Aspirin, Plavix, and Other Antiplatelet Medications: What the Oral and Maxillofacial Surgeon Needs to Know.

Most patients with coronary artery disease and peripheral vascular disease are on long-term antiplatelet therapy and dual therapy. Achieving a balance between ischemic and bleeding risk remains an important factor in managing patients on antiplatelet therapy. For most outpatient surgical procedures, maintenance and continuation of this therapy are recommended. Consultation with the patient's cardiologist, physician, and/or vascular surgeon is always recommended before interrupting or withholding this treatment modality.

Prevalence of Metabolic Syndrome in Patients with HIV in the Era of Highly Active Antiretroviral Therapy.

OBJECTIVES: Since the introduction of combination antiretroviral therapy (cART) as the standard of care for HIV disease, there has been a precipitous decline in the death rate due to HIV/ AIDS. The purpose of this study was to report the prevalence of metabolic syndrome in HIV infected patients. METHODS: Retrospective, cross-sectional, observational study of 259 patients with HIV infection treated with cART from an urban community hospital. Metabolic syndrome prevalence was defined using the International Diabetes Federation (IDF) and the U.S. National Cholesterol Education Program Adult Treatment Panel III (ATP III) criteria. Study patients were included regardless of the duration of cART. RESULTS: The prevalence of metabolic syndrome was 27% using IDF criteria and 26% using ATP III criteria. Logistic regression analysis found an association between treatment with the protease inhibitor darunavir and metabolic syndrome. (OR 3.32 with 95% confidence interval between 1.54 and 7.15). CONCLUSION: There is a high prevalence of metabolic syndrome and obesity in HIV patients treated with cART, especially those taking the protease inhibitor darunavir.

Prospective chest pain evaluation in the emergency department with use of high-sensitivity C-reactive protein (PROCEED-CRP study).

We evaluated the clinical value of a single measurement of high-sensitivity C-reactive protein (hs- CRP) in patients presenting to the emergency department with chest pain. We screened 408 consecutive patients of whom 292 comprised the final cohort for this study. Hs-CRP measured in the emergency department (ED) in patients presenting with chest pain and admitted for evaluation of acute myocardial infarction was neither sensitive nor specific in predicting acute myocardial infarction, myocardial ischemia on SPECT imaging, need for coronary revascularization, or cardiovascular or all-cause rehospitalization at 30 days. In addition, use of a specific CRP cut off >1 was not associated with an increase in all-cause rehospitalization at 30 days.

Isolated left ventricular noncompaction: a review of three different presentations for a rare disease.

Isolated left ventricular noncompaction (ILVNC) is a rare cardiomyopathy with a genetic background characterized by numerous prominent trabeculations and deep intertrabecular recesses. It occurs in the absence of any coexisting congenital lesion or hemodynamic abnormality and is rare in the adult population. Heart failure, ventricular arrhythmias, and embolic events are the three major clinical manifestations of ILVNC. Medical and surgical treatment is similar to other systolic dysfunction cardiomyopathies and depends on the presenting clinical manifestations. In this review, we present three patients with different clinical presentations of ILVNC leading to different treatment modalities ranging from medications alone to device implantation and transplantation. Pathologic findings from one of our patients are also presented.

Long-term outcome of Tako-tsubo cardiomyopathy.

BACKGROUND: Current data suggest an excellent outcome for patients with Tako-tsubo cardiomyopathy (TC). The objectives of this study were to evaluate the long-term outcome and the prognostic implication of thrombolysis in myocardial infarction myocardial perfusion grade (TMPG) in patients with TC. METHODS: Retrospective analysis of all patients diagnosed with TC at our hospital between 2003 and 2008. RESULTS: During the five-year period, we identified 27 patients with TC out of 1374 cases of emergent left heart catheterisation (2%). Mean follow-up was 27 ± 16 months. The majority were Caucasian (81%) female (96%), postmenopausal (96%), with a mean age of 68 ± 14 years. A precipitating stressor event was found in 74% of the patients, 30% being gastrointestinal triggers. Fourteen patients (52%) reached a combined end point of all cause death, cardiogenic shock, sudden cardiac death and rehospitalisation for cardiac reasons. TMPG was abnormal in 37% cases with no correlation with the outcome. CONCLUSIONS: The long-term outcome of patients with TC is worse than previously reported. TMPG does not correlate with the outcome in TC.

A rare cause of systolic murmur: unruptured right sinus of Valsalva aneurysm with right ventricular outflow tract obstruction and supracristal ventricular septal defect.

Dyspnea and heart murmur are common reasons for referrals in cardiology and both are associated with a broad differential diagnosis. Sinus of Valsalva aneurysms are rare abnormalities of the aortic root that should be considered in the differential diagnosis in young and middle aged patients. Sinus of Valsalva aneurysms are often associated with supracristal ventricular septal defects and can be identified on transthoracic echocardiography. Diagnosis of a SVA should trigger a careful search for ventricular septal defect, which may necessitate transesophageal echocardiography.

Endocarditis complicating central venous catheter bloodstream infections: a unique form of health care associated endocarditis.

BACKGROUND: Endocarditis complicating central venous catheter blood stream infection (CVC-BSI) is a serious complication and is being seen with increasing frequency. METHODS: All patients discharged from our institution with International Classification of Disease (ICD-9) codes of endocarditis and CVC-BSI were identified. The medical records of those meeting our inclusion criteria were reviewed. RESULTS: From October 1, 1998 until December 31, 2006, 24 patients were identified with inpatient mortality of 20.8%. Nine cases were nosocomial and 15 were non-nosocomial. The most common comorbidities were diabetes mellitus (45.8%), chronic kidney disease (58.4%), prior valvular abnormalities (37.5%), and multiple prior hospitalizations (65.2%). There were 13 external lines, 9 tunneled lines, and 2 implantable ports. Responsible microorganisms included Staphylococcus aureus in 54.6%, coagulase-negative staphylococci in 37.5%, Candida species (spp.) in 16.6%, and enterococci in 12.5%. Five cases were polymicrobial. The line tip was within the right atrium (RA) in 37.5%, the superior vena cava (SVC)-RA junction in 20.8%, the SVC in 33.3%, and the pulmonary artery in 4.2% of patients. Sites of endocardial involvement were the aortic valve in 6 patients, mitral valve in 7 patients, tricuspid valve in 6 patients, right atrial wall in 11 patients, and pacemaker wire in 2 patients. Isolated right-sided involvement occurred in 50% of cases, isolated left-sided in 33.4%, and bilateral involvement in 16.6%. Transesophageal echocardiography (TEE) was necessary for diagnosis in 10 cases (41.6%). CONCLUSIONS: Endocarditis complicating CVC-BSI more often involves right-sided structures, with catheter tips in or near the right atrium, frequently requires TEE for diagnosis, and has significant inpatient mortality.

Nesiritide in the initial management of acute decompensated congestive heart failure.

BACKGROUND: In the era of evolving therapy for heart failure (HF), optimal medical therapy has become challenging. Nesiritide is being used for HF therapy but its impact is still controversial. METHODS: Prospective and randomized controlled study of 34 patients who presented to the emergency department (ED) with HF and remained symptomatic despite maximal standard therapy delivered for at least one hour. All patients had B-type natriuretic peptide BNP >100 pg/dl. Patients were randomized into Group A which received maximal standard therapy and group B which received nesiritide bolus followed by an infusion (0.01 mcg/kg/min) in addition to maximal therapy. Primary endpoints included HF hospital readmission, and hospital length of stay (LOS). Secondary endpoints included HF, cardiovascular, all-cause mortality, and adverse events. Composite risk score was designed. Results were analyzed using a logistic regression model and bootstrapping simulating approach. RESULTS: Decrease in rehospitalizations for HF was observed during the 30 days and six-month follow-up in Group B. Earlier initiation of nesiritide therapy consistently shortened hospital LOS. Group B had a decrease in 30-day mortality but not after one year. CONCLUSIONS: Acute HF patients who do not respond to maximal standard therapy appear to benefit from the early addition of nesiritide.

Coronary artery aneurysms.

Aneurysmal coronary artery disease is frequently encountered in clinical cardiology practice. Although more commonly associated with atherosclerosis, a variety of other acquired (eg, inflammatory, infectious, iatrogenic) or congenital causes have been identified. Recent research on the pathogenesis of coronary aneurysms has yielded interesting results. Advances in imaging have also provided new insights as to the nature of angiographic coronary aneurysms. Critical assessment of the abnormal flow dynamics and pathophysiology of aneurysms has been performed and there is an improved understanding of the associated complications. We present an extensive review of the recent literature highlighting the major advances in the field.

Papillary fibroelastoma arising from the pulmonary valve associated with pulmonary embolization.

Cardiac papillary fibroelastomas are rare, usuallybenign tumors that can be detected at autopsy, during open-heart surgery, or with echocardiography. They usually arise from the cardiac valves and more commonly are found on the left side of the heart. Embolization of left-sided and tricuspid valve tumors has been well documented. This is the 1st reported case of pulmonary embolization of a papillary fibroelastoma arising from the pulmonary valve.

Caseous calcification of the mitral valve ring.

Mitral annular calcification (MAC) is found in 10% of patients older than 50 years of age, and represents deposition of calcium between the basal infero-lateral ventricular wall and the posterior leaflet of the mitral valve. Caseous calcification, formed from a mixture of calcium, cholesterol and fatty acids, is an uncommon variant found on echocardiography in 0.6% of patients with MAC. The characteristic echographic appearance is of a large echo-dense structure with echo-lucent center and smooth borders. Caseous MAC carries a benign prognosis despite its impressive appearance and should not be misdiagnosed as a more serious condition such as myocardial abscess or tumor.

Intraaortic balloon pump insertion through the subclavian artery. Subclavian artery insertion of IABP.

The intraaortic balloon pump (IABP) is frequently used in the management of cardiac failure in the setting of myocardial infarction or as a bridge for coronary revascularisation surgery. The IABP is usually inserted through the femoral artery. Occasionally severe aorto-iliac occlusive disease prevents the retrograde passage of the balloon, in which case an anterograde route, usually through the ascending aorta is used. We describe four patients in whom an IABP was placed through the subclavian artery by the joint efforts of cardiologists and vascular surgeons.

Intramural hematoma of the descending thoracic aorta.

Aortic intramural hematoma (AIH) is part of the acute aortic syndrome together with aortic dissection and penetrating aortic ulcer. AIH represents up to 12% of acute aortic syndrome cases and has a clinical presentation indistinguishable from that of classic aortic dissection. A patient with AIH is presented and the diagnostic, prognostic and therapeutic implications of the disease are discussed.

Coronary vasculitis with acute myocardial infarction in a young woman with systemic lupus erythematosus.

Myocardial infarction in patients with systemic lupus erythematosus (SLE) is most commonly a consequence of atherosclerosis. Coronary vasculitis with aneurysms is a rare cause of myocardial ischemia in SLE. We present a case of a 22-year-old woman with a 4-year history of SLE who was admitted with acute onset of chest pain. Although initially treated for lupus pericarditis, she was subsequently found to have an acute myocardial infarction. Cardiac catheterization revealed multiple areas of aneurysmal coronary dilatation and only moderate stenoses of the secondary branches.In view of the angiographic findings, coronary revascularization was not indicated. Anticoagulant therapy was initiated as a result of the presence of large aneurysmal coronary dilatations, which are predisposed to in situ thrombosis and distal embolization. The coronary vasculitis was treated with immunosuppressive therapy. Measures aimed at secondary prevention of coronary artery disease, including optimization of lipid profile, blood pressure control, and prevention of left ventricular postinfarct remodeling, were initiated and continued indefinitely.

Patterns of anticoagulation in patients hospitalized with atrial fibrillation: warfarin is underused in paroxysmal atrial fibrillation.

Paroxysmal atrial fibrillation (PAF) has a similar stroke risk when compared with chronic atrial fibrillation (CAF). Our study sought to define the incidence of warfarin use at time of admission and discharge in patients hospitalized with PAF and CAF. Anticoagulation rates upon hospital admission were 89% in the patients with CAF and 38% in patients with PAF, and increased to 100% for patients with CAF and 81% for patients with PAF at the time of hospital discharge. Despite a similar risk of stroke, patients with paroxysmal atrial fibrillation were less likely to receive long-term oral anticoagulation (AC) compared to patients with chronic atrial fibrillation.