Atrioventricular conduction disorders in aortic valve infective endocarditis.

BACKGROUND: Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases. AIM: To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis. METHODS: Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year. RESULTS: High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up. CONCLUSIONS: High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.

Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study.

AIMS: Newer P2Y12 blockers (prasugrel and ticagrelor) demonstrated significant ischaemic benefit over clopidogrel after acute coronary syndrome (ACS). However, both drugs are associated with an increase in bleeding complications. The objective of the present study was to evaluate the benefit of switching dual antiplatelet therapy (DAPT) from aspirin plus a newer P2Y12 blocker to aspirin plus clopidogrel 1 month after ACS. METHODS AND RESULTS: We performed an open-label, monocentric, and randomized trial. From March 2014 to April 2016, patients admitted with ACS requiring coronary intervention, on aspirin and a newer P2Y12 blocker and without adverse event at 1 month, were assigned to switch to aspirin and clopidogrel (switched DAPT) or continuation of their drug regimen (unchanged DAPT). The primary outcome was a composite of cardiovascular death, urgent revascularization, stroke and bleeding as defined by the Bleeding Academic Research Consortium (BARC) classification ≥2 at 1 year post ACS. Six hundred and forty six patients were randomized and 645 analysed, corresponding to 322 patients in the switched DAPT and 323 in the unchanged DAPT group. The primary endpoint occurred in 43 (13.4%) patients in the switched DAPT group and in 85 (26.3%) patients in the unchanged DAPT (HR 95%CI 0.48 (0.34-0.68), P < 0.01). No significant differences were reported on ischaemic endpoints, while BARC ≥ 2 bleeding occurred in 13 (4.0%) patients in the switched DAPT and in 48 (14.9%) in the unchanged DAPT group (HR 95%CI 0.30 (0.18-0.50), P < 0.01). CONCLUSION: A switched DAPT is superior to an unchanged DAPT strategy to prevent bleeding complications without increase in ischaemic events following ACS.

Acute coronary syndrome and cerebral arterial gas embolism in a scuba diver.

BACKGROUND: Pulmonary barotrauma is a rare but feared complication of scuba diving, with around 30% mortality. OBJECTIVE: We report an uncommon case of pulmonary barotrauma complicated by arterial gas embolism with both coronary and neurological ischemic injuries after scuba diving. CASE REPORT: A 46-year-old-man was admitted to our hospital for acute coronary syndrome and stroke following a scuba dive. After hyperbaric oxygen therapy, the patient recovered fully with a subsequent normal coronary angiogram. CONCLUSION: Myocardial ischemia can be a complication of scuba diving, but does not always reveal significant obstructive coronary artery disease.

Effect of increased aspirin dose after stenting in association with ClOpidogrel: the FIASCO randomized study.

BACKGROUND: Increased doses of antiplatelet therapy have been proposed to overcome the variability of response. However, the chronic dose of aspirin after DES remains controversial. METHODS AND RESULTS: We assessed in a prospective and randomized study the benefit of higher dose of aspirin, in association with clopidogrel, on aspirin response and non COX-specific platelet testing in patients receiving Drug Eluting Stent (DES) for stable angina pectoris. 50 consecutive patients receiving DES for stable angina pectoris were prospectively included. They received loading dose of 250 mg aspirin and 600 mg clopidogrel and antiplatelet response was assessed with Arachidonic Acid-induced aggregation (AA-Ag) and ADP-induced aggregation (ADP-Ag) for aspirin and clopidogrel response respectively. Patients were randomized to either 75 or 160 mg of aspirin with 150 mg clopidogrel and platelet testing were repeated one month after hospital discharge. The two groups (aspirin "75 mg" or "160 mg") had no difference for aspirin response: AA-Ag (5.2 +/- 1.7% vs 6 +/- 2%, p = 0.75) and non COX-specific pathway testing: ADP-Ag (47 +/- 3% vs 49 +/- 4%, p = 0.61). CONCLUSION: The present study did not show any benefit of higher dose of aspirin neither on aspirin responsiveness, nor on inhibition of non COX-specific pathway. These data does not support use of higher dose than 75 mg of aspirin in association with clopidogrel in patients receiving DES, especially while higher doses have been associated with increased bleeding risk.

Prognostic value of ischaemia-modified albumin in patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: Ischaemia-modified albumin (IMA) is a new sensitive diagnostic biochemical marker of myocardial ischaemia. The purpose of the study was to analyse the prognostic value of IMA in patients admitted for non-ST-segment elevation acute coronary syndromes (NSTE ACS). METHODS: Consecutive patients admitted for NSTE ACS in our institution were prospectively included. IMA, cardiac troponin I (TnI) and C-reactive protein (CRP) were measured in all patients within 3h of last chest pain. The clinical combined endpoint was major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction (MI) and recurrent ischaemia leading to urgent revascularization. The independent prognostic impact of IMA on occurrence of the combined endpoint during hospitalization and at 1 year was tested by a logistic regression model and was systematically adjusted for other known clinical and biological predictors. RESULTS: Seventy-nine patients were enrolled. Nine (11.4%) patients experienced the combined endpoint during hospitalization and 16 (20.2%) during 1-year follow-up. Median IMA level was significantly higher in patients with MACE during hospitalization (115 [93-126]U/mL versus 100 [42-138]U/mL; p=0.007) and at 1 year (114 [93-126]U/mL versus 97 [42-138]U/mL; p<0.001). After adjustment for conventional prognostic risk factors, IMA remained an independent predictor of MACE both during hospitalization (odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.01-1.16; p=0.03) and at 1 year (hazards ratio [HR]: 1.07; 95% CI: 1.03-1.12; p=0.003). CONCLUSION: Baseline levels of IMA were associated with both short- and long-term cardiovascular (CV) events in patients admitted for NSTE ACS.

Glycoprotein IIb/IIIa inhibitors improve outcome after coronary stenting in clopidogrel nonresponders: a prospective, randomized study.

OBJECTIVES: The aim of this study was to assess, in clopidogrel nonresponders undergoing elective percutaneous coronary intervention (PCI), the benefit of adjusted antiplatelet therapy with glycoprotein (GP) IIb/IIIa antagonist administration during PCI for 1-month clinical outcome. BACKGROUND: Numerous biological studies have reported interindividual variability in platelet response to clopidogrel with clinical relevance, and high post-treatment platelet reactivity (adenosine diphosphate-induced aggregation >70%) has been proposed to define nonresponse to clopidogrel. These nonresponders might benefit from tailored antiplatelet therapy. METHODS: One hundred forty-nine clopidogrel nonresponders referred for elective PCI were prospectively included and randomized to "conventional group" (n = 75) or "active group" with GP IIb/IIIa antagonist (n = 74). All patients received 250-mg aspirin and 600-mg clopidogrel before PCI and platelet testing. RESULTS: The rate of cardiovascular events at 1 month was significantly lower in the "active group" than in the "conventional group": 19% (n = 14) versus 40% (n = 30), p = 0.006, odds ratio: 2.8; 95% confidence interval: 1.4 to 6.0. No patient in either group had post-procedural Thrombolysis In Myocardial Infarction major bleeding or required transfusions. CONCLUSIONS: The present study suggested benefit of tailored antiplatelet therapy during elective PCI with GP IIb/IIIa antagonist for clopidogrel nonresponders without increased bleeding risk.