Comparison of Drug-Coated Balloons With Drug-Eluting Stents in Patients With In-Stent Restenosis: A Systematic Review and Meta-Analysis.

In-stent restenosis (ISR) is the gradual narrowing of the stented coronary segment, presenting as angina or leading to an acute myocardial infarction. Although its incidence has decreased with the use of newer drug-eluting stents (DES), it still carries significant mortality and morbidity risks. We compared the 2 most common interventions for managing DES-related ISR: drug-coated balloons (DCBs) and DES. Electronic databases were searched to identify all randomized controlled trials comparing DCB with DES in patients with DES-ISR. The Mantel-Haenszel method with a random-effects model was used to calculate pooled risk ratios. Five trials comprising 1,100 patients (577 in DCB and 523 in DES group) were included in the final study. The mean follow-up was 42 months. DCB was found to have a higher risk for target lesion revascularization (risk ratio 1.41, p = 0.02) compared with DES. No difference was observed in all-cause mortality, target vessel revascularization, myocardial infarction, or stroke between the 2 intervention arms. In conclusion, management of DES-ISR with DCB has a higher risk of target lesion revascularization compared with re-stenting with DES. The 2 therapeutic interventions are comparable in terms of efficacy and safety profile.

Thirty-day hospital readmission in females with acute heart failure and breast cancer: A retrospective cohort study from national readmission database.

BACKGROUND: Breast Cancer and cardiovascular diseases are amongst the two leading causes of mortality in the United States, and the two conditions are connected in part because of recognized cardiotoxicity of cancer treatments. The aim of this study is to investigate the predictors risk factors for thirty-day readmission in female breast cancer survivors presenting with acute heart failure. METHODS: This is a retrospective cohort study of acute heart failure (AHF) hospitalization in female patients with breast cancer in 2019 using the National Readmission Database (NRD), which is the largest publicly available all-payer inpatient readmission database in the United States. Our study sample included adult female patients aged 18 years and older. The primary outcome of interest was the rate of 30- day readmission. RESULTS: In 2019, there were 8332 total index admissions for AHF in females with breast cancer and 7776 patients were discharged alive. The mean age was 74.4 years (95% CI: 74, 74.7). The percentage of readmission at 30 days among those discharged alive was 21.8% (n = 1699). Hypertensive heart disease with chronic kidney disease accounted for the majority of readmission in AHF with breast cancer followed by sepsis, acute kidney injury, respiratory failure, pneumonia, and atrial fibrillation. Demographic factors including higher burden of comorbidities predict readmission. The total in-hospital mortality in index admission was 6.67% (n = 556) and for readmitted patients was 8.77% (n = 149). The mean length of stay for index admission was 7.5 days (95% CI: 7.25, 7.75). CONCLUSIONS: Readmission of female breast cancer survivors presenting with AHF is common and largely be attributed to high burden of comorbidities including hypertension, and chronic kidney disease. A focus on close outpatient follow-up will be beneficial in lowering readmissions.

Meta-Analysis Comparing Drug-Coated Balloon Versus Plain Old Balloon Angioplasty for In-stent Restenosis of Coronaries.

BACKGROUND: Despite the advent of newer stents, in-stent restenosis has been a persistent and formidable challenge. Trials have demonstrated the superiority of drug-coated balloons (DCB) over plain-old balloon angioplasty (POBA). A recent AGENT IDE trial highlighted the need for a more comprehensive understanding hence we conducted a meta-analysis aimed at elucidating their respective clinical outcomes. METHODS: A literature search was conducted by 2 investigators (SS and MH) using MEDLINE (EMBASE and PubMed) using a systematic search strategy by PRISMA till November 01, 2023. CRAN-R software was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias tool (Supplemental Table 5). RESULTS: We included 6 studies with a total of 1171 patients. Our analysis showed decreased odds of multiple outcomes with statistically significant results including TVR (OR 0.33, CI 0.19-0.57), TVF (OR 0.30, CI 0.09-0.99), TLR (OR 0.22, CI 0.10-0.46), restenosis (OR 0.1343, CI 0.06-0.27), and MACE (OR 0.2 CI 0.12-0.37). Although MI and all-cause mortality showed decreased odds with all-cause mortality at 0.8 (95% CI: 0.363-2.09), and MI at 0.6 (95% CI: 0.0349-1.07), the reductions did not reach statistical significance. CONCLUSION: Our analysis by scrutinizing six RCTs favored DCB over POBA. However, extensive research for deeper understanding cannot be overemphasized.

Drug-eluting stent vs. Balloon angioplasty in patients with in-stent restenosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: In-stent restenosis (ISR) is seen in up to 20% of cases and is the primary cause of percutaneous coronary intervention (PCI) failure. With the use of re-stenting with a drug-eluting stent (DES), plain old balloon angioplasty (BA) use is decreasing. We aim to compare the efficacy and safety profile of DES over BA in the management of ISR. METHODS: Electronic databases were searched to identify all randomized controlled trials (RCTs) comparing DES to BA for coronary ISR. The mantel-Haenszel method with a random effects model was used to calculate pooled risk ratios (RR). RESULTS: Four trials comprising 912 patients (543 in DES and 369 in the BA group) were included in the final study. The mean follow-up was 45 months. DES was found to be superior with a lower requirement of target vessel revascularization (TVR) (RR: 0.45, 95% CI: 0.31-0.64, p-value <0.0001), and target lesion revascularization (TLR) (RR: 0.59, 95%CI: 0.44-0.78, p-value 0.0002) compared to BA. However, all-cause mortality, cardiovascular mortality, incidence of myocardial infarction (MI), and target lesion thrombosis were not different between the two intervention arms. CONCLUSION: DES was found to be superior to BA for the management of coronary ISR with a reduction in the risk of TLR and TVR. No difference in mortality, risk of MI, or target lesion thrombosis was observed between the two interventions.

A Rare Case of Arterial and Venous Thrombosis in COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has brought attention to the significant risk of thrombotic complications in infected individuals. We present a rare case of a 64-year-old male with COVID-19 who developed bilateral deep vein thrombosis (DVT), pulmonary embolism (PE), and thrombus in the thoracic and abdominal aorta. The patient exhibited common symptoms of COVID-19 and required intensive care unit admission due to respiratory failure. Subsequent investigations revealed thrombi in the lower extremities, pulmonary arteries, and aorta. Prompt anticoagulation therapy was initiated, and vascular surgery consultation was sought. This case highlights the increased risk of venous and arterial thrombotic events in COVID-19 patients and emphasizes the importance of comprehensive management strategies. The interplay of various factors in COVID-19 contributes to a prothrombotic state, necessitating a multi-modal approach to address thrombotic complications. Further research is needed to optimize treatment protocols and improve outcomes for COVID-19 patients with thrombotic complications.

Exploring the Causal Relationship Between Arterial and Venous Thromboembolism: A Case Series With Review of Literature.

Venous thromboembolism (VTE) occurs due to venous stasis or low flow state within the blood vessels, resulting in subsequent fibrin and platelet aggregation leading to thrombosis. Arterial thrombosis affects various arteries including coronaries and is primarily due to platelet aggregation with little fibrin deposition leading to thrombosis. Although both arterial and venous thrombosis are considered as separate entities, some studies have suggested an association between them despite having distinctive causative factors. We retrospectively reviewed patients at our institution who were admitted with acute coronary syndrome (ACS) and underwent cardiac catheterization over a decade between 2009 and 2020 to look for patients who had both venous thromboembolic events and ACS. Here, we report a case series of three such patients who were found to have both VTE and coronary arterial thrombosis. However, it is unclear if having one of venous vs arterial clot increases the risk of having other vascular conditions, and further studies are needed to evaluate this hypothesis in the near future.

Metformin-Associated Lactic Acidosis: A Case Report and Review.

Metformin is widely prescribed as the first-line medication for type II diabetes mellitus. While the gastrointestinal side effects of metformin such as nausea, vomiting, diarrhea, and heartburn are quite common, one dangerous side effect of metformin, lactic acidosis, is extensively discussed yet rarely reported. Here, we discuss a 53-year-old female with type II diabetes mellitus who presented to an emergency department (ED) with chief complaints of dizziness and lightheadedness. The patient had chronic kidney disease (CKD) with a baseline estimated glomerular filtration rate (eGFR) of 45 mL/minute/1.73 m2. Initial laboratory results showed acute kidney injury (AKI) with hyperkalemia and lactic acidosis of 20 mmol/L. The patient was admitted to the ICU requiring emergent dialysis. Later, she was diagnosed with metformin-associated lactic acidosis (MALA). Her AKI and lactic acidosis subsequently improved. Metformin-associated lactic acidosis (MALA) is a rare but serious side effect of metformin. It is primarily reported in patients with chronic renal failure; therefore, it should be used with caution in these patients. Renal replacement therapy (RRT) is the critical management option for patients with MALA. Because of this, physicians prescribing metformin should carefully monitor all patients and assess the risk of developing severe side effects.

Post myocardial infarction left ventricular intramural dissecting hematoma: a case report describing a very rare complication.

BACKGROUND: Dissecting intramural hematoma is a rare complication of acute myocardial infarction (AMI) and has been associated with increased mortality. There has been paucity of literature to establish protocols and guidelines for management in such cases. CASE PRESENTATION: We hereby report the case of a 45-year-old male patient with left ventricular intramural dissecting hematoma (LV-IDH) who presented with chest pain and breathlessness and diagnosed as non-ST-elevation myocardial infarction (NSTEMI). Transthoracic echocardiography (TTE) was performed showing LV-IDH, confirmed with cardiac magnetic resonant imaging (cMRI). Selective coronary arteriography (CAG) was performed showing significant obstructive coronary artery disease (CAD). Further management with conservative approach involved discussion with patient, cardiothoracic surgeon and cardiology team including heart failure specialist and interventional cardiology. CONCLUSIONS: This case describes a rare complication of AMI and also focuses on utility of TTE and cMRI in the diagnosis of this rare complication. Both diagnosis and management are challenging and have to be individualized in similar cases. Multidisciplinary care coordination is important in management of patients with this diagnosis.