Case Report: Asymptomatic SARS-COV2 infection triggering recurrent Takotsubo syndrome.

Takotsubo syndrome (TTS) is a rare disease mimicking acute coronary syndrome, often triggered by physical or emotional stress, and characterized by transient left ventricular dysfunction. Recurrences are described in about 5% of cases and may have different clinical and imaging patterns. In the present report, SARS-COV-2 infection, even in the absence of symptoms and overt emotional stress, seems correlated with recurrence of TTS, due to the absence of other recognized triggers. The hypothesis is that in predisposed patients, events like catecholamine-induced myocyte injury, direct viral damage, cytokine storm, immune-mediated damage, and procoagulant state, all possibly induced by the infection, may elicit endothelial dysfunction as substrate for TTS onset.

Immediate coronary angiography and systematic targeted temperature management are associated with improved outcome in comatose survivors of cardiac arrest.

Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short- and long-term outcome of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. All consecutive comatose CA survivors without obvious extra-cardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST elevation on electrocardiogram, and good neurological recovery. We enrolled 107 patients with a median age of 64.9 (57.7-73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty-six (61.7%) patients underwent PCI. In-hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in-hospital survival. Long-term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log-rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non-shockable) and ST deviation (elevation vs no-elevation), and improved the long-term survival of patients discharged with good neurological recovery. Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST deviation in the post-ROSC electrocardiogram. The benefit was sustained at long-term particularly in those with neurological recovery.

Tailored medical and interventional therapy against recurrent stent thrombosis after drug-eluting stenting.

Dual antiplatelet therapy with aspirin and a thienopyridine (ticlopidine or clopidogrel) has strikingly improved the results of percutaneous coronary intervention (PCI) through a marked reduction in the rate of stent thrombosis (ST). Emerging data suggest that resistance to antiplatelet treatment may be a risk factor for ST. We report about a patient, aspirin and clopidogrel poor responder, who experienced 4 ST in 10 days. After the second ST, during antiplatelet therapy with aspirin (100 mg/die) and clopidogrel (75 mg/die), the patient's platelet function was investigated with Platelet Function Analyzer 100, VerifyNow P2Y12 System and light transmission aggregometry (LTA). High platelet reactivity and combined resistance to aspirin and clopidogrel were found, and, as a consequence, treatment was switched to clopidogrel 150 mg and aspirin 300 mg/die. In spite of this adjustment, the third ST occurred. Poor responsiveness to aspirin and clopidogrel was still confirmed. Because of combined clopidogrel and aspirin resistance and to unsuccessful PCI treatment, a single coronary artery bypass graft (CABG) was planned. Awaiting surgery, 3 days later, the fourth ST occurred. It is angiographically confirmed and thus, CABG was performed. After CABG, in chronic treatment with aspirin (300 mg/die) and ticlopidine (500 mg/die), no bleeding complications occurred and the patient did not experience recurrent ischemia (2 years follow-up). A better platelet inhibition by ticlopidine than that obtained by clopidogrel was observed. Our case report remarks the importance to identify these poor responder patients as the treatment can be tailored with alternative therapeutic options (ticlopidine, prasugrel, warfarin) and/or different revascularization strategies (CABG).

Abciximab: a reappraisal of its use in coronary care.

Platelet reactivity plays a pivotal role in the pathogenesis of ischemic adverse events during and after acute coronary syndromes (ACS), and percutaneous coronary intervention (PCI). Glycoprotein (GP) IIb/IIIa inhibitors are the strongest antiplatelet agents currently available on the market and three different compounds, namely abciximab, tirofiban, and eptifibatide, have been approved for clinical use. Abciximab has been investigated in the clinical field far more extensively than the other GPIIb/IIIa inhibitors. Abciximab is an anti-integrin Fab fragment of a human - mouse chimeric monoclonal antibody with high affinity and a slow dissociation rate from the GP IIb/IIIa platelet receptor. Abciximab, given shortly before the coronary intervention, is superior to placebo in reducing the acute risk of ischemic complications (EPIC, EPISTENT, EPILOG trials); moreover, in the ISAR-REACT 2 study abciximab has been shown to reduce the risk of adverse events in patients with non ST-segment elevation ACS who are undergoing PCI even after optimal pre-treatment with 600 mg of clopidogrel. Finally, abciximab has been also used in abciximab-coated stent, with only bolus administration regimen and for direct intracoronary use with promising results that may extend and/or modify its current use in clinical practice in future.

Two-year clinical follow-up after sirolimus-eluting versus bare-metal stent implantation assisted by systematic glycoprotein IIb/IIIa Inhibitor Infusion in patients with myocardial infarction: results from the STRATEGY study.

OBJECTIVES: We sought to investigate whether the previously reported midterm clinical benefit of planned sirolimus-eluting stent (SES) implantation in patients with ST-segment elevation myocardial infarction (STEMI) was maintained over a 24-month time period. Moreover, the distribution of clinical events in relation to thienopyridine discontinuation was thoroughly investigated. BACKGROUND: No randomized data are currently available on the safety/benefit profile of SES in this subset of patients beyond 12 months. METHODS: Between March 2003 and April 2004, 175 patients with STEMI were randomly allocated to tirofiban infusion followed by SES or abciximab plus bare-metal stent (BMS). Complete follow-up information up to 720 days was available for all patients. RESULTS: The cumulative incidence of death, myocardial infarction (MI), or target vessel revascularization (TVR) remained lower in the tirofiban-SES compared with the abciximab-BMS group at 2 years (24.2% vs. 38.6%, respectively; hazard ratio [HR] 0.56 [95% confidence interval (CI) 0.33 to 0.98]; p = 0.038). The composite of death/MI was similar in the tirofiban-SES (16.1%) and the abciximab-BMS groups (20.5%, HR 0.77 [95% CI 0.38 to 1.55]; p = 0.43) while the need for TVR was markedly reduced (9.8% vs. 25.5%, respectively; HR 0.34 [95% CI 0.16 to 0.77]; p = 0.01) in the tirofiban-SES arm. The rate of confirmed, probable, or possible stent thrombosis did not differ in the 2 groups, nor the incidence of death/MI after thienopyridine discontinuation. CONCLUSIONS: The midterm clinical benefit of planned SES implantation assisted by tirofiban infusion in STEMI patients was mainly carried over after 2 years with no overall excess of late adverse events after thienopyridine discontinuation.

Assessing health risk from benzene pollution in an urban area.

A health hazard, specifically the leukaemia risk, is evaluated from different sources of benzene exposure with relation to a population living in an urban area of Italy. The population exposure is calculated for a reference year by sex and lifestyle, with respect to smokers and non smokers. Potential health risk is therefore quantified by means of mathematical models and the relative significance of the different sources is described. The results of the analysis are useful for the identification of appropriate risk reduction strategies to minimize exposure, in particular when resulting from lifestyle and personal activities.