An Uncommon Case of Spontaneous Hemopericardium in a Patient Treated with Rivaroxaban.

We describe a case of an 88-year-old woman with a severe bluntly ematic pericardial effusion. Radiological and laboratory examinations excluded all the most common causes of hemopericardium, and the diagnosis of spontaneous hemopericardium associated with the treatment with rivaroxaban was made. This is the first case report describing a hemopericardium in a patient treated with rivaroxaban who did not take other herbal products or drugs that may significantly increase rivaroxaban blood levels. This report emphasizes the need for the careful use of new oral anticoagulants, and the importance of taking in mind uncommon side effects. Spontaneous hemopericardium should be considered in these patients.

Automated carbon dioxide digital angiography for lower-limb arterial disease evaluation: safety assessment and comparison with standard iodinated contrast media angiography.

INTRODUCTION: Carbon dioxide (CO2) has been validated as a contrast agent in a large series of studies. A particular advantages of CO2 over iodinated contrast medium (ICM) is the absence of nephrotoxicity and allergic reactions. One of the limitations of CO2 angiography is the difficulty of CO2 manual injection due to its compressibility. The manual gas injection does not permit optimal control of the gas output. Development of an automated CO2 injector has overcome these problems. AIM: This study compares the feasibility, safety, and diagnostic accuracy of automated CO2 digital subtraction angiography (DSA) in comparison with ICM-DSA in the evaluation of critical limb ischemic (CLI) patients. METHODS: We performed DSA with both CO2 and ICM on 40 consecutive CLI patients and directly compared the two techniques. Sixteen females and 24 males participated in the study (mean age, 71.7 years). We assessed the diagnostic accuracy of CO2 in identifying arterial stenosis in the lower limb, with ICM-DSA used as the gold standard. RESULTS: The overall diagnostic accuracy of CO2-DSA was 96.9% (sensitivity, 99.0%; specificity, 96.1%; positive predictive value, 91.1%; negative predictive value, 99.6%). Tolerable minor symptoms occurred in 3 patients. No allergic reactions or significant decline in renal function were observed in patients receiving the CO2 injection. CONCLUSION: Carbon dioxide DSA is a valuable and safe alternative to traditional ICM-DSA for evaluating CLI patients. This modality should be considered as the standard choice for CLI patients undergoing angiographic evaluation who are known to have renal insufficiency or contrast allergy.

The prognostic role of troponin I elevation after elective percutaneous coronary intervention.

OBJECTIVES: To assess the prognostic role of isolated troponin I (TnI) elevation after elective percutaneous coronary intervention (PCI) in patients with stable coronary artery disease. BACKGROUND: The prognostic role of minor troponin elevation after PCI is controversial. METHODS: A total of 1532 consecutive patients who underwent elective PCI were included. Follow-up data were obtained for 1432 of 1532 (93.4%) patients. The events taken into account in the follow-up included total mortality, cardiac death, hospitalization for acute myocardial infarction and/or unstable angina. RESULTS: The following variables were identified as predictive of major adverse cardiac events (MACE) by univariate analysis: age 75 years at least (P = 0.012), ejection fraction less than 50% (P = 0.001), prior myocardial infarction (P = 0.031) and TnI 1.0 ng/ml at least after PCI (P = 0.04). The Cox-regression model identified the TnI elevation after PCI, the older age and the ejection fraction as independent predictors of MACE during follow-up (TnI: P = 0.042; older age: P = 0.001; ejection fraction: P = 0.003). In a subgroup of patients with preserved ejection fraction, the incidence of MACE was significantly higher in those with TnI of at least 1.0 ng/ml at least than in the ones with TnI less than 1.0 ng/ml, with the highest incidence among the older cohort. The multivariate analysis confirmed the TnI elevation 1.0 ng/ml at least after PCI and the older age as predictors of MACE. CONCLUSION: This study documented that in clinically stable patients, minor TnI elevations after elective PCI are independent predictors of MACE during follow-up, as are older age and reduced ejection fraction. Additionally, TnI elevation was a predictor of MACE during follow-up in a subset of patients with preserved ejection fraction. The combination of TnI elevation and older age confers the highest risk of MACE.

[Drug-eluting stents in non-coronary arteries]. / Gli stent medicati nei distretti arteriosi non coronarici.

According to the available literature, drug-eluting stents (DES) are used mainly in coronary arteries. However, DES are used in non-coronary districts as well. The indication for DES implantation in non-coronary arteries is the same as that in the coronary circulation that is to prevent restenosis. Although data from both controlled studies and observational reports do exist, the use of DES in the non-coronary circulation is very limited and is not comparable with that for the treatment of coronary artery disease. The most important factors one has to consider before DES implantation in non-coronary arteries are histologic features, blood flow characteristics and compressive extrinsic forces. Further studies on larger populations are warranted to define the ideal combination stent/drug and the clinical indications for the correct use of DES in non-coronary vascular districts.

Stress-induced QTc-interval shortening as an ancillary marker of ischemia in patients with complete left bundle branch block.

BACKGROUND: In patients with left bundle branch block (LBBB), ischemia-induced repolarization changes associated with QTc-interval shortening may be recorded during coronary angioplasty. We aimed to assess whether these repolarization changes may be predictive of severe coronary artery disease in patients with LBBB. METHODS: Fifty noninfarcted LBBB patients underwent dipyridamole stress test and coronary angiography for chest pain. To localize the site of ischemia, we considered four groups of conventional ECG leads (V1-V2-V3; V4-V5-V6; aVL-I; III-aVF-II), exploring the anteroseptal, lateral, high-lateral, and inferior left ventricular walls. ST-T changes and QTc intervals were estimated at rest and peak stress, lead by lead, in each group of leads and the fractional percentage difference between rest-stress QTc intervals ([DELTA]QTc) was calculated. A [DELTA]QTc greater than -10% was used to define significant QTc-interval shortening. Coronary stenosis of more than 70% and more than 90% were considered 'significant' and 'severe'. RESULTS: According to dipyridamole stress test response, two groups were identified: group I (35 patients) with dipyridamole-induced ischemia and group II (15 patients) without dipyridamole-induced ischemia. The wall motion score index at peak stress (compared with resting wall motion score index) was significantly higher in group I (1.98 +/- 0.13 vs. 1.28 +/- 0.08, P < 0.0001) than in group II (1.36 +/- 0.18 vs. 1.25 +/- 0.08, P = 0.296). The patients of group I showed a significant QTc-interval shortening ([DELTA]QTc = -16.9 +/- 3.9%), whereas this did not happen in patients of group II ([DELTA]QTc = +8.8 +/- 2.4%, P < 0.0001). The patients of group I also had a more severe stenosis in the vessel related to the stress-induced dyssynergic area (I = 90.5 +/- 9.5 vs. II = 34.3 +/- 31.1%; P < 0.0001). CONCLUSION: In patients with LBBB, stress-induced pseudonormalization pattern, associated with QTc-interval shortening, allows the identification of cardiac areas supplied by severely stenosed coronary arteries.

Multislice computed tomography for the evaluation of coronary bypass grafts and native coronary arteries: comparison with traditional angiography.

BACKGROUND: Multislice computed tomography (CT) is a promising new noninvasive technique for the detection of atherosclerotic disease within a vessel's wall. The present study was designed to assess the diagnostic accuracy of 64-slice CT in detecting graft disease and in the evaluation of native vessels distally to the grafts. METHODS: Forty consecutive patients with previous coronary artery bypass underwent both invasive coronary angiography and 64-slice CT. The CT data were acquired over 7-12 s period during a single-breath hold using the Smartprep technique. Images were reconstructed using the retrospective modality on a synchronized ECG in a time frame of between 40 and 80% of the R-R interval. RESULTS: A total of 118 grafts were investigated (80 vein and 38 arterial conduits). At CT, 31/38 arterial grafts were classified as patent and free from significant lesions, whereas seven appeared diseased (five complete occlusion and two significant stenoses along the body of the graft). Out of 80 vein grafts, 52 appeared free of disease and 28 diseased (23 total occlusion and five critical stenosis). An absolute concordance between CT and angiographic findings was documented for all arterial and venous grafts (100% diagnostic concordance). The accuracy of 64-slice CT in the assessment of distal run-off arteries was 90%. CONCLUSION: The 64-slice CT detected with very high accuracy the presence of diseased arterial and vein grafts. Moreover, an optimal diagnostic accuracy was also documented in the appraisal of native vessels distal to the graft anastomoses. On the basis of these results, 64-slice CT can be proposed for the study of patients after coronary artery bypass and may represent an effective screening technique to select those patients with indications of new revascularization.

Protective role of chronic statin therapy in reducing myocardial damage during percutaneous coronary intervention.

OBJECTIVE: Percutaneous coronary intervention (PCI) is frequently associated with troponin I (TnI) elevation. Experimental studies suggest that statins may reduce ischaemia-reperfusion myocardial injury. The study objective was to verify whether chronic treatment with statins might reduce the occurrence and the extent of periprocedural myocardial damage in patients undergoing PCI. METHODS: Five hundred and fifty-two consecutive patients undergoing PCI were included: 279 were not on statins before PCI, 273 were on statins. TnI levels >or= 0.3 ng/ml were considered indicative of myocardial injury. RESULTS: Statin-treated patients had a higher prevalence of hyperlipidaemia, previous myocardial infarction, and revascularization procedures. Coronary angiography also documented a higher prevalence of multivessel disease. No difference between the two groups was observed regarding the PCI-treated vessel, type of lesions, use of stents and of anti-IIb/IIIa inhibitors. Patients on statins showed the lowest incidence of TnI >or= 0.3 ng/ml (29 vs. 48%, P = 0.00001) and of creatine kinase-MB elevation (7 vs. 12%, P = 0.04). The mean peak TnI levels were significantly lower in patients on statins (1.07 +/- 3.8 vs. 2.73 +/- 12.3, P = 0.00006). Multivariate analysis identified preprocedural statin therapy as the only independent negative predictor of postprocedural abnormal TnI levels (odds ratio = 0.52; 95% confidence intervals 0.34-0.79; P = 0.003). CONCLUSIONS: This study shows that chronic therapy with statins reduces the incidence of periprocedural myocardial damage after PCI. The beneficial effect of statins was independent of either the most important clinical and angiographic characteristics or the use of other cardiovascular drugs including beta-blockers. These data support the specific cardioprotective role of statins.