Clinical impact of preemptive pharmacogenomic testing on antiplatelet therapy in a real-world setting.

CYP2C19 genotyping to guide antiplatelet therapy after patients develop acute coronary syndromes (ACS) or require percutaneous coronary interventions (PCIs) reduces the likelihood of major adverse cardiovascular events (MACE). Evidence about the impact of preemptive testing, where genotyping occurs while patients are healthy, is lacking. In patients initiating antiplatelet therapy for ACS or PCI, we compared medical records data from 67 patients who received CYP2C19 genotyping preemptively (results >7 days before need), against medical records data from 67 propensity score-matched patients who received early genotyping (results within 7 days of need). We also examined data from 140 patients who received late genotyping (results >7 days after need). We compared the impact of genotyping approaches on medication selections, specialty visits, MACE and bleeding events over 1 year. Patients with CYP2C19 loss-of-function alleles were less likely to be initiated on clopidogrel if they received preemptive rather than early or late genotyping (18.2%, 66.7%, and 73.2% respectively, p = 0.001). No differences were observed by genotyping approach in the number of specialty visits or likelihood of MACE or bleeding events (all p > 0.21). Preemptive genotyping had a strong impact on initial antiplatelet selection and a comparable impact on patient outcomes and healthcare utilization, compared to genotyping ordered after a need for antiplatelet therapy had been identified.

A Case of Intraventricular Coronary Artery Perforation Following Percutaneous Coronary Intervention in the Setting of Myocardial Bridge of Left Anterior Descending Artery.

Coronary artery perforation during percutaneous coronary intervention is a rare but potentially fatal complication. Intraventricular rupture is more commonly seen in setting of myocardial bridging where the epicardial coronary artery takes an intramuscular course. We describe a case of acute thrombotic in-stent restenosis of the intramyocardial (myocardial bridge) distal left anterior descending artery complicated by intraventricular perforation in the setting of an anterior ST elevation myocardial infarction managed by covered stenting.

ST Elevation MI with Normal Coronary Arteries: A MINOCA Case.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a syndrome characterized by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography. CASE REPORT: A 35-year-old female patient presented with typical chest pain. EKG revealed sinus rhythm, 1 mm ST elevation in DI-aVL, prominent R waves in V1-V3 and ST-segment depression in DIII-aVF. She underwent emergent coronary angiography which revealed normal coronary arteries. Troponin levels peaked at 123 ng/mL. 2D Transthoracic echocardiogram showed an EF of 50 percent with lateral wall hypokinesis. A cardiac magnetic resonance imaging (CMR) showed myocardial scar tissue. Epicardial late gadolinium enhancement (LGE) was noted in the lateral left ventricular wall consistent with transmural myocardial infarction. DISCUSSION: MINOCA is not an uncommon presentation of acute MI (AMI). It is more frequent in younger women and nonwhites, is associated with fewer traditional risk factors, and usually presents with non-ST-segment elevation- myocardial infarction. Patients with MINOCA should undergo further testing to reveal the underlying etiology as treatment will vary depending on the cause. MINOCA is not a benign syndrome, with outcomes comparable to their AMI-CAD counterparts especially in younger patients.

Review on Short Term Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention with Drug Eluting Stent.

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) have been a debatable topic for several decades. With the newer generation drug eluting stents, risk of major adverse cardiovascular events (MACE) has significantly reduced and hence, shorter duration of DAPT (one to three months) is now recommended especially in patients with high bleeding risk. Our review highlights the current guidelines and the recommendations from the recent trials.

Transcatheter tricuspid valve-in-valve implantation for very early bioprosthetic tricuspid stenosis secondary to pacemaker lead entrapment: a case report.

Background: Tricuspid stenosis (native and prosthetic) is rare. Redo-sternotomy for isolated tricuspid replacement is associated with a higher risk. The efficacy and durability of transcatheter valve implantation for severe tricuspid stenosis are unclear. Case summary: Successful tricuspid valve-in-valve implantation (Edwards 26 mm Ultra) was performed to exteriorize a retained, unextractable pacemaker lead causing very early surgical bioprosthetic valve dysfunction in a 66-year-old Caucasian woman. The original indication for surgical replacement was pacemaker lead-related severe tricuspid regurgitation. History of CABG and subsequent surgical replacement rendered the risk of a third sternotomy and open-heart surgery prohibitive. Conclusion: Successful reduction in the severity of bioprosthetic tricuspid stenosis and improvement of right heart failure with transcatheter valve-in-valve implantation was observed. Percutaneous tricuspid valve implantation could be considered an alternative to redo-sternotomy for severe bioprosthetic tricuspid stenosis.

ST-Segment Elevation Myocardial Infarction Due to an Ectatic Infarct-Related Coronary Artery: Case Series and Review of the Literature.

Coronary artery ectasia is an infrequent finding seen in a localized or diffuse fashion in patients undergoing coronary angiogram. This angiographic entity is attributed to coronary artery atherosclerosis. The ectatic coronary artery segment may be a culprit and perpetuate the thrombus formation in patients with acute myocardial infarction due to the altered normal laminar flow and deranged platelet and endothelial activation. Besides, it may lead to slow flow/no-reflow during the percutaneous coronary intervention and constitutes a significant management challenge. In this article, we report three patients with ST-segment elevation myocardial infarction from the culprit ectatic infarct-related artery and discuss the various management strategies.

COVID-19 and Cardiovascular Disease: A Comprehensive Review.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a pandemic that impacted the lives of billions of people worldwide. Angiotensin-converting enzyme 2 (ACE2) receptor act as a gate for viral cell entry through binding to virus S-protein. Cardiovascular patients are thought to be more susceptible to severe COVID-19 infection due to overexpression of ACE2 receptors in these patients. There is a growing body of evidence suggesting worse outcomes and increased mortality among COVID-19 patients with preexisting cardiovascular diseases. SARS-CoV-2 is capable of causing a wide range of cardiovascular diseases including myocarditis, heart failure, arrhythmia, myocardial ischemia and venous thromboembolism. Drug-disease interaction in COVID-19 patients with preexisting cardiovascular conditions has become a major concern. In this review, we discuss different aspects of the relationship between COVID-19 and the cardiovascular system along with a brief pharmacological overview.

Post COVID-19 Large Atrial Thrombus Found Incidentally.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has become a leading cause of morbidity and mortality worldwide. One of the major complications of COVID-19 infection is the hypercoagulability state. Cardiac thrombi and venous thromboembolism (VTE) have been documented with severe COVID-19 infection. We present a case of large right atrial (RA) thrombus in transit incidentally diagnosed following a mild COVID-19 in a previously vaccinated patient. CASE SUMMARY: An 85-year-old male presented to the emergency department two weeks following resolution of a mild COVID-19 infection due to an incidentally discovered large RA thrombus. Computed tomography with angiography of the chest was positive for acute pulmonary thromboembolic disease with large clot burden and findings consistent with right heart strain. The patient remained hemodynamically stable and was successfully managed with anticoagulation. CONCLUSION: RA thrombi and VTE can occur in patients with mild COVID-19 infection and in the setting of full COVID-19 vaccination. Echocardiography is a useful imaging modality in this patient population.

Complete Heart Block Causing Takotsubo Syndrome: A Case Report.

The association of complete atrioventricular (AV) block with Takotsubo syndrome (TTS) is well known, but the cause-and-effect relationship has not been determined. We present the case of a 91-year-old female with complete AV block who went untreated for over a year and later developed Takotsubo syndrome. Reversal of wall movement defects was seen after a permanent pacemaker was implanted, and routine follow-up showed that the implanted pacemaker worked normally.

Impact of Emergency Medical Service Provider Training and Institutional Volume Experience on ST-Elevation Myocardial Infarction Patient Outcomes in Rural Setting.

INTRODUCTION: Rural sites provide management challenges for ST-elevation myocardial infarction (STEMI) patients. The impact of emergency medical service (EMS) training and institutional volume experience on STEMI outcomes was examined. METHODS: All STEMI patients transferred to Sanford from 32 sites in rural South Dakota from 2010-2019 were analyzed. "Time to electrocardiogram (EKG)" (TEKG) and "Time from EKG to Thrombolytics" (TThrom) were calculated. Sites were compared based on EMS training (advanced life support (ALS) vs. basic life support (BLS)) and institutional volume experience (less than or equal to five vs. greater than five STEMI). RESULTS: 514 STEMI patients from 32 sites in South Dakota were analyzed. Average TEKG was 20 (±15) and 14 (±10) minutes for ALS and BLS trained services, respectively (p=0.25). More experienced sites had an average TEKG of 26 (±15) minutes, while sites with ≤ five STEMI patients had an average time of 15 (±13) minutes. TThrom did not differ significantly between sites based on our metrics. CONCLUSION: The present study concludes that EMS provider training (BLS vs ALS) and institutional volume experience do not significantly impact patient-related outcomes when treating STEMI patients. This result is possibly attributed to increased educational efforts for rural health care providers in general and the establishment of the South Dakota statewide STEMI Network "Mission: Lifeline" which standardized STEMI care and improved connectivity between remote responders and the larger PCI-capable facilities.

Complex Coronary Intervention - When Time Is of Essence: Ping Pong Technique.

Coronary artery disease (CAD) continues to be a significant cause of morbidity and mortality in the U.S. The prognosis and treatment of which is dependent on various factors including type, size, localization and extent of the coronary plaque and severity of the stenosis. Management of critical ostial left main CAD poses peculiar challenges. The present case report demonstrates a unique percutaneous coronary intervention technique helpful in the management of such complex left main coronary lesions.

Heart Failure with Preserved Ejection Fraction: Concise Review.

Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent disease, causing a significant burden to the elderly population. Due to the inconsistencies in the standard definition and criteria for diagnosis, HFpEF is often underdiagnosed and left untreated. Although diastolic dysfunction is one of the key driving factors of the disease process, other factors like systolic limitations, endothelial dysfunction, arterial stiffness, and poor ventricular-arterial coupling are also contributing factors. While various treatment modalities have been investigated, the management continues to remain supportive. This review highlights the various American College of Cardiology/American Heart Association and European Society of Cardiology definitions, pathophysiology, and current treatment modalities available for HFpEF.

Approach to high intracoronary thrombus burden in the era of COVID-19.

Since the start of the COVID-19 pandemic, several cases have reported extensive multivessel coronary thrombosis as a cardiovascular manifestation of SARS-CoV-2 infection. This case describes a patient who developed non-ST elevation myocardial infarction during hospitalization for acute hypoxic respiratory failure due to COVID-19. We review the immediate and delayed revascularisation strategies of culprit and non-culprit lesions in the setting of high intracoronary thrombus burden induced by SARS-CoV-2. Successful percutaneous intervention and stenting of a culprit lesion and resolution of an intracoronary thrombus using a delayed strategy of lesion passivation with adjuvant pharmacotherapy are demonstrated on index and follow-up angiography.

Percutaneous Closure of a Cribriform Secundum Atrial Septal Defect and Patent Foramen Ovale.

Atrial septal defects (ASDs) and patent foramen ovale (PFO) are common congenital cardiac malformations that portend a higher risk of ischemic stroke. Percutaneous closure of ASDs using septal occluder devices has proven to be a safe and effective alternative to surgery. We present a case of symptomatic cribriform secundum ASD and PFO who underwent successful percutaneous closure using two Amplatzer occluder devices using a novel "sandwich technique."

Segmental Coronary Vasospasm Mimicking ST-Elevation Myocardial Infarction in an Incidentally COVID-Positive Patient.

Coronary vasospasm is an underdiagnosed cause of myocardial infarction in the absence of obstructive coronary artery disease. Systemic inflammation is one of several triggers associated with coronary vasospasm. We report the case of a 47-year woman incidentally found to be COVID-positive (RT-PCR) during evaluation of constitutional symptoms and breast cellulitis. Later in the hospitalization, she developed sudden-onset typical angina at rest; 12 lead EKG showed inferolateral ST-elevations. Urgent coronary angiogram showed nitrate-responsive subtotal focal occlusions in the right coronary and circumflex arteries. In the absence of sepsis, it is difficult to attribute coronary vasospasm solely to cellulitis. Focal coronary artery spasm mimicking ST-elevation myocardial infarction successfully managed solely with intracoronary nitroglycerine in an incidentally COVID-positive patient adds to the diverse manifestations of COVID infection. The exact mechanism of focal, as opposed to diffuse coronary vasospasm is unclear.

New and Emerging Technology in Cardiovascular Therapeutics.

The last decade has seen the introduction of a number of important technological innovations in the management of advanced cardiovascular disease. These include transcatheter aortic valve replacement systems, a transcatheter mitral valve repair device, a left atrial appendage occluder device, coronary bioresorbable vascular scaffolds, leadless fully implantable pacemaker systems, wireless implantable pulmonary artery pressure monitors, transcatheter left ventricular assist pumping devices, drug-coated balloons, and robotic percutaneous coronary intervention devices. With the exception of drug coated balloon platforms, all have been utilized in our institution for patients from South Dakota and neighboring states. The objective of this study is to briefly describe these innovative devices, summarize the evidence for their benefit, and offer helpful pearls for the primary care providers who are key members of the care team for these patients.

CYP2C19 genotype-directed P2Y12 inhibitor antiplatelet therapy normalizes risk for major adverse cardiovascular events after percutaneous coronary intervention.

OBJECTIVE: To study the use of CYP2C19 genotyping to guide P2Y12 inhibitor selection to maximize efficacy, and attenuate risk in appropriate patients who underwent PCI for CAD. METHODS: We performed a retrospective analysis of 868 patients with CAD who received CYP2C19 genotyping after PCI and changed P2Y12 inhibitor based on the results. Patients were divided into two groups based on clopidogrel metabolizer status. Group I: Intermediate (IM) and poor metabolizers (PM). Group II: Ultra-rapid (UM), rapid (RM) and normal metabolizers (NM). Each group was then categorized to one of two treatment arms guided by CYP2C19 genotype. Category 1: IM/PM started on clopidogrel, switched to ticagrelor or prasugrel; 2:IM/PM started on ticagrelor/prasugrel, continued these medications; 3: UM/RM/NM started on ticagrelor/prasugrel, switched to clopidogrel; 4: UM/RM/NM started on clopidogrel, continued clopidogrel. Death due to cardiac causes, bleeding events, non-fatal MI, target vessel revascularization (TVR), and MACE in all four categories were considered at 1, 6 and 12 months. RESULTS: We did not observe significant difference between phenotypes for MACE at 1 (p = 0.274), 6 (p = 0.387), and 12 months (p = 0.083). Death due to cardiac causes, MI, and bleeding events were not significant at 1, 6, and 12 months. There was no significant difference in TVR at 6 (p = 0.491), and 12 months (p = 0.423) except at 1 month (p = 0.012). CONCLUSION: CYP2C19 genotype-based intervention can be implemented effectively and reliably to guide selection of P2Y12 inhibitor to optimize patient quality and safety when appropriate in post PCI patients.