Safety and Efficacy of Enoxaparin During Low-Risk Elective Percutaneous Coronary Intervention.

Intravenous unfractionated heparin (UFH) is the most frequently used anticoagulant for percutaneous coronary intervention (PCI). Intravenous enoxaparin, a low-molecular-weight heparin, has superior pharmacokinetic and pharmacodynamic properties compared with UFH. Multiple trials have shown enoxaparin to be safe and effective in PCI. However, there has not been a contemporary study evaluating its safety and efficacy. To assess its efficacy and safety, intravenous enoxaparin during PCI through radial artery access was evaluated in PCI patients from January 2015 to December 2019. Outcomes included procedural success, all-cause mortality, ischemic complications, and bleeding complications from the time of the procedure until hospital discharge. A total of 1019 consecutive eligible patients were identified. Median age was 63 years, and 70% were men. The indication for PCI was stable and unstable angina in two-thirds of cases (77%). Few patients had myocardial infarction (MI) (2.2%) as the indication for intervention. The procedure was successful in 98.2% of cases. There were no deaths. Procedural MI occurred in 0.3% of patients. Acute stent thrombosis occurred in 0.4%. Urgent revascularization and stroke occurred in 0.1% each. Small wrist hematomas occurred in 0.3% and all were managed conservatively. There was one radial artery pseudoaneurysm. There were no cases of major bleeding. In conclusion, this single-center study showed that intravenous enoxaparin is a reasonable alternative anticoagulant for use in low-risk and elective non-MI PCI through radial artery access.

Significance of abnormal stress electrocardiography with normal cardiac imaging during stress testing-a meta-analysis.

BACKGROUND AND AIMS: Diagnostic testing for coronary artery disease frequently involves functional stress testing where imaging is often coupled with electrocardiogram (ECG) analysis. While decision-making is straightforward when both functional testing and ECG are either positive or negative, interpretation is challenging and prognostic importance uncertain with positive ECG and negative imaging since imaging is considered more sensitive. Prior studies have demonstrated mixed results. We sought to perform a meta-analysis of published studies to determine the significance of this particular type of discordant stress test result. METHODS AND RESULTS: PubMed, Cochrane, and Google Scholar were searched to identify studies reporting results of functional imaging (pharmacological exercise echocardiography or SPECT) and ECG analysis, along with the major adverse cardiovascular events (MACE) at patient follow-up. Studies were stratified based on functional imaging modality used. Primary outcome was a composite of all-cause death or myocardial infarction, and secondary outcome was the need for coronary revascularization. Random effects model was used to calculate risk ratios (RR), and heterogeneity among studies was assessed using the Higgins I2 value. Nine studies with a total of 23,715 patients were included. Primary end point was more common with discordant results with exercise stress echocardiography (RR 1.33, 95% confidence intervals [1.08-1.63]) or pharmacological SPECT (RR 6.53 95% CI [2.31-18.48]). CONCLUSIONS: Patients in the discordant exercise stress echocardiography and pharmacological SPECT groups were more likely to suffer the primary end point than those with a normal stress test. Discordant results should be interpreted carefully in the clinical context, given their prognostic impact based on the stress modality used.

Machine Learning in Cardiovascular Risk Prediction and Precision Preventive Approaches.

PURPOSE OF REVIEW: In this review, we sought to provide an overview of ML and focus on the contemporary applications of ML in cardiovascular risk prediction and precision preventive approaches. We end the review by highlighting the limitations of ML while projecting on the potential of ML in assimilating these multifaceted aspects of CAD in order to improve patient-level outcomes and further population health. RECENT FINDINGS: Coronary artery disease (CAD) is estimated to affect 20.5 million adults across the USA, while also impacting a significant burden at the socio-economic level. While the knowledge of the mechanistic pathways that govern the onset and progression of clinical CAD has improved over the past decade, contemporary patient-level risk models lag in accuracy and utility. Recently, there has been renewed interest in combining advanced analytic techniques that utilize artificial intelligence (AI) with a big data approach in order to improve risk prediction within the realm of CAD. By virtue of being able to combine diverse amounts of multidimensional horizontal data, machine learning has been employed to build models for improved risk prediction and personalized patient care approaches. The use of ML-based algorithms has been used to leverage individualized patient-specific data and the associated metabolic/genomic profile to improve CAD risk assessment. While the tool can be visualized to shift the paradigm toward a patient-specific care, it is crucial to acknowledge and address several challenges inherent to ML and its integration into healthcare before it can be significantly incorporated in the daily clinical practice.

Significance of indeterminate and abnormal stress electrocardiography despite normal imaging in patients with suspected coronary artery disease - An analysis of the PROMISE trial.

BACKGROUND: Abnormal and indeterminate electrocardiographic (ECG) changes during cardiac stress imaging are not uncommon. While the prognostic importance of abnormal ECG despite normal imaging has been previously studied, prognosis of indeterminate stress ECG changes is uncertain. METHODS: We studied the prognostic value of stress ECG changes in symptomatic patients without known CAD and normal stress imaging from the PROMISE trial. Patients with normal ECG (concordant), indeterminate ECG and abnormal ECG (discordant) were identified among those with negative exercise imaging stress test (EIST) and negative vasodilator nuclear stress test (PIST). Outcomes of interest were major adverse cardiovascular endpoint (MACE, including all-cause mortality, myocardial infarction, and unstable angina hospitalization) and likelihood of coronary revascularization. RESULTS: In EIST, indeterminate stress ECG [1.1% vs. 0.2% adjusted hazard ratio (aHR) 4.2, (95% CI 1.11-15.6), p = 0.034] and discordant ECG [7.2% vs. 0.2% adjusted hazard ratio (aHR) 27.6, (95% CI 9.6-79.8), p < 0.0001] were associated with increased likelihood of revascularization compared to normal stress ECG. Similar findings were observed with PIST [indeterminate vs concordant [1.7% vs. 0.5% adjusted hazard ratio (aHR) 5.9, (95% CI 1.1-31.7), p = 0.041; discordant vs concordant 15.4% vs. 0.5% adjusted hazard ratio (aHR) 24.2, (95% CI 4.6-127.7), p = 0.0002]. MACE rates were similar between ECG subgroups, in both EIST and PIST. CONCLUSION: In symptomatic patients without known CAD undergoing stress imaging, indeterminate and discordant ECG changes results may indicate presence of obstructive CAD despite normal imaging results and predict increased likelihood of coronary revascularization despite no significant difference in MACE.

Prognostic significance of post-stress reduction in left ventricular ejection fraction with adenosine stress in Jordanian patients with normal myocardial perfusion.

BACKGROUND: The significance of post-stress reduction in left ventricular ejection fraction (LVEF) in patients with normal perfusion on adenosine stress/rest imaging remains controversial. METHODS: Consecutive patients who underwent 2-day adenosine gated stress/rest 99mTc-sestamibi imaging and had normal perfusion were analyzed. LVEF was quantified at rest and 1 hour post-adenosine. Patients were followed up for hard (cardiac death or nonfatal MI) and soft (coronary revascularization or congestive heart failure) cardiac events for 24.1 ± 11.0 months. RESULTS: Of 560 patients included in the study, 135 (24.1%) had a post-stress reduction in LVEF of ≥ 5%. Rest LVEF (P < 0.001), known history of CAD (P = 0.01) and transient ischemic dilatation ratio (P = 0.02) were independent predictors of LVEF reduction. Event-free survivals were similar in patients with and without ≥ 5% LVEF reduction (P = 0.8). The unadjusted hazard ratio (95% CI) for cardiac events for ≥ 5% LVEF reduction was 1.09 (0.55-2.15), P = 0.81, while the hazard ratio adjusted for known history of CAD, smoking, post-stress LVEF and peak heart rate was 0.87 (0.44-1.75), P = 0.71. CONCLUSIONS: Significant post-adenosine reduction in LVEF occurs in about one-fourth of patients with normal perfusion but does not confer adverse prognosis compared with patients without such reduction.

Hematologic markers of distant metastases in gastric cancer.

BACKGROUND: High neutrophil-lymphocyte ratio (NLR) is associated with poor overall survival (OS) in gastric cancer. This study evaluates whether NLR, in addition to other parameters including absolute neutrophil count (ANC), absolute lymphocyte count (ALC), absolute eosinophil count (AEC), absolute monocyte count (AMC), monocyte-lymphocyte ratio (MLR), and platelet-lymphocyte ratio (PLR) are associated with distant metastases, a common and poor prognostic feature of gastric cancer. METHODS: Clinical data from 502 gastric cancer patients treated at King Hussein Cancer Center (Amman, Jordan) have been retrospectively reviewed. We examined the association between ANC, ALC, AEC, AMC, NLR, MLR and PLR with the baseline distant metastases and OS. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal NLR cutoff value for association with distant metastases. RESULTS: Univariate and multivariate analyses showed that patients with high baseline NLR (≥3.9) had more distant metastases on presentation than patients with low NLR (<3.9), (P value: 0.0001 and 0.0005, respectively). Furthermore, patients with high baseline ANC (≥6,015/µL), AEC (≥215/µL), PLR (≥0.15) had more distant metastases in comparison to patients with low baseline ANC (<6,015/µL), AEC (<215/µL), PLR (<0.15) (P value: 0.024, 0.001, and 0.001, respectively). High ANC, NLR, MLR and PLR are associated with poor OS (P value: 0.046, 0.0003, 0.027, and <0.0001, respectively). CONCLUSIONS: High ANC, AEC, NLR, and PLR are associated with distant metastases on presentation in gastric cancer. In the era of cancer immunotherapy, whether these immune phenomena predict the response of gastric cancer to immunotherapy is unknown.

MTHFR gene polymorphisms in hypothyroidism and hyperthyroidism among Jordanian females

ABSTRACT Objective Methylenetetrahydrofolate reductase (MTHFR) is involved in DNA methylation that is associated with autoimmune pathology. We investigated the association between MTHFR genetic polymorphisms at g.677C>T and g.1298A>C and their haplotypes, and the risk of thyroid dysfunction among Jordanian females. Subjects and methods A case-control study involving 98 hypothyroidism cases, 66 hyperthyroidism cases and 100 controls was conducted. Polymerase chain reaction/restriction fragment length polymorphism technique was performed to determine genotypes. Statistical analysis using SPSS software was performed. Results Genetic analysis showed a significant difference in genotype frequency of g.1298A>C between cases, and controls [hypothyroidism: AA (45.9%), AC (37.8%), CC (16.3%); hyperthyroidism: AA (9.1%), AC (69.7%), CC (21.2%); controls: AA (37.8%), AC (29.6%), CC (32.7%); CChypo vs. AAhypo: 2.55, 95% CI: (1.18-5.52); OR at least on Chypo: 1.79, 95% CI: (1.07-2.99)]; CChyper vs. AAhyper: 4.01, 95% CI: (1.79-9.01); OR at least on Chyper: 0.18, 95% CI: (0.07-0.48)]. There was no significant difference in genotype frequency of g.677C>T between cases and controls [hypothyroidism: CC (50.0%), CT (32.7%), TT (17.3%); hyperthyroidism: CC (77.3%), CT (15.2%), TT (7.6%); controls: CC (55.6%), CT (32.3%), TT (12.1%)]. There was a significant difference of MTHFR haplotypes among hypothyroidism cases and controls. TA and CC had a lower hypothyroidism risk whereas; TC showed a higher risk. Conclusions g.1298A>C genetic polymorphism of MTHFR may modulate the risk of thyroid disease. CC, TA, and TC haplotypes affect the risk of hypothyroidism. Larger samples should be included in the future to verify the role of MTHFR polymorphisms in thyroid diseases.

MTHFR gene polymorphisms in hypothyroidism and hyperthyroidism among Jordanian females.

OBJECTIVE: Methylenetetrahydrofolate reductase (MTHFR) is involved in DNA methylation that is associated with autoimmune pathology. We investigated the association between MTHFR genetic polymorphisms at g.677C>T and g.1298A>C and their haplotypes, and the risk of thyroid dysfunction among Jordanian females. SUBJECTS AND METHODS: A case-control study involving 98 hypothyroidism cases, 66 hyperthyroidism cases and 100 controls was conducted. Polymerase chain reaction/restriction fragment length polymorphism technique was performed to determine genotypes. Statistical analysis using SPSS software was performed. RESULTS: Genetic analysis showed a significant difference in genotype frequency of g.1298A>C between cases, and controls [hypothyroidism: AA (45.9%), AC (37.8%), CC (16.3%); hyperthyroidism: AA (9.1%), AC (69.7%), CC (21.2%); controls: AA (37.8%), AC (29.6%), CC (32.7%); CChypo vs. AAhypo: 2.55, 95% CI: (1.18-5.52); OR at least on Chypo: 1.79, 95% CI: (1.07-2.99)]; CChyper vs. AAhyper: 4.01, 95% CI: (1.79-9.01); OR at least on Chyper: 0.18, 95% CI: (0.07-0.48)]. There was no significant difference in genotype frequency of g.677C>T between cases and controls [hypothyroidism: CC (50.0%), CT (32.7%), TT (17.3%); hyperthyroidism: CC (77.3%), CT (15.2%), TT (7.6%); controls: CC (55.6%), CT (32.3%), TT (12.1%)]. There was a significant difference of MTHFR haplotypes among hypothyroidism cases and controls. TA and CC had a lower hypothyroidism risk whereas; TC showed a higher risk. CONCLUSIONS: g.1298A>C genetic polymorphism of MTHFR may modulate the risk of thyroid disease. CC, TA, and TC haplotypes affect the risk of hypothyroidism. Larger samples should be included in the future to verify the role of MTHFR polymorphisms in thyroid diseases.