Role of Cyp2c19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: Identification of a reliable discriminatory test to accurately stratify patient responses to antiplatelet therapy following coronary revascularization has become increasingly desirable to optimize therapeutic efficacy and safety. RECENT FINDINGS: The expansion of platelet function testing to include genotype assessment has been an evolutionary journey, initially fraught with confounding results. However, more recent and rigorous data analysis suggests that genotype testing- guided, tailored antiplatelet therapy may hold promise in optimizing treatment of patients after coronary intervention. Current evidence increasingly supports the use of genotype guided CYP2C19 testing to better match the post coronary intervention patient with the most efficacious and least risky antiplatelet inhibitor. The risk stratification of poor, intermediate, and good metabolizers of these drugs with such testing promises to yield clinical dividends in terms of morbidity, mortality and cost control, in this growing patient population.

Sleep apnea and cardiovascular risk.

PURPOSE OF REVIEW: Obstructive sleep apnea (OSA) is associated with several cardiovascular risk predictors that have only recently begun to be studied in detail. The strong association between OSA and hypertension, coronary artery disease, congestive heart failure, and sudden cardiac death underscores its significant impact on cardiovascular health. This brief review considers the links between OSA and cardiovascular risk. RECENT FINDINGS: OSA is an important contributor to endothelial dysfunction and damage, while repetitive hypoxia and hypercarbia contribute to autonomic dysfunction and sympathetic stimulation. In turn, these derangements have deleterious hematologic effects, including hypercoagulability and abnormal platelet aggregability, which are important in the pathogenesis of atherothrombotic disease. SUMMARY: The varied deleterious effects of OSA on cardiovascular health stem from a unique 'perfect storm' of hypoxic oxidative stress, autonomic dysregulation, endothelial damage, and inflammation occurring at the microvascular level. Further research may disentangle these multiple etiologic threads and provide a better understanding of the underlying pathophysiological relationship between OSA and cardiovascular disease.

PCI or CABG for Left Main Disease: Does Disease Location Matter?

PURPOSE OF REVIEW: This review attempts to specifically assess impact of disease location in left main artery on mortality and cardiovascular outcomes in patients treated with percutaneous coronary intervention versus coronary artery bypass surgery. RECENT FINDINGS: The management of left main disease, once thought to be the sole province of cardiothoracic surgeon, has recently undergone a reappraisal by the cardiovascular medicine community. For many years, societal guideline recommendations advised bypass surgery as the "de rigeur" method of revascularization for unprotected left main disease. However, recent studies suggest that coronary intervention, especially with advances in drug-eluting stent technology, has mounted a serious challenge to surgical bypass in treatment of this disease. Although overall mortality rates are comparable for percutaneous coronary intervention and bypass surgery, left main disease location does influence long-term outcomes for percutaneous coronary intervention more than bypass surgery. A patient- and lesion-centered approach to treatment of this disease may provide optimal outcomes.

Food for Thought or Feeding a Dogma? Diet and Coronary Artery Disease: a Clinician's Perspective.

PURPOSE OF REVIEW: To provide an overview of nutrition studies evaluating the association of dietary saturated fat and meat intake with the development of coronary artery disease (CAD) and discuss implications of recent data. RECENT FINDINGS: Recent studies have led to the re-evaluation of the role of saturated fat in CAD. Randomized controlled trials (RCTs) support Mediterranean diet to reduce cardiovascular risk. Recent data revealed significant association of intake of meat or poultry with increased risk, but fish consumption was associated with lower risk of incident CAD. In this review, we provide a brief overview of the studies and data that have led to the re-evaluation of the link between saturated fat and CAD. Due to conflicting data from long-term prospective cohort studies and significant heterogeneity, associations of unprocessed meat with CAD are less clear compared to the role of processed meat. Pooled data from prospective cohort studies have overcome some of these limitations and show association of both processed and unprocessed meat and poultry intake but not fish consumption with incident CAD. These findings were also validated recently in a large UK Biobank prospective study. While recognizing the limitations of these cohort studies, we discuss relevant landmark RCTs. We finally consider the challenges with RCTs in nutrition research to improve the quality of evidence and need for evidence-based dietary guidelines with respect to saturated fat intake from a clinical perspective.

What's past is prologue.

Above knee and below knee patency for synthetic endografts are vastly different. Long-term data is encouragingly similar to synthetic bypass grafting. Optimize use of synthetic endografts in above knee femoropopliteal segments in non-critical limb ischemia patients.

Medical and interventional options to treat pulmonary embolism.

Venous thromboembolism remains one of the most common conditions. Pulmonary embolism carries a mortality rate of over 15 % in the first 3 months after diagnosis. Venous thromboembolism is the fourth leading cause of death in the Western world, and the third leading cause of cardiovascular death trailing myocardial infarction and stroke. This section highlights the medical and interventional options presently available to treat this potentially lethal disease.

Reduced-Dose Thrombolysis in Acute Pulmonary Embolism A Systematic Review.

Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality and the second-leading cause of death in cancer patients. The clinical efficacy of thrombolysis for acute PE has been proven, yet the therapeutic window seems narrow, and the optimal dosing for pharmaceutical reperfusion therapy has not been established. Higher doses of systemic thrombolysis inevitably associated with an incremental increase in major bleeding risk. To date, there is no high-quality evidence regarding dosing and infusion rates of thrombolytic agents to treat acute PE. Most clinical trials have focused on thrombolysis compared with anticoagulation alone, but dose-finding studies are lacking. Evidence is now emerging that lower-dose thrombolytic administered through a peripheral vein is efficacious in accelerating thrombolysis in the central pulmonary artery and preventing acute right heart failure, with reduced risk for major bleeding. The present review will systematically summarize the current evidence of low-dose thrombolysis in acute PE.

Evaluation of Four Validated Risk Scores to Predict Outcomes in Hispanic Patients With Acute Pulmonary Embolism.

Risk stratification plays an essential role in the management of acute pulmonary embolism (PE). Several risk scores have been studied to support risk stratification and management. While ethnic differences in acute PE risk factors exist, current risk scores lack validation for Hispanic patients. Therefore, the present study retrospectively investigated the performance of the pulmonary embolism severity index (PESI), simplified PESI (sPESI), the European Society of Cardiology risk assessment (ESC), and the Bova score, to predict 30-day mortality in Hispanic patients presenting with an acute PE. Among 437 patients admitted with acute PE, 30-day mortality was 10.8%; 30-day mortality in low-risk groups ranged from 0% (sPESI, ESC) to 0.2% (PESI, Bova), and 3.0% (Bova) to 5.7% (PESI) in the highest risk groups, respectively. All four scores produced statistically significant discrimination between different risk strata. However, no single scoring system was able to identify all patients with 30-day mortality. The findings of the present study suggest that PESI, sPESI, ESC, and Bova scores provide important information about 30-day mortality in Hispanic in-patients presenting with acute PE. However, additional clinical information could further improve predictability that is not provided by a single scoring system.

Low-Dose Alteplase versus Conventional Anticoagulation to treat Submassive Pulmonary Embolism in Hispanic Patients.

The use of low-dose tissue plasminogen activator (tPA) in Hispanic patients with submassive pulmonary embolism (PE) is understudied. The purpose of this study is to explore the use of low-dose tPA in Hispanic patients with submissive PE compared with counterparts that received heparin alone. We retrospectively analyzed a single-center registry of patients with acute PE between 2016 and 2022. Out of 72 patients admitted for acute PE and cor pulmonale, we identified six patients that were treated with conventional anticoagulation (heparin alone) and six patients who received low-dose tPA (and heparin afterward). We analyzed if low-dose tPA was associated with differences in length of stay (LOS) and bleeding complications. Both groups were similar in regard to age, gender, and PE severity (based on Pulmonary Embolism Severity Index scores). Mean total LOS for the low-dose tPA group was 5.3 days, compared with 7.3 days in the heparin group ( p = 0.29). Mean intensive care unit (ICU) LOS for the low-dose tPA group was 1.3 days compared with 3 days in the heparin group ( p = 0.035). There were no clinically relevant bleeding complications documented in either the heparin or the low-dose tPA group. Low-dose tPA for submassive PE in Hispanic patients was associated with a shorter ICU LOS without a significant increase in bleeding risk. Low-dose tPA appears to be a reasonable treatment option in Hispanic patients with submassive PE who are not at high bleeding risk (<5%).

Prevalence and clinical significance of deep vein thrombosis in Hispanic patients with acute pulmonary embolism.

The prevalence of concomitant deep vein thrombosis (DVT) and its impact on 30-day outcomes in Hispanic patients with acute pulmonary embolism (PE) is unknown. We retrospectively studied a cohort of Hispanic patients admitted for acute PE to determine the relationship of concomitant DVT to clot burden on chest computer tomography (CT), right heart strain, and 30-day mortality. We identified 391 patients admitted with acute PE; 168 (42.9%) had concomitant DVTs on admission; 39 patients (9.9%) died during the 30-day follow-up: 12 patients without concomitant DVT and 27 with concomitant DVT, respectively (p < .001). The presence of a proximal DVT independently predicted 30-day mortality even after adjusting for age, gender and admission PE severity index scores (PESI) (hazard ratio [HR] 2.0; 95% confidence interval [CI]: 1.4-3.0, p = .001). Proximal DVTs remained a significant predictor of 30-day mortality in patients with low and intermediate PESI scores (HR 2.5; 95% CI: 1.1-6.0, p = .035). The prevalence of concomitant DVT in Hispanic patients presenting with acute DVT is relatively lower than other ethnic groups. However, a proximal location of a DVT is of significant prognostic relevance. Hispanic patients with acute PE should routinely undergo compression doppler ultrasonography (CDUS) of the lower extremities.

An unusual case of renal artery stent restenosis: a case report.

The authors report a case of renal artery stent restenosis exacerbated by the likely displacement of multiple bare metal stents that had been contiguously deployed 3 months previously. The unusual features of this case are discussed along with putative mechanisms of stent displacement in visceral arteries. The restenotic disease was successfully treated with excimer laser atherectomy and cutting balloon atherotomy.

Buerger Test for Erythromelalgia Revisited.

Leo Buerger, MD, was the first to describe dependent rubor associated with marked atherosclerosis. Historically, dependent rubor has been described as erythromelalgia (or erythromelia), and terms such as chronic rubor, reactionary rubor, induced rubor, and hyperemic response have also been used to describe this sign associated with peripheral vascular disease. This brief review will reacquaint physicians with the Buerger test, which is used to assess arterial sufficiency, as well as erythromelalgia, and the proposed mechanisms responsible for erythromelalgia. The Buerger test is an important consideration when examining patients for erythromelalgia, which remains distinct from erythema associated with skin and soft-tissue infections.

Biventricular takotsubo cardiomyopathy: case study and review of literature.

Biventricular takotsubo cardiomyopathy is associated with more hemodynamic instability than is isolated left ventricular takotsubo cardiomyopathy; medical management is more invasive and the course of hospitalization is longer. In March 2011, a 62-year-old woman presented at our emergency department with abdominal pain, nausea, and vomiting. On hospital day 2, she experienced chest pain. An electrocardiogram and cardiac enzyme levels suggested an acute myocardial infarction. She underwent cardiac angiography and was found to have severe left ventricular systolic dysfunction involving the mid and apical segments, which resulted in a left ventricular ejection fraction of 0.10 to 0.15 in the absence of obstructive coronary artery disease. Her hospital course was complicated by cardiogenic shock that required hemodynamic support with an intra-aortic balloon pump and dobutamine. A transthoracic echocardiogram revealed akinesis of the mid-to-distal segments of the left ventricle and mid-to-apical dyskinesis of the right ventricular free wall characteristic of biventricular takotsubo cardiomyopathy. After several days of medical management, the patient was discharged from the hospital in stable condition. To the best of our knowledge, this is the first review of the literature on biventricular takotsubo cardiomyopathy that compares its hemodynamic instability and medical management requirements with those of isolated left ventricular takotsubo cardiomyopathy. Herein, we discuss the case of our patient, review the pertinent medical literature, and convey the prevalence and importance of right ventricular involvement in patients with takotsubo cardiomyopathy.

A quick fix: graft rescue for iatrogenic pseudoaneurysm.

We present a case of delayed rupture of a femoro-popliteal saphenous vein bypass graft after stent-supported angioplasty, resulting in a large, severely symptomatic pseudoaneurysm of the thigh. This was successfully treated with deployment of a covered stent graft. The possible mechanisms of pseudoaneurysm formation in this case are discussed, and a brief review of the literature regarding the endovascular management of this clinical entity is offered.