Spontaneous coronary artery dissection: A review of medical management approaches.

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome (ACS) that usually presents in young female patients. Risk factors include female sex, physical and emotional stressors, and fibromuscular dysplasia, and diagnosis is usually made by coronary angiography aided by intravascular ultrasound (IVUS) or optical coherence tomography (OCT). While conservative treatment is usually preferred over percutaneous coronary intervention or surgery, medical management of SCAD has been under debate. This comprehensive review aims to summarize findings from recent studies exploring various medical treatment approaches for the management of SCAD. Antiplatelet therapy with aspirin is generally safe and beneficial for SCAD patients, with dual antiplatelet (DAPT) being recommended for patients undergoing PCI. In the absence of intervention, DAPT may be given for a short period followed by a longer single-antiplatelet (SAPT) therapy with aspirin. Beta-blockers appear to be safe and effective for SCAD patients. On the other hand, fibrinolytics, anticoagulants, and glycoprotein IIa/IIIb inhibitors are contraindicated. Cardiovascular medications such as renin-angiotensin-aldosterone system (RAAS) inhibitors, mineralocorticoid receptor antagonists, and statins are not recommended in the absence of left ventricular dysfunction. Hormonal therapy is contraindicated for patients who develop SCAD during pregnancy and future pregnancy is discouraged in that patient population.

Socioeconomic disparities in the management and outcomes of acute myocardial infarction.

BACKGROUND: Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear. METHODS: Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and 'ethnic-minority' patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality. RESULTS: More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001). CONCLUSION: Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients.

Cardiovascular outcomes of transradial versus transfemoral percutaneous coronary intervention in End-Stage renal Disease: A Regression-Based comparison.

Background: Limited data is available on the comparison of outcomes of transradial (TR) and transfemoral (TF) access for percutaneous coronary intervention (PCI) in patients with end-stage stage renal disease (ESRD). Methods: Online databases were queried to compare cardiovascular outcomes among TR. and TF in ESRD patients. The outcomes assessed included differences in mortality, cerebrovascular accidents (CVA), periprocedural myocardial infarction (MI), bleeding, transfusion, and periprocedural cardiogenic shock (CS). Unadjusted odds ratios (OR) were calculated using a random-effect effect model. Results: A total of 6 studies including 7,607 patients (TR-PCI = 1,288; TF-PCI = 6,319) were included. The overall mean age was 67.7 years, while the mean age for TR-PCI and TF-PCI was 69.7 years and 67.9 years, respectively. TR-PCI was associated with lower incidence of mortality (OR 0.46 95 % CI 0.30-0.70, p < 0.05, I2 0.00 %), bleeding (OR 0.45 95 % CI 0.29, 0.68, p < 0.05, I2 3.48 %), and transfusion requirement (OR 0.52 95 % CI 0.40, 0.67, p < 0.05, I2 0.00 %) (Fig. 1). There were no differences among TR-PCI and TF-PCI for periprocedural MI, periprocedural CS, and CVA outcomes. Conclusion: TR access was associated with lower mortality, bleeding, and transfusion requirement as compared to TF access in patients with ESRD undergoing PCI.

Corrigendum to "Outcomes of open mitral valve replacement versus Transcatheter mitral valve repair; insight from the National Inpatient Sample Database" [IJC Heart Vasculat. 28 (2020) 100540].

[This corrects the article DOI: 10.1016/j.ijcha.2020.100540.].

Clinical and angiographic success and safety comparison of coronary intravascular lithotripsy: An updated meta-analysis.

BACKGROUND: Intravascular lithotripsy (IVL) can be used to assist stent deployment in severe coronary artery calcifications (CAC). METHODS: Studies employing IVL for CAC lesions were included. The primary outcomes included clinical and angiographic success. The secondary outcomes, including lumen gain, maximum calcium thickness, and calcium angle at the final angiography site, minimal lumen area site, and minimal stent area site, were analyzed by the random-effects model to calculate the pooled standardized mean difference. Tertiary outcomes included safety event ratios. RESULTS: Seven studies (760 patients) were included. The primary outcomes: pooled clinical and angiographic success event ratio parentage of IVL was 94.4% and 94.8%, respectively. On a random effect model for standard inverse variance for secondary outcomes showed: minimal lumen diameter increase with IVL was 4.68 mm (p-value < 0.0001, 95% CI 1.69-5.32); diameter decrease in the stenotic area after IVL session was -5.23 mm (95 CI -22.6-12.8). At the minimal lumen area (MLA) and final minimal stent area (MSA) sites, mean lumen area gain was 1.42 mm2 (95% CI 1.06-1.63; p < 0.00001) and 1.34 mm2 (95% CI 0.71-1.43; p < 0.00001), respectively. IVL reduced calcium thickness at the MLA site (SMD -0.22; 95% CI -0.40-0.04; P = 0.02); calcium angle was not affected at the MLA site. The tertiary outcomes: most common complication was major adverse cardiovascular events (n = 48/669), and least common complication was abrupt closure of the vessel (n = 1/669). CONCLUSIONS: Evidence suggests that IVL safely and effectively facilitates stent deployment with high angiographic and clinical success rates in treating severely calcified coronary lesions.

Outcomes of Percutaneous Coronary Intervention in Patients With Acquired Immunosuppression.

There are limited data on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with acquired immunosuppression who are frequently underrepresented in clinical trials. All PCI procedures between October 2015 and December 2018 in the Nationwide Inpatient Sample were retrospectively analyzed, stratified by immunosuppression status. Multivariable logistic regression models were performed to examine (1) the association between immunosuppression status and in-hospital outcomes, expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CIs) and (2) predictors of mortality among patients with severe acquired immunosuppression. In this contemporary analysis of nearly 1.5 million PCI procedures, approximately 4% of patients who underwent PCI had acquired immunosuppression. Of these, chronic steroid use accounted for approximately half of the cohort who underwent PCI who had acquired immunosuppression, with the remainder divided between hematologic cancer, solid organ active malignancy, and metastatic cancer, with the latter group having the highest rates of composite of in-hospital mortality or stroke (9.3%) (mortality 7.5% and acute ischemic stroke 2.4%). In conclusion, immunosuppression was independently associated with increased adjusted odds of adverse clinical outcomes, specifically mortality or stroke (aOR 1.11, 95% CI 1.06 to 1.15, p <0.001) and in-hospital mortality (aOR 1.21, 95% CI 1.13 to 1.29, p <0.001), with outcomes dependent on the cause of immunosuppression.

Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis.

Subclavian steal syndrome is a rare phenomenon occurring from retrograde blood flow in the vertebral artery due to proximal stenosis in the subclavian artery. As a result, the arm gets blood supply from the vertebral artery at the expense of the vertebrobasilar system. The patient remains largely asymptomatic until there is an increase demand for blood supply to the arm, resulting in a constellation of symptoms including dizziness, vertigo, blurred vision, diplopia, headache, syncope, postural hypotension, neurologic deficits, and rarely, memory problems. The management approach depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.

Percutaneous coronary intervention in patients with cancer and readmissions within 90 days for acute myocardial infarction and bleeding in the USA.

AIMS: The post-discharge outcomes of patients with cancer who undergo PCI are not well understood. This study evaluates the rates of readmissions within 90 days for acute myocardial infarction (AMI) and bleeding among patients with cancer who undergo percutaneous coronary intervention (PCI). METHODS AND RESULTS: Patients treated with PCI in the years from 2010 to 2014 in the US Nationwide Readmission Database were evaluated for the influence of cancer on 90-day readmissions for AMI and bleeding. A total of 1 933 324 patients were included in the analysis (2.7% active cancer, 6.8% previous history of cancer). The 90-day readmission for AMI after PCI was higher in patients with active cancer (12.1% in lung, 10.8% in colon, 7.5% in breast, 7.0% in prostate, and 9.1% for all cancers) compared to 5.6% among patients with no cancer. The 90-day readmission for bleeding after PCI was higher in patients with active cancer (4.2% in colon, 1.5% in lung, 1.4% in prostate, 0.6% in breast, and 1.6% in all cancer) compared to 0.6% among patients with no cancer. The average time to AMI readmission ranged from 26.7 days for lung cancer to 30.5 days in colon cancer, while the average time to bleeding readmission had a higher range from 38.2 days in colon cancer to 42.7 days in breast cancer. CONCLUSIONS: Following PCI, patients with cancer have increased risk for readmissions for AMI or bleeding, with the magnitude of risk depending on both cancer type and the presence of metastasis.

COVID-19 cardiovascular epidemiology, cellular pathogenesis, clinical manifestations and management.

Coronavirus Disease 2019 (COVID-19) is a rapidly progressing global pandemic that may present with a variety of cardiac manifestations including, but not limited to, myocardial injury, myocardial infarction, arrhythmias, heart failure, cardiomyopathy, shock, thromboembolism, and cardiac arrest. These cardiovascular effects are worse in patients who have pre-existing cardiac conditions such as coronary artery disease, hypertension, diabetes mellitus, and coagulation abnormalities. Other predisposing risk factors include advanced age, immunocompromised state, and underlying systemic inflammatory conditions. Here we review the cellular pathophysiology, clinical manifestations and treatment modalities of the cardiac manifestations seen in patients with COVID-19.

Outcomes of open mitral valve replacement versus Transcatheter mitral valve repair; insight from the National Inpatient Sample Database.

BACKGROUND: Transcatheter mitral valve repair and replacement (TMVR) is a minimally invasive alternative to conventional open-heart mitral valve replacement (OMVR). The present study aims to compare the burden, demographics, cost, and complications of TMVR and OMVR. METHODS: The United States National Inpatient Sample (US-NIS) for the year 2017 was queried to identify all cases of TMVR and OMVR. Categorical and continuous data were analyzed using Pearson chi-square and independent t-test analysis, respectively. An adjusted odds ratio (aOR) based on the ordinal logistic regression (OLR) model was calculated to determine the association between outcome variables. RESULTS: Of 19,580 patients, 18,460 (94%) underwent OMVR and 1120 (6%) TMVR. Mean ages of patients were 63 ± 14 years (OMVR) and 67 ± 13 years (TMVR). Both cohorts were predominantly Caucasian (73% OMVR vs. 74.0% TMVR). The patients who underwent TMVR were more likely to belong to a household with an income in the highest quartile (26.1% vs. 22.0% for OMVR) versus the lowest quartile (22.1% vs. 27.8%). The average number of days from admission to TMVR was less compared to OMVR (2.63 days vs. 3.02 days, p = 0.015). In-hospital length of stay (LOS) was significantly lower for TMVR compared to OMVR (11.56 vs. 14.01 days, p=<0.0001). Adjusted in-hospital mortality taking into account comorbidities showed no significant difference between the two groups (OR 1.2, 0.93-1.68, p = 0.15). CONCLUSION: Patients undergoing TMVR were older and more financially affluent. TMVR was more costly but was associated with a shorter hospital stay and similar mortality to OMVR.