Quadri-Chamber Thrombi and Impending Paradoxical Embolism: Thrombus in Transit Through Patent Foramen Ovale.

Thrombus-in-transit through patent foramen ovale (PFO) is an extremely rare diagnosis that can often be associated with pulmonary embolism. Currently, data exists to guide management options; however, there is no medical consensus with regard to the optimal treatment strategy for thrombus-in-transit through PFO.

Optimization of Antiplatelet Therapy in STEMI.

OPINION STATEMENT: Antiplatelet therapy is an essential component of ST elevation myocardial infarction (STEMI) management. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel has previously been the standard of care for STEMI management, but the advent of newer, more potent P2Y12 inhibitors has expanded the options for the management of STEMI. As compared with clopidogrel, these newer P2Y12 agents-such as prasugrel and ticagrelor-allow for further reductions in ischemic end points, without the robust increases in bleeding seen in previous studies of antithrombotic therapies. Understanding the nuances of these newer agents allows optimization of therapy for the individual patient and circumstance. Ultimately, combining these newer therapies, in specific populations, and specific approaches-alternative access strategies (e.g., radial)-may allow us to maximize efficacy and reduce the risk of antiplatelet therapies in treating patients with STEMI.

Long-Term Outcomes in Patients With Diabetes Mellitus Related to Prolonging Clopidogrel More Than 12 Months After Coronary Stenting.

BACKGROUND: Recent large clinical trials show lower rates of late cardiovascular events by extending clopidogrel >12 months after percutaneous coronary revascularization (PCI). However, concerns of increased bleeding have elicited support for limiting prolonged treatment to high-risk patients. OBJECTIVES: The aim of this analysis was to determine the effect of prolonging clopidogrel therapy >12 months versus ≤12 months after PCI on very late outcomes in patients with diabetes mellitus (DM). METHODS: Using the Veterans Health Administration, 28,849 patients undergoing PCI between 2002 and 2006 were categorized into 3 groups: 1) 16,332 without DM; 2) 9,905 with DM treated with oral medications or diet; and 3) 2,612 with DM treated with insulin. Clinical outcomes, stratified by stent type, ≤4 years after PCI were determined from the Veterans Health Administration and Medicare databases and risk was assessed by multivariable and propensity score analyses using a landmark analysis starting 1 year after the index PCI. The primary endpoint of the study was the risk of all-cause death or myocardial infarction (MI). RESULTS: In patients with DM treated with insulin who received drug-eluting stents (DES), prolonged clopidogrel treatment was associated with a decreased risk of death (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.42 to 0.82) and death or MI (HR: 0.67; 95% CI: 0.49 to 0.92). Similarly, in patients with noninsulin-treated DM receiving DES, prolonged clopidogrel treatment was associated with less death (HR: 0.61; 95% CI: 0.48 to 0.77) and death or MI (HR: 0.61; 95% CI: 0.5 to 0.75). Prolonged clopidogrel treatment was not associated with a lower risk in patients without DM or in any group receiving bare-metal stents. CONCLUSIONS: Extending the duration of clopidogrel treatment >12 months may decrease very late death or MI only in patients with DM receiving first-generation DES. Future studies should address this question in patients receiving second-generation DES.

Contemporary medical management of peripheral arterial disease: a focus on risk reduction and symptom relief for intermittent claudication.

Peripheral arterial disease (PAD) is primarily caused by progressive systemic atherosclerosis manifesting in the lower extremities. This review addresses the epidemiology, clinical presentation and evaluation, and medical management of PAD, with a focus on intermittent claudication. Key advances in the recognition of cardiovascular risk in asymptomatic individuals with mildly abnormal ankle-brachial index, newer reflections on exercise therapy, and a review of established and investigational agents for the treatment of symptomatic PAD, such as cilostazol, statins, and angiotensin-converting enzyme inhibitors, are highlighted.