosis have low-lying eyelids that can hinder their vision. Oxymetazoline hydrochloride ophthalmic solution (0.1%) is prescribed to patients to improve their vision by lifting the upper eyelids. Blepharospasm consists of involuntary, bilateral orbicularis oculi muscle movements that result in twitching and eyelid closure. Botulinum toxin is a treatment used to treat blepharospasm by preventing muscle contraction; but it is not always effective. CASE PRESENTATION: The effects of treatment with both oxymetazoline hydrochloride ophthalmic solution (0.1%) and botulinum toxin are assessed in three patients: (1) Patient A, a 58-year-old Filipina woman; (2) patient B, a 62-year-old Korean woman; and (3) patient C, A 57-year-old Vietnamese woman. All patients had been diagnosed with blepharoptosis as well as blepharospasm. Each patient was given an opportunity to complete an optional survey to assess not only the efficacy of oxymetazoline hydrochloride ophthalmic solution (0.1%) together with botulinum toxin but also their perceived stress during the past month. CONCLUSIONS: Administering botulinum toxin for the treatment of blepharospasm in patients A and B yielded the expected results; adding oxymetazoline hydrochloride ophthalmic solution (0.1%), a medical treatment for ptosis, to the treatment regimen yielded an unexpected reduction of blepharospasm. We propose that botulinum toxin and oxymetazoline hydrochloride ophthalmic solution (0.1%) can have a synergistic effect on reducing blepharospasm when used concomitantly. We present three cases in which combined use of botulinum toxin with oxymetazoline hydrochloride ophthalmic solution (0.1%) reduced blepharospasm, and propose possible reasons for such effects. We also discuss previous literature in agreement with the results of our cases.

Prevalence of major electrocardiographic abnormalities in patients with hypertension in a primary care clinic in Hong Kong.

BACKGROUND: Hypertension is strongly associated with cardiovascular events. Studies have shown that electrocardiographic (ECG) abnormalities were associated with increased risks for cardiovascular events. However local data is limited. The objectives of this study were: (1) to determine the prevalence of major electrocardiographic abnormalities in patients with hypertension in primary care in Hong Kong, and (2) to determine the association of major electrocardiographic abnormalities with patients' socio-economical background, cardiovascular disease and cardiovascular risk factors. METHODS: This was a cross-sectional study. Subjects were hypertensive patients aged between 18 and 80 who were enrolled in the Risk Assessment and Management Programme (RAMP) in a general outpatient clinic in Hong Kong. Outcome measures were prevalence of probable ischaemic heart disease (IHD), complete left bundle branch block (LBBB), left ventricular hypertrophy (LVH) and atrial fibrillation (AF) in patients with hypertension. The Pearson Chi-square test, independent t-test and Mantel-Haenszel test were used to measure the association between socioeconomic characteristics and cardiovascular risk factors, and ECG abnormalities. RESULTS: 504 hypertensive patients aged 18-80 were recruited in a general outpatient clinic. 6.3% had probable IHD, 0.4% had complete LBBB, 4.0% had LVH and 1.0% had AF. Probable IHD was associated with smoking (P = 0.032), hypercholesterolaemia (P = 0.037) and higher 10-year CV risk (P = 0.04). Complete LBBB was associated with smoking (P = 0.021) and hypercholesterolaemia (P = 0.022). LVH was associated with male gender (P = 0.001) and longer duration of hypertension (P = 0.035). AF was not significantly associated with any of the clinical or sociodemographic parameters. CONCLUSIONS: This study showed that a significant proportion of patients with hypertension at the primary care setting in Hong Kong had probable ischaemic heart disease, left ventricular hypertrophy and atrial fibrillation. This finding is consistent with both overseas data and historic data in Hong Kong. The detection of electrocardiographic abnormalities is helpful in hypertension management by improving risk stratification.

Intraocular pressure improvement in patients receiving teprotumumab for the treatment of thyroid eye disease: a case series.

BACKGROUND: Teprotumumab is a novel treatment that reduces inflammation and symptoms caused by thyroid eye disease. There are limited data on teprotumumab's effect on intraocular pressure. CASE PRESENTATION: We report nine patients diagnosed with thyroid eye disease whose intraocular pressure decreased during teprotumumab treatment for 8 weeks: patient 1, a 67-year-old Hispanic woman; patient 2, an 86-year-old African-American man; patient 3, a 71-year-old Caucasian woman; patient 4, a 72-year-old Hispanic woman; patient 5, a 65-year-old Caucasian woman; patient 6, a 54-year-old Caucasian man; patient 7, a 54-year-old Asian man; patient 8, a 31-year-old Asian woman; patient 9, a 60-year-old Caucasian woman. The diagnosis of thyroid eye disease was based on increased redness, swelling, and excessive tearing; abnormal proptosis, lid retraction, and diplopia measurements were also taken during physical examination. Intraocular pressure in primary, lateral gaze, and upgaze was documented. There was significant (p = 0.0397) improvement of primary gaze eye pressure from pre-teprotumumab infusions (baseline) to completion of the treatment course. CONCLUSIONS: Teprotumumab significantly decreased the intraocular pressure for patients during the duration of the study. Teprotumumab is a novel medication that is approved for the primary treatment of thyroid eye disease in both acute and chronic thyroid eye disease. Previous treatments used to treat thyroid eye disease include glucocorticoids, radiotherapy, or orbital decompression surgery; however, these treatments all have significant limitations. Teprotumumab is an effective noninvasive alternative for decreasing symptoms of thyroid eye disease and, as shown, also lowers intraocular pressure. However, teprotumumab should not be used as a substitute for glaucoma medications; its ability to lower intraocular pressure may be in addition to lowering periorbital pressure and retro-orbital pressure.

Novel Three-Stent Strategy in Left Main Coronary Artery Trifurcation Disease - Combination of DK Crush and Culotte Techniques.

True trifurcation disease in left main coronary artery is an infrequent but highly complex substrate for percutaneous coronary intervention. Evidence for optimal stenting strategy for such anatomy is lacking. We describe a novel three-stent strategy using a combination of double-kissing crush (DK crush) and Culotte techniques in three patients. This approach, based on established bifurcation stenting techniques, appeared reproducible in all three cases.

Absorbable Suture Embolization in Distal Coronary Perforation.

Coronary artery perforation is a rare but serious complication during percutaneous coronary intervention. Distal or small vessel perforation is usually treated by coil, fat, or microsphere embolization. We describe 5 cases of distal coronary perforation that were managed successfully by a novel technique that uses absorbable sutures. (Level of Difficulty: Advanced.).

Acute Myocardial Infarction Within 24 Hours After COVID-19 Vaccination.

COVID-19 vaccination was launched in the United States in mid-December 2020. There are limited data on the risk of thrombotic events related to COVID-19 vaccines. In conclusion, we report 2 cases of acute myocardial infarction with onset <24 hours after the first dose of a COVID-19 vaccine in patients presenting with shoulder pain.

Left circumflex artery injury following surgical mitral valve replacement: a case report.

BACKGROUND: Mitral valve (MV) repair or replacement surgery is indicated for a variety of conditions. Although uncommon, damage to the left circumflex (LCx) coronary artery, which courses in close proximity to the MV annulus, is a devastating complication. CASE SUMMARY: This report describes the case of a 63-year-old woman following re-operative MV replacement. Shortly after being transferred to the surgical intensive care unit after MV replacement, her EKG was notable for persistent inferolateral ST-segment elevations and reciprocal ST-segment depressions. Emergency transthoracic echocardiogram revealed a reduced left ventricular ejection fraction of 35-40% and mid to distal lateral wall motion hypokinesis. She was emergently taken to the cardiac catheterization laboratory where coronary angiography demonstrated complete occlusion of her mid LCx artery. She underwent urgent percutaneous coronary intervention of the lesion and was started on dual antiplatelet treatment, anticoagulation for comorbid atrial fibrillation, as well as guideline directed medical therapy with improvement in her EKG changes and cardiac function. CONCLUSION: Prompt diagnosis and recognition of LCx injury is crucial. Management involves immediate percutaneous recanalization or surgical coronary bypass grafting.

Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department.

BACKGROUND: Assessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores. OBJECTIVE: Our aim was to assess the performance of Thrombosis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); history, electrocardiogram, age, risk factors, and troponin (HEART) scores; and the North America Chest Pain Rule (NACPR) without components of clinical gestalt in predicting 30-day major adverse cardiac events (MACE). METHODS: We performed a prospective cohort study in adult patients who attended the ED with undifferentiated chest pain. Clinical prediction rules were applied and calculated. The clinical prediction rules were modified from the original ones, excluding components requiring judgment by clinical gestalt. The primary outcome was MACE. Performance of the tests were evaluated by receive operating characteristic curves and the area under curves (AUC). RESULTS: There were 1081 patients included in the study. Thirty-day MACE occurred in 164 (15.2%) patients. The AUC of the GRACE score was 0.756, which was inferior to the TIMI score (AUC 0.809) and the HEART score (AUC 0.845). A TIMI score ≥ 1 had a sensitivity of 97% and a specificity of 45.7%. A GRACE score ≥ 50 had a sensitivity of 99.4% and a specificity of 7.5%. A HEART score ≥ 1 had a sensitivity of 98.8% and a specificity of 11.7%. The NACPR had a sensitivity of 93.3% and a specificity of 51.5%. CONCLUSIONS: Without clinical gestalt, the modified HEART score had the best discriminative capacity in predicting 30-day MACE.

Carboxyl-terminal truncated HBx regulates a distinct microRNA transcription program in hepatocellular carcinoma development.

BACKGROUND: The biological pathways and functional properties by which misexpressed microRNAs (miRNAs) contribute to liver carcinogenesis have been intensively investigated. However, little is known about the upstream mechanisms that deregulate miRNA expressions in this process. In hepatocellular carcinoma (HCC), hepatitis B virus (HBV) X protein (HBx), a transcriptional trans-activator, is frequently expressed in truncated form without carboxyl-terminus but its role in miRNA expression and HCC development is unclear. METHODS: Human non-tumorigenic hepatocytes were infected with lentivirus-expressing full-length and carboxyl-terminal truncated HBx (Ct-HBx) for cell growth assay and miRNA profiling. Chromatin immunoprecipitation microarray was performed to identify the miRNA promoters directly associated with HBx. Direct transcriptional control was verified by luciferase reporter assay. The differential miRNA expressions were further validated in a cohort of HBV-associated HCC tissues using real-time PCR. RESULTS: Hepatocytes expressing Ct-HBx grew significantly faster than the full-length HBx counterparts. Ct-HBx decreased while full-length HBx increased the expression of a set of miRNAs with growth-suppressive functions. Interestingly, Ct-HBx bound to and inhibited the transcriptional activity of some of these miRNA promoters. Notably, some of the examined repressed-miRNAs (miR-26a, -29c, -146a and -190) were also significantly down-regulated in a subset of HCC tissues with carboxyl-terminal HBx truncation compared to their matching non-tumor tissues, highlighting the clinical relevance of our data. CONCLUSION: Our results suggest that Ct-HBx directly regulates miRNA transcription and in turn promotes hepatocellular proliferation, thus revealing a viral contribution of miRNA deregulation during hepatocarcinogenesis.