Old Drugs for New Indications in Cardiovascular Medicine.

Inflammation participates in the initiation and progression of atherosclerotic cardiovascular disease, and it is a critical inciting factor leading to acute ischemic events. Evidence has shown that certain anti-inflammatory medications used to treat non-atherosclerotic inflammatory diseases reduce cardiovascular events. This article reviews evidence that commonly used anti-inflammatory therapies (colchicine, allopurinol, methotrexate), reduce cardiovascular events. We discuss potential mechanisms of action, efficacy, and safety of these therapies and propose a clinical trials design to investigate their efficacy.

Prognostic impact of SPECT-MPI after renal transplantation.

BACKGROUND: While renal transplantation is increasingly performed for end-stage renal disease, there is a paucity of data on cardiac screening and prognostication post-transplant. We determined the prognostic value of SPECT-MPI in a cohort who underwent renal transplantation. METHODS: Among 4933 renal transplant recipients identified from the Canadian Organ Replacement Register, we examined outcomes of patients who underwent SPECT-MPI in Ontario, Canada. We determined morbidity and mortality using hospitalization and vital statistics registries, according to SPECT-MPI findings. RESULTS: We studied 282 renal transplant recipients (median age 46 years [25th, 75th percentile 37, 58]) with detailed SPECT-MPI results available, followed for a median of 5.7 (3.3, 7.7) years. Among those undergoing SPECT-MPI (66% pharmacologic stress), 41% had an abnormal summed stress score (SSS > 0) and 31% demonstrated abnormal summed difference score (SDS > 0). Rates of cardiovascular death were 0.4 per 100 person-years among those with normal stress perfusion (SSS = 0) and 0.4 per 100 person-years with SDS = 0. After adjusting for age, sex, prior myocardial infarction (MI), and cardiac risk factors, an SSS ≥ 4 conferred increased risk of cardiovascular death or cardiovascular hospitalization with adjusted hazard ratios of 2.52 (95% CI 1.41, 4.52, P = .002) for SSS 4-6 and 2.61 (95% CI 1.52, 4.49, P < .001) for SSS ≥ 7. SDS was a significant predictor of cardiovascular death or hospitalization, with adjusted hazard ratios of 2.96 (95% CI 1.72, 5.09, P < .001) for SDS 4-6 and 3.26 (95% CI 1.64, 6.50, P < .001) for SDS ≥ 7. CONCLUSION: Among renal transplant recipients, SPECT-MPI predicted risk of cardiovascular death and cardiovascular hospitalization events.

Prophylactic Anticoagulation to Prevent Left Ventricular Thrombus Following Acute Myocardial Infarction: A Systematic Review and Meta-Analysis.

Clinical practice guidelines from the American Heart Association recommend consideration of prophylactic anticoagulation to prevent left ventricular thrombus (LVT) formation in patients with anterior ST-elevation myocardial infarction. These guidelines were given a low certainty of evidence (class IIb, level C), relying primarily on case studies and expert consensus to inform practice. Our objective was to compare the safety and efficacy of prophylactic anticoagulation, in addition to dual antiplatelet therapy, in the current era of timely primary percutaneous coronary intervention. Electronic databases, including EMBASE, MEDLINE, and Cochrane Library, were systematically searched from January 2012 through June 2022. A total of 7,378 publications were screened, and 5 publications were eventually included in this review: 1 randomized control trial and 4 retrospective studies involving 1,461 patients. Data were pooled using a fixed-effects model and reported as odds ratios (ORs) with 95% confidence intervals (CIs). The primary outcome of interest was the rate of LVT formation, and the secondary outcomes were the rate of major bleeding and systemic embolism. Pooled analysis showed a significantly lower rate of LVT formation (OR 0.28, 95% CI 0.11 to 0.73, p <0.01) and significantly higher rates of bleeding (OR 2.85, 95% CI 1.13 to 7.24, p = 0.03) in the triple therapy group compared with dual antiplatelet therapy. No significant difference was observed in the rate of systemic embolism between the groups (OR 0.37, 95% CI 0.12 to 1.13, p = 0.08). In this meta-analysis, there is no conclusive evidence to either support or oppose the use of triple therapy for LVT prevention in patients with anterior ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Appropriately powered randomized controlled trials are warranted to further evaluate the benefits of LVT prevention against the risks of major bleeding in this population.

Incidence of left ventricular thrombus following STEMI in the modern era via multimodality imaging: A systematic review and meta-analysis.

Background: Left ventricular thrombus (LVT) is a significant complication in STEMI. Previous studies were conducted prior to modern timely percutaneous reperfusion networks. Current expert opinion suggests incidence in the current era has decreased. We conducted a systematic review and meta-analysis to better understand the incidence and diagnosis of LVT in patients with STEMI treated with timely percutaneous techniques as assessed by multimodality imaging. Methods: Cochrane, EMBASE, LILACS, and MEDLINE were searched over the last 10 years only including studies using contemporary techniques. The primary outcome was detection of LVT in patients via echocardiogram with or without contrast or Cardiac MRI (cMRI) following STEMI (both anterior and any territory) treated with PCI. Data was pooled across studies and statistical analysis was conducted via random effects model. Results: 31 studies were included. 18 studies included data on any territory STEMI, totaling 14,172 patients, and an incidence of 5.6% [95% CI 4.3-7.0]. 18 studies were included in analysis for anterior STEMI, totaling 7382 patients and incidence of 12.7% [95% CI 9.8-15.6]. Relative to cMRI as a gold standard, the sensitivity of non-contrast echocardiography to detect LVT was 58.2% [95% CI 46.6-69.2] with a specificity of 97.8% [95% CI 96.3-98.8]. Conclusions: Incidence of LVT in STEMI patients treated with contemporary timely percutaneous revascularization is in keeping with historical data and remains significant, suggesting this remains an ongoing issue for further investigation. Numerically, both cMRI and contrast echo detected more LVT compared to non-contrast echo in any-territory STEMI patients.

PR prolongation as a predictor of atrial fibrillation onset: A state-of-the-art review.

First-degree atrioventricular block (1-AVB), characterized by a PR interval exceeding 200 milliseconds, has traditionally been perceived as a benign cardiac condition. Recently, this perception has been challenged by investigations that indicate a potential association between PR prolongation and an elevated risk of atrial fibrillation (AF). To consolidate these findings, we performed a comprehensive review to assess the available evidence indicating a relationship between these two conditions. We searched MEDLINE and EMBASE databases as well as manually searched references of retrieved articles. We selected 18 cohort studies/meta-analyses involving general and special populations. Consistent findings across expansive cohort studies reveal that incremental increases in the PR interval may serve as an independent risk factor for AF. However, our analyses underscore the need for further research into the association between 1-AVB, defined by a specified PR interval cutoff, and the risk of AF.

The Effect of Sex on Door-to-Balloon Time in Patients Presenting With ST-Elevation Myocardial Infarction and Referred for Primary Percutaneous Coronary Intervention: A Systematic Review.

Timely reperfusion using primary percutaneous coronary intervention (pPCI) is the cornerstone of acute ST-elevation myocardial infarction (STEMI) management. We conducted a systematic review to examine the effect of sex on door-to-balloon (D2B) time and symptom-to-balloon (S2B) time. We observed longer D2B times and S2B times in female patients presenting with STEMI and referred for pPCI when compared to male patients. Future work is required to try and elucidate and mitigate sex-based front-line treatment delays for female STEMI patients.

Acute myocardial infarction and anorexia nervosa.

OBJECTIVE: A case of acute myocardial infarction (AMI) in a patient with anorexia nervosa is presented. METHOD: Clinlcal records, electrocardiogram, echocardiogram and coronary angiogram data of a patient with anorexia nervosa, presenting with AMI were evaluated. A Pubmed literature search was used to review cardiac complications of anorexia nervosa. RESULTS: The patient presented with an anterior ST elevation AMI. She underwent emergent coronary angiography with successful reperfusion of a 100% occluded proximal left anterior descending coronary artery. DISCUSSION: Anorexia nervosa is an eatlng disorder affectlng mainly female adolescents. Eating disorders carry the highest mortality rate compared to other psychiatric conditions (Caslero and Frishman, Cardiol Rev 14, 227-231, 2006). It is reported that 80% of patients with an eating disorder are affected by a cardiac complication. Sudden cardiac death secondary to arrhythmia is often the cause of death in these patlents (Caslero and Frishman, Cardiol Rev 14, 227-231, 2006). AMI is rarely described as a cardiac presentation in this patient population.

Preprocedural computed tomography angiography in differentiating chronic total from subtotal coronary occlusions.

INTRODUCTION: Differentiation of chronic total occlusion (CTO) from subtotal coronary occlusions (STOs) is often difficult to make from coronary angiography. These differences are very important, as the technical expertise and tools required are significantly different for revascularization of these lesions. We sought to determine if preprocedural computed tomography angiography (CTA) can help better diagnose and differentiate CTO from STO. METHODS: We searched three databases (Ovid MEDLINE, EMBASE, EBM reviews) from 1 January 1946 to 1 March 2019. Studies reporting on the use of computed tomography (CT) to aid in CTO revascularization were included. Case reports and case series were excluded. RESULTS: We identified 577 articles, and using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method, 4 articles met prespecified inclusion criteria. A total of 669 patients were included. The statistically significant CT-derived parameters determined to help differentiate CTO from STO were found to include longer lesion length (four out of four studies), larger contrast density difference (one out of four studies), presence of collaterals (two out of four studies) and the presence of the reverse attenuation gradient sign (two out of four studies). CONCLUSION: This systematic review shows the utility of preprocedural CTA to help differentiate CTO from STO using a number of CT-derived parameters as above. Further, this study highlights the need for further research to develop specific validated parameters for differentiation of CTO and STO.

The Effect of Transcatheter Mitral Valve Repair on Short-Term Mortality in Patients With Chronic Kidney Disease - A Systematic Review and Meta-Analysis.

Transcatheter Mitral Valve Repair (TMVr) offers clinically significant benefit to select symptomatic patients with severe mitral regurgitation (MR). We conducted a systematic review and meta-analysis of clinical trials and observational studies to identify the effect of pre-procedural Chronic Kidney disease (CKD) on short-term mortality in TMVr. We found CKD is a predictor of 30-day mortality in patients undergoing TMVr. Specifically, a GFR < 30 mL/min conveys a significant increase in 30-day mortality. This is significant for patient selection, prognostication, as well as identifies an area of need for further research. SUMMARY FOR ANNOTATED TABLE OF CONTENTS: A systematic review and meta-analysis looking at short-term mortality in patients undergoing Transcatheter Mitral Valve Repair with chronic kidney disease. Findings show severe renal disease is associated with increased 30-day mortality.

Association Between Revascularization and Quality of Life in Patients With Coronary Chronic Total Occlusions: A Systematic Review.

BACKGROUND: Percutaneous revascularization of coronary chronic total occlusions (CTO) has increased due to advances in technology and operator expertise. Quality of life (QoL) remains an important but understudied outcome following CTO revascularization. Our aim is to conduct a systematic review of the impact of CTO revascularization on QoL. METHODS: We searched three databases (Ovid MEDLINE, EMBASE, EBM reviews) from January 1st, 1990 to May 17th, 2020. Studies reporting on the following QoL metrics post CTO revascularization were included: QoL subscale of the Seattle Angina Questionnaire (SAQ-QoL). The ROBINS-I tool and Cochrane risk of bias tool were used to critically assess for risk of bias. RESULTS: We identified 1476 articles, of which 21 articles met inclusion criteria. Three categories of studies were identified with distinct patient populations. In the first category (1 study), CTO patients treated with either PCI or CABG compared to medical therapy had a significant improvement in SAQ-QoL compared to baseline (PCI 54.2 to 74.3; CABG 56.1 to 78.0; p < 0.05). In the second category (1 study), CTO patients compared to non-CTO patients had similar improvements in SAQ-QoL post PCI (CTO baseline 53.2 to 80.3; non-CTO baseline 56.5 to 80.6; p < 0.05). Finally, a third category with only CTO patients treated with PCI to the CTO vessel included 19 studies, all of which on average showed a significant improvement in SAQ-QoL post successful PCI, compared to non-successful PCI. CONCLUSION: Despite the limited literature, revascularization of CTO vessel was generally associated with improvement in QoL. BRIEF SUMMARY: Quality of life (QoL) is an important but understudied outcome following CTO revascularization. We conducted a systematic review of the impact of CTO revascularization on QoL. Despite the limitations of a lack of enough randomized control trials and the small number of studies, our systematic review highlights a trend of improvement in QoL indices after revascularization of CTO.

Impact of Transcatheter Mitral Valve Repair on Preprocedural and Postprocedural Hospitalization Rates.

OBJECTIVES: The objective of this study was to determine the effect of transcatheter mitral valve repair (TMVr) on hospitalization rates by assessing pre- and postprocedural hospitalization patterns. BACKGROUND: TMVr has emerged as the treatment of choice for selected patients with mitral regurgitation, but the impact of these procedures on hospital utilization remains unclear. METHODS: All patients who underwent TMVr in Ontario, Canada, between 2011 and 2017 were included in this observational study using population-based data. Hospitalization person-year rates were assessed in the years before and after TMVr and 4 predefined intervals: 1 to 30, 31 to 90, 91 to 182, and 183 to 365 days. Main outcomes of interest were all-cause and heart failure (HF) hospitalizations. Poisson regression models were used to compare incidence rates across all time periods. RESULTS: The study cohort included 523 patients. In the year preceding TMVr, 66.2% of patients were hospitalized compared with 47.4% in the year following. There were stepwise increases in both all-cause and HF hospitalization rates in the periods preceding the index procedure, and all postprocedural periods had significantly lower hospitalization rates. The adjusted rate ratios for all-cause and HF-related hospitalization in the year after TMVr were 0.65 (95% CI: 0.56-0.76) and 0.38 (95% CI: 0.29-0.51), respectively. All time periods had significant reductions in all-cause and HF hospitalization in the adjusted analysis. CONCLUSIONS: In this population-based study, significant reductions were observed in both all-cause and HF-related hospitalizations in all time periods after TMVr compared with the year prior. This suggests that TMVr has a sustained effect on hospitalization rates despite a high-risk population.

Canadian Multicenter Chronic Total Occlusion Registry: Ten-Year Follow-Up Results of Chronic Total Occlusion Revascularization.

BACKGROUND: Chronic total occlusions (CTO) occur in nearly 20% of coronary angiograms. CTO revascularization, either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting surgery (CABG), is infrequently performed, approximately one-third of cases. Long-term outcomes are unknown. The objective of the study was to determine whether early CTO revascularization of patients, either by CABG or PCI, was associated with improved clinical outcomes. METHODS: One thousand six hundred twenty-four patients from the Canadian CTO registry were followed for at least 9.75 years. Revascularization was performed according to routine clinical practice. Patients were grouped according to CTO revascularization status (PCI or CABG of CTO vessel, CTO revasc) or no CTO revasc (medical therapy only, or PCI/CABG of non-CTO vessels only), within 3 months of initial angiogram. Patients were followed for mortality, revascularization procedures (PCI and CABG), and hospitalizations for acute coronary syndromes and heart failure. RESULTS: Early CTO revasc was performed in 28.2% of patients (17.5% CABG, 10.7% PCI). The CTO revasc group was younger, with more males and generally fewer comorbidities. There was a significantly lower mortality probability at 10 years in the CTO revascularization group (22.7% [95% CI, 19.0%-26.9%]) compared with the no CTO revasc group (36.6% [95% CI, 33.8%-39.5%]). At 10 years, revascularization rates (14.0% versus 22.8%) and acute coronary syndrome hospitalization rates (10.0% versus 16.6%) were significantly lower in the CTO revasc group. Baseline-adjusted analysis showed CTO revasc was associated with significantly lower all-cause mortality (hazard ratio, 0.67 [95% CI, 0.54-0.84]). In both landmark and time varying analyses, association with lower mortality was particularly robust for CTO revascularization by CABG (hazard ratio 0.56 and 0.60, respectively), with a marginally significant result for PCI in the time varying analysis (hazard ratio 0.711 [95% CI, 0.51-0.998]). CONCLUSIONS: Early CTO revascularization was associated with significantly lower all-cause mortality, revascularization rates, and hospitalization for acute coronary syndrome at 10 years, and mainly driven by outcomes in patients with CABG.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion.

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Cystic tumour of the atrioventricular node: treatment dilemma.

An asymptomatic 18-year-old black woman was found to have an incidental finding of third-degree atrioventricular (AV) block on a routine ECG. 2-Dimensional transthoracic echocardiography showed a heterogeneous mass in the region of the peri-membranous septum in the AV node area. A cardiac MRI showed a well-defined cystic mass arising from the right side of the interatrial septal wall. An MRI compatible permanent pacemaker was implanted with plans to monitor the tumour with non-invasive imaging. Cystic tumour of the AV node is a rare primary cardiac tumour. It is known as the smallest and most common primary cardiac tumour that can cause sudden death. All previous six cases of living patients with cystic tumour of the AV node reported in the literature were females and symptomatic. We present a rare case of a patient with cystic tumour of the AV node, and we highlight the treatment dilemmas for this condition.

Radiation safety in the cardiac catheterization lab: A time series quality improvement initiative.

BACKGROUND: Interventional cardiologists have one of the highest annual radiation exposures yet systems of care that promote radiation safety in cardiac catheterization labs are lacking. This study sought to reduce the frequency of radiation exposure, for PCI procedures, above 1.5Gy in labs utilizing a Phillips system at our local institution by 40%, over a 12-month period. METHODS: We performed a time series study to assess the impact of different interventions on the frequency of radiation exposure above 1.5Gy. Process measures were percent of procedures where collimation and magnification were used and percent of completion of online educational modules. Balancing measures were the mean number of cases performed and mean fluoroscopy time. INTERVENTIONS: Information sessions, online modules, policies and posters were implemented followed by the introduction of a new lab with a novel software (AlluraClarity©) to reduce radiation dose. RESULTS: There was a significant reduction (91%, p<0.05) in the frequency of radiation exposure above 1.5Gy after utilizing a novel software (AlluraClarity©) in a new Phillips lab. Process measures of use of collimation (95.0% to 98.0%), use of magnification (20.0% to 14.0%) and completion of online modules (62%) helped track implementation. The mean number of cases performed and mean fluoroscopy time did not change significantly. CONCLUSION: While educational strategies had limited impact on reducing radiation exposure, implementing a novel software system provided the most effective means of reducing radiation exposure.

Management of Chronic Total Coronary Occlusion in Stable Ischemic Heart Disease by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Versus Medical Therapy.

Coronary chronic total occlusions (CTOs) are found in approximately 20% of angiograms. We sought to assess the variation in the management of patients with CTOs and to compare the clinical outcomes of CTO lesions with those of non-CTO lesions. We conducted a population-based cohort study and included all patients with stable angina who underwent cardiac catheterization from October 1, 2012, to June 30, 2013, in Ontario, Canada. The primary outcome was a composite of mortality and hospitalization for myocardial infarction. A total of 7,864 patients were included, of whom 2,279 (29%) had a CTO. There were substantial differences in revascularization rates for patients with CTOs across hospitals in Ontario (44.9% to 94.1%). Revascularization was associated with improved outcomes in the overall cohort. Although the advantage of coronary artery bypass grafting over medical therapy was consistent in both patients with CTOs and patients without CTOs, the benefit of percutaneous coronary intervention (PCI) was limited to patients without CTOs (hazard ratio 0.56, 95% confidence interval 0.40- to 0.78), with no difference in patients with CTOs. The CTO lesion, however, was revascularized in few of the PCI cases (41.1%), with PCI limited to the non-CTO lesion in most patients.

Role of palliative radiotherapy in the management of mural cardiac metastases: who, when and how to treat? A case series of 10 patients.

Cardiac metastases (CM), although a rare manifestation of metastatic cancer, are increasing in incidence with the improved prognosis and increased longevity of many patients with cancer. This condition may be life-threatening, especially for bulky rapidly growing tumors. Such cancer presentations may be amenable to palliative radiotherapy to improve symptoms and to prevent further cardiac function decline. Here, we report on our experience with 10 patients with mural CM who received radiotherapy (RT) to the heart with palliative intent. The radiation treatment was given in different clinical situations using different dose and fractionation, and with a variety of outcomes. Palliative RT was a reasonably effective treatment, leading to good radiographic response in five patients who were evaluable for radiologic response. The mean duration of response in responding patients was 6.3 months (range: 3-11 months). This report describing clinical dilemmas around CM radiation therapy summarizes the previous experiences with radiation in treatment of CM and may assist in the considerations of palliative treatment for these patients.

Percutaneous Coronary Intervention in a Patient With Severe Systemic Vasculitis and Myocardial Infarction.

A 72-year-old woman presented with acute coronary syndrome. There was diffuse coronary ectasia and severe stenosis in the proximal left anterior descending artery consistent with coronary vasculitis. Despite treatment with high-dose immunosuppression, she underwent percutaneous coronary intervention for refractory angina.