Identifying and Treating Vulnerable Atherosclerotic Plaques.

Acute coronary syndromes and, in particular, ST-elevation myocardial infarction are usually caused by coronary thrombosis in which the thrombus develops either on a disrupted plaque (usually a thin-capped fibroatheroma) or an eroded atherosclerotic plaque. These thrombus-prone plaques are vulnerable or high-risk. Although, traditionally, cardiologists have concentrated on treating significant coronary obstruction, there has been great interest over the last 2 decades in possibly preventing the thrombotic causes of myocardial infarction/sudden coronary death by mostly identifying and stabilizing these asymptomatic vulnerable or high-risk plaques, which, at least on invasive angiography, are mostly nonobstructive. Computed tomographic angiography and intravascular imaging during invasive coronary angiography have now been shown to identify a majority of these vulnerable or high-risk plaques before symptoms, thus opening up new preventive strategies. In conclusion, this article discusses the identification and management of these thrombus-prone lesions and patients with these lesions either with noninvasive techniques and systemic therapies or possibly through a new and bold interventional paradigm.

Amiodarone-Induced Neutropenia: An Uncommon Side Effect of a Common Drug.

Amiodarone is widely used as an antiarrhythmic agent for the treatment of both supraventricular and ventricular arrhythmias in various inpatient as well as outpatient settings. Classified as a class III antiarrhythmic agent, it acts mainly by inhibition of potassium channels in the cardiac muscle. Adverse effects are quite common and usually involve pulmonary, gastrointestinal, endocrine, dermatologic, or neuromuscular systems. Although hematologic side effects including thrombocytopenia have also been reported, amiodarone-induced neutropenia is quite rare. We present a case of amiodarone-induced neutropenia in a 66-year-old Caucasian gentleman. He presented to our hospital with cardiac arrest due to ventricular-fibrillation and had received amiodarone as a part of his therapy. His hospital course was complicated by neutropenia which was found to have a clear temporal relation with amiodarone. His initial white blood cell count was 6400/mm3 with an absolute neutrophil count (ANC) of 4800/mm3. His ANC started to downtrend and reached a nadir of 400/mm3 at day six of therapy. This improved significantly after stopping amiodarone, without any change in other medications. Given the rapid improvement of his neutropenia with the discontinuation of amiodarone, further workup with a bone marrow biopsy was not performed. Severe selective neutropenia, also known as agranulocytosis, is a life-threatening condition due to increased risk of severe infections. Antiarrhythmic agents such as tocainamide, procainamide, and flecainide are generally known to cause agranulocytosis. The mechanism of agranulocytosis or neutropenia is thought to be mediated by either immune-mediated destruction or direct and indirect toxicity to myeloid precursors. Although amiodarone has been in use for over 20 years in the management of tachyarrhythmias, agranulocytosis as a direct side effect of amiodarone therapy has been rarely reported. It is important to keep in mind this rare but potentially life-threatening adverse effect of amiodarone when initiating therapy.

Cardiovascular Disease Risk in Survivors of Breast Cancer.

PURPOSE OF REVIEW: Early detection and improved treatment in breast cancer have resulted in an increased number of survivors. Cardiovascular disease now remains an important cause for morbidity and mortality in this population. There is a growing gap in the knowledge about the optimal long-term cardiovascular management of this population. FINDINGS: Breast cancer and cardiovascular disease share a number of common risk factors. Different breast cancer treatment modalities, including anthracyclines, radiation, and hormonal therapy, can act in synergy with preexisting and/or new cardiovascular risk factors to result in significant cardiovascular disease. We summarize the recent evidence about cardiovascular effects of breast cancer therapy and recommendations for their diagnosis and management during the cancer treatment continuum into survivorship. We also present current research initiatives and how they inform clinical care.

Spontaneous Coronary Artery Dissection in Levo-Transposition of the Great Arteries.

Spontaneous coronary artery dissection (SCAD) is an uncommon form of acute coronary syndrome (ACS). With the increasing recognition of this condition presenting as ACS in females, clinicians should always remain vigilant for it. This case describes a patient with congenital heart disease presenting with SCAD. (Level of Difficulty: Advanced.).