Risk Factors for Coronary Heart Disease Among Lebanese Women: A Case-Control Study.

Purpose: Women are increasingly concerned by coronary heart disease (CHD), with peculiarities of their own, particularly concerning risk factors. The aim of the study was to assess the risk factors for CHD in Lebanese women over forty. Patients and Methods: A case-control study was carried out in 6 hospitals in Beirut and Mount-Lebanon, from December 2018 to December 2019 including 1500 patients (1200 controls and 300 cases). Women were stratified into pre- and post-menopausal groups. Personal and medical data were collected from hospital records and during an interview where validated questionnaires were used. Binary logistic regressions were performed to investigate potential predictors of CHD in the 2 groups. Results: In post-menopausal women, dyslipidemia (adjusted odds ratio [aOR], 3.018; 95% confidence interval, 2.102-4.332), hypertension (aOR: 2.449, [1.386-4.327]), a family history of CHD (aOR: 2.724, [1.949-3.808]), cigarette smoking (aOR: 2.317, [1.574-3.410]) and common non-rheumatic joint pain (aOR: 1.457, [1.053-2.016]) were strongly associated with CHD. Conversely, living in Mount Lebanon seemed protective, compared to Beirut (aOR: 0.589, [0.406-0.854]), as well as having a moderate monthly income (aOR: 0.450, [0.220-0.923]), adhering to a Mediterranean diet (aOR: 0.965, [0.936-0.994]), and practicing physical activity [PA] (aOR: 0.396, [0.206-0.759] and 0.725, [0.529-0.992], respectively for high and moderate vs low PA). In pre-menopausal women, dyslipidemia (aOR: 6.938, [1.835-26.224]), hypertension (aOR: 6.195, [1.318-29.119]), family histories of dyslipidemia (aOR: 6.143, [1.560-24.191]) and CHD (aOR: 4.739, [1.336-16.805]) reached statistical significance. Conclusion: The identification of factors associated with CHD in women, some of which are frequent and trivialized in post-menopause, underlines the need to put in place specific and dedicated CHD prevention strategies in women.

Deleterious synergistic effects of acute heart failure and diabetes mellitus in patients with acute coronary syndrome: Data from the FAST-MI Registries.

BACKGROUND: Diabetes mellitus (DM) predisposes patients to acute myocardial infarction (AMI) and acute heart failure (AHF). AIMS: To assess correlates of AHF occurring at the early stage of AMI and synergism between early AHF and DM on 5-year mortality. METHODS: FAST-MI 2005 and 2010 included 7839 consecutive patients admitted for AMI. RESULTS: Overall, 2151 patients (27.4%) had a history of diabetes mellitus (DM), of whom 629 (29.2%) were on insulin. Patients with versus without DM were older (mean age: 70.0 vs. 64.7years; P<0.001), with more comorbidities and more severe coronary artery disease. Early AHF (pulmonary oedema or cardiogenic shock) was the most frequent in-hospital complication (12.5%) and was twice as frequent in patients with versus without DM (20.2% vs. 9.6%; adjusted odds ratio: 1.66, 95% confidence interval [CI]: 1.43-1.94; P<0.001). Among in-hospital survivors, patients with DM without AHF and those with AHF without DM had 50% increases in 5-year mortality (adjusted hazard ratio [aHR]: 1.50, 95% CI: 1.32-1.69 and aHR: 1.46, 95% CI: 1.23-1.74; both P<0.001) versus patients without DM or AHF; with the risk among those with DM and AHF being doubled (aHR: 1.97, 95% CI: 1.66-2.34; P<0.0001). CONCLUSION: Early AHF is the most frequent complication of AMI and is twice as common in patients with versus without DM. After adjustment, early AHF and DM are associated with reduced 5-year survival with synergistic effects in patients with both conditions. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov (NCT00673036 and NCT01237418).

Chimney Stenting for Coronary Occlusion During TAVR: Insights From the Chimney Registry.

OBJECTIVES: The aim of this study was to determine the safety and efficacy of chimney stenting, a bailout technique to treat coronary artery occlusion (CAO). BACKGROUND: CAO during transcatheter aortic valve replacement (TAVR) is a rare but often fatal complication. METHODS: In the international Chimney Registry, patient and procedural characteristics and data on outcomes are retrospectively collected from patients who underwent chimney stenting during TAVR. RESULTS: To date, 16 centers have contributed 60 cases among 12,800 TAVR procedures (0.5%). Chimney stenting was performed for 2 reasons: 1) due to the development of an established CAO (n = 25 [41.6%]); or 2) due to an impending CAO (n = 35 [58.3%]). The majority of cases (92.9%) had 1 or more classical risk factors for CAO. Upfront coronary protection was performed in 44 patients (73.3%). Procedural and in-hospital mortality occurred in 1 and 2 patients, respectively. Myocardial infarction (52.0% vs. 0.0%; p < 0.01), cardiogenic shock (52.0% vs. 2.9%; p < 0.01), and resuscitation (44.0% vs. 2.9%; p < 0.01) all occurred more frequently in patients with established CAO compared with those with impending CAO. The absence of upfront coronary protection was the sole independent risk factor for the combined endpoint of death, cardiogenic shock, or myocardial infarction. During a median follow-up time of 612 days (interquartile range: 405 to 842 days), 2 cases of stent failure were reported (1 in-stent restenosis, 1 possible late stent thrombosis) after 157 and 374 days. CONCLUSIONS: Chimney stenting appears to be an acceptable bailout technique for CAO, with higher event rates among those with established CAO and among those without upfront coronary protection.

Transcatheter Aortic Valve Replacement for Severe Aortic Regurgitation With Acute Refractory Cardiogenic Shock.

From January 2013 to January 2017, 686 consecutive patients were referred to our centre for transcatheter aortic valve replacement, including 5 subjects with severe aortic regurgitation and acute refractory cardiogenic shock. These patients were contraindicated for surgical treatment by the heart team because of high surgical risk (median logistic EuroSCORE: 74.6/Society of Thoracic Surgeons score: 37.9). The success rate of valve implantation was 100% through transfemoral access with self-expandable devices. The observed 30-day mortality rate was 20%. Hence, the transcatheter aortic valve replacement procedure might represent a successful and life-saving intervention for treatment of patients with severe aortic regurgitation who present with acute refractory cardiogenic shock.

Microcatheter-Facilitated Primary Angioplasty in ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Direct stenting is the best method for achieving reperfusion in primary percutaneous coronary intervention (PPCI). We hypothesized that the use of a microcatheter (MC) during PPCI when Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 1 after wire crossing would allow visualization of the downstream artery with an optimal TIMI 3 flow at the end of the procedure. METHODS: In this pilot study, PPCI patients with TIMI flow ≤ 1 after wire crossing formed the MC group (n = 60); the MC was positioned in the distal part of the culprit artery and a small amount of contrast was injected through it to determine stent size and length to treat the culprit lesion. The MC group was compared with previous consecutive patients treated using standard PPCI (n = 94; similar characteristics except for the rate of previous percutaneous coronary intervention). RESULTS: In the MC group, downstream arteries were visualized in 98% of cases and direct stenting was achieved in 72% vs 31% (P < 0.0001). Final TIMI 3 flow was similar in both groups (97%). There was less manual thrombectomy (20% vs 63%; P < 0.001) and bailout glycoprotein IIb/IIIa inhibitor use (6.7% vs 29.8%; P < 0.002). The incidence of major adverse events (death, shock, severe arrhythmia) and left ventricular ejection fraction were similar. The peak cardiac enzymes level was significantly lower in the MC group. CONCLUSIONS: The MC strategy appears feasible and safe. It could allow exploring new strategies on the basis of more systematic direct stenting and prepared reperfusion by injecting drugs through the MC before reperfusion.

Usefulness of Transcatheter Aortic Valve Implantation for Treatment of Pure Native Aortic Valve Regurgitation.

Patients with pure native aortic valve regurgitation (NAVR) and increased surgical risk are often denied surgery. This retrospective study aimed to evaluate the "off-label" use of transcatheter heart valves (THV) for the treatment of NAVR. A total of 254 high surgical risk patients with NAVR (age 74 ± 12 years, Society of Thoracic Surgeons risk score 6.6 ± 6.2%) underwent transcatheter aortic valve implantation (TAVI) with early generation (43%) or newer generation (57%) devices at 46 different sites. Device success was significantly higher in patients treated with newer as compared with early generation THV (82% vs 47%, p <0.001). The difference was driven by lower rates of device malpositioning (9% vs 33%) and aortic regurgitation (AR) ≥ moderate (4% vs 31%) and translated into higher clinical efficacy at 30 days in patients treated with newer as compared with early generation THV (72% vs 56%, p = 0.041). Both THV under- and oversizing were associated with an increased risk of THV malpositioning. In conclusion, TAVI is a feasible treatment strategy in selected high-risk patients with NAVR but is associated with a considerable risk of THV malpositioning and residual AR. Although newer-generation THV are associated with better outcomes, novel devices for the treatment of NAVR are warranted.

[How to detect myocardial ischemia in patients following acute coronary syndrome treated by PCI?] / Quel dépistage de l'ischémie myocardique après angioplastie dans le syndrome coronaire aigu ?

Unstable coronary artery disease is a more aggressive condition than stable coronary artery disease, accounting for the high incidence of major adverse cardiovascular events following acute coronary syndromes (ACS), which includes the need for iterative repeat revascularization. The aim of myocardial ischemia screening in post-ACS patients is to detect this unfavourable evolution (either on initial culprit or non culprit lesions) and to prevent any clinical complication. Although there is no strict recommendation in this particular situation, screening should be based on the use of stress imaging techniques. The optimal timing and frequency for testing will depend on the clinical characteristics of the patients and the coronary revascularization procedure features.

Rupture of mitral valve chordae in hypertrophic cardiomyopathy.

BACKGROUND: While occasional reports of mitral valve chordal rupture have been described in hypertrophic cardiomyopathy, the exact prevalence and characteristics of this event in a large medical cohort have not been reported. AIM: To assess the prevalence of mitral valve chordal rupture in hypertrophic cardiomyopathy and the clinical, echocardiographic, surgical and histological profiles of those patients. METHODS: We searched for patients with mitral valve chordal rupture diagnosed by echocardiography among all electronic files of patients admitted to our centre for hypertrophic cardiomyopathy between 2000 and 2010. RESULTS: Among 580 patients admitted for hypertrophic cardiomyopathy, six patients (1%, 5 men, age 68-71 years) presented with mitral valve chordal rupture, symptomatic in five cases, always involving the posterior mitral leaflet. In all cases, echocardiography before rupture showed mitral valve systolic anterior motion, with anterior (and not posterior) leaflet elongation compared with a random sample of patients with non-obstructive hypertrophic cardiomyopathy (P=0.006) (and similar to that observed in obstructive hypertrophic cardiomyopathy). Significant resting left ventricular outflow tract obstruction was always present before rupture and disappeared after rupture in the five cases requiring mitral valve surgery for severe mitral regurgitation. Histological findings were consistent with extensive myxomatous degeneration in all cases. CONCLUSION: Mitral valve chordal rupture is: infrequent in hypertrophic cardiomyopathy; occurs in aged patients with obstructive disease; involves, essentially, the posterior mitral leaflet; and causes, in general, severe mitral regurgitation requiring surgery. Myxomatous degeneration may be the substrate for rupture in these patients.

Effect of ezetimibe/atorvastatin combination on oxidized low density lipoprotein cholesterol in patients with coronary artery disease or coronary artery disease equivalent.

Ezetimibe is effective in providing additional low-density lipoprotein (LDL) cholesterol lowering when coadministered with statins, but its effect beyond LDL cholesterol lowering is unknown. Oxidized LDL (ox-LDL) is a better predictor of adverse cardiovascular events than standard lipid parameters. The objective of this study was to investigate the effect of ezetimibe on ox-LDL. A total of 100 patients with coronary artery disease or coronary artery disease equivalent were randomized to atorvastatin 40 mg/day and ezetimibe 10 mg/day or to atorvastatin 40 mg/day and placebo. LDL cholesterol, LDL cholesterol subfractions, and ox-LDL were measured at baseline and after 8 weeks of therapy. The ezetimibe group had a larger reduction in total LDL cholesterol compared to placebo. This was due mainly to a larger reduction in large buoyant LDL (24% vs 10%, p = 0.008). Ox-LDL level did not change in the placebo group (50 +/- 13 vs 51 +/- 13 U/L), while it decreased in the ezetimibe group, from 51 +/- 13 to 46 +/- 10 U/L (p = 0.01 vs baseline and p = 0.02 vs final level in placebo). The change in ox-LDL correlated significantly with those in total LDL and in large buoyant LDL (r = 0.6 and r = 0.5, respectively, p <0.01 for both), but not with that of small dense LDL, high-density lipoprotein, or very low density lipoprotein. In conclusion, this study demonstrates that ezetimibe decreases ox-LDL cholesterol through reductions in total LDL cholesterol and in large buoyant LDL cholesterol.