Pericardial Tuberculosis in a Non-endemic Region Presenting as a Persistent Upper Respiratory Tract Infection With Negative Serology, Bronchial Washings, and Pleural Aspirate.

This paper reports on the unlikely case of a 68-year-old man presenting with a non-resolving, mild lower respiratory tract infection, subsequently diagnosed with pericardial tuberculosis (TB) in the absence of TB risk factors and with negative TB serology. Pericardial and pleural effusions were found incidentally on CT pulmonary angiogram, with a small pericardial effusion without tamponade seen on the echocardiogram. During his three-month inpatient stay, the patient was rarely very unwell, though no treatment led to clinical and biochemical resolution of symptoms. Later deterioration prompted another echocardiogram, which found a moderate-sized pericardial effusion, septal bounce, and new regional wall motion abnormalities. To avert the impending cardiac tamponade, the patient underwent pericardiectomy, which provided a tissue diagnosis of TB. Pericardial TB is extremely uncommon, especially outside of TB endemic regions, though it is well described. This case is especially noteworthy, as serology, bronchial washings, and pleural aspirate had been negative for TB though a Quantiferon test was positive. The diagnosis was only confirmed after pericardiectomy. The patient was subsequently treated with anti-TB therapy, with a good clinical response. This case highlights diagnostic challenges and strategies for investigating and managing similar complex scenarios, particularly in non-endemic settings.

Contemporary management of infective endocarditis in pregnancy.

INTRODUCTION: Infective endocarditis (IE) during pregnancy is a rare condition that is associated with a high level of morbidity and mortality. The epidemiology, diagnosis, treatment, and prognosis have changed significantly in the last two decades. The declining incidence of rheumatic heart disease, improved life expectancy with congenital heart disease, advances in cardiac surgery and cardiac devices, rise in resistant microorganisms, complications of the opioid epidemic, and increasing maternal age are some of the many factors contributing to these changes. AREAS COVERED: This article explores existing literature on the topic including case reports, case series, registry data, and clinical guidelines. The focus of this article is the evolving epidemiology, predisposing factors and preventative measures, clinical presentation, investigation, management, and potential complications of IE in pregnancy. EXPERT OPINION: Robust prospective data on the management of IE in pregnancy is lacking, and obtaining these data will be very challenging. It is imperative that international registries are used to provide data on best clinical practices and inform future clinical guidelines. Multimodal imaging should be incorporated in the investigation of complicated cases. A multidisciplinary approach to the management of this rare and life-threatening condition is essential to ensure the best outcomes for both the mother and the fetus.

Severe Aortic Valvular Incompetence From IgG4-Related Disease: An Unusual Entity.

IgG4-related disease (IgG4-RD) is a new clinical entity characterized by lymphoplasmacytic lesions rich in IgG4-positive plasma cells. Myocardial involvement is extremely rare and not a typical cardiovascular manifestation of IgG4-RD. We report a rare case of IgG4-RD-associated myocardial mass causing severe aortic incompetence, successfully treated with surgery and corticosteroids. (Level of Difficulty: Intermediate.).

Clinical Outcomes and Associations With Radial to Femoral Crossover in ST-Elevation Myocardial Infarction.

Radial access during primary percutaneous coronary intervention is associated with reduced mortality and major bleeding compared with femoral access and is the recommended access site. Nevertheless, failure to secure radial access may necessitate crossover to femoral access. This study aimed to identify the associations with crossover from radial to femoral access in all comers with ST-elevation myocardial infarction and to compare the clinical outcomes with those patients who did not require crossover. From 2016 to 2021, a total of 1,202 patients presented to our institute with ST-elevation myocardial infarction. Associations, clinical outcomes, and independent predictors of crossover from radial to femoral access were identified. From 1,202 patients, radial access was used in 1,138 patients (94.7%) and crossover to femoral access occurred in 64 patients (5.3%). Patients who required crossover to femoral access had higher rates of access site complications and longer length of stay in the hospital. Inpatient mortality was higher in the group requiring a crossover. This study identified 3 independent predictors of crossover from radial to femoral access in primary percutaneous coronary intervention: cardiogenic shock, cardiac arrest before arrival at the catheterization laboratory, and previous coronary artery bypass grafting. Biochemical infarct size and peak creatinine was also found to be higher in those requiring crossover. In conclusion, crossover in this study portended an increased rate of access site complications, greatly prolonged length of stay, and a significantly higher risk of death.

Post-percutaneous coronary intervention CYP2C19 genotyping in an Irish population: The potential role in identifying clopidogrel therapy-related bleeding risks.

AIMS: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains the standard of care. CYP2C19 genetic polymorphisms cause variable clopidogrel bioactivation. Increased function (CYP2C19*17) allele carriers (rapid metabolizers [RM] or ultrarapid metabolizers [UM]) are clopidogrel hyper-responders, hence are more susceptible to clopidogrel-related bleeding. Since current guidelines recommend against routine genotyping following PCI, data on the clinical utility of CYP2C19*17 genotype guided strategy are sparce. Our study provides real-world data on the 12-month follow-up of CYP2C19 genotyping in patients post-PCI. METHODS: This is a cohort study within an Irish population receiving 12-month DAPT following PCI. It identifies the prevalence of CYP2C19 polymorphisms within an Irish population and describes the ischaemic and bleeding outcomes after 12 months of DAPT. RESULTS: A total of 129 patients were included with the following CYP2C19 polymorphism prevalence: 30.2% hyper-responders (26.4% RM [1*/17*], 3.9% UM [17*/17*]) and 28.7% poor-responders (22.5% IM [1*/2*], 3.9% IM [2*/17*], 2.3% PM [2*/2*]). A total of 53 and 76 patients received clopidogrel and ticagrelor, respectively. At 12 months, total bleeding incidence within the clopidogrel group was positively correlated with CYP2C19 activity: IM/PM (0.0%), NM (15.0%) and RM/UM (25.0%). The positive relationship showed a moderate association that was statistically significant: rτ = 0.28, P = 0.035. CONCLUSIONS: The prevalence of CYP2C19 polymorphisms in Ireland is 58.9% (30.2% CYP2C19*17, 28.7% CYP2C19*2) with an approximately one in three chance of being a clopidogrel hyper-responder. Positive correlation between bleeding and increasing CYP2C19 activity within the clopidogrel group (n = 53) suggests possible clinical utility of a genotype-guided strategy identifying high bleeding risk with clopidogrel in CYP2C19*17 carriers, but further studies are required.

Total ischaemic time in STEMI: factors influencing systemic delay.

Total ischaemic time in ST-elevation myocardial infarction (STEMI) has been shown to be a predictor of mortality. The aim of this study was to assess the total ischaemic time of STEMIs in an Irish primary percutaneous coronary intervention (pPCI) centre. A single-centre prospective observational study was conducted of all STEMIs referred for pPCI from October 2017 until January 2019. There were 213 patients with a mean age 63.9 years (range 29-96 years). The mean ischaemic time was 387 ± 451.7 mins. The mean time before call for help (patient delay) was 207.02 ± 396.8 mins, comprising the majority of total ischaemic time. Following diagnostic electrocardiogram (ECG), 46.5% of patients had ECG-to-wire cross under 90 mins as per guidelines; 73.9% were within 120 mins and 93.4% were within 180 mins. Increasing age correlated with longer patient delay (Pearson's r=0.2181, p=0.0066). Women exhibited longer ischaemic time compared with men (508.96 vs. 363.33 mins, respectively, p=0.03515), driven by a longer time from first medical contact (FMC) to ECG (104 vs. 34 mins, p=0.0021). The majority of total ischaemic time is due to patient delay, and this increases as age increases. Women had longer ischaemic time compared with men and longer wait from FMC until diagnostic ECG. This study suggests that improved awareness for patients and healthcare staff will be paramount in reducing ischaemic time.

Mechanical Chest Compressions and Intra-Aortic Balloon Pump Combination for Refractory Ventricular Fibrillation During Primary PCI.

This case highlights the successful resuscitation of a 43-year-old man with ST-segment elevation myocardial infarction and refractory ventricular fibrillation by using a combination of mechanical chest compressions and intra-aortic balloon pump insertion. This bailout strategy facilitated primary multivessel percutaneous coronary intervention in a center without on-site extracorporeal membrane oxygenation. (Level of Difficulty: Advanced.).

Peak troponin T in STEMI: a predictor of all-cause mortality and left ventricular function.

BACKGROUND: The clinical significance of peak troponin levels following ST-elevation myocardial infarction (STEMI) has not been definitively established. The purpose of this study was to examine the relationship between peak high-sensitivity cardiac troponin T (hs-cTnT) and all-cause mortality at 30 days and 1 year, and left ventricular ejection fraction (LVEF) in STEMI. METHODS: A single-centre retrospective observational study was conducted of all patients with STEMI between January 2015 and December 2017. Demographics and clinical data were obtained through electronic patient records. Standard Bayesian statistics were employed for analysis. RESULTS: During the study period, 568 patients presented with STEMI. The mean age was 63.6±12 years and 76.4% were men. Of these, 535 (94.2%) underwent primary percutaneous coronary intervention, 12 (2.1%) underwent urgent coronary artery bypass and 21 (3.7%) were treated medically. Mean peak hs-cTnT levels were significantly higher in those who died within 30 days compared with those who survived (12 238 ng/L vs 4657 ng/L, respectively; p=0.004). Peak hs-cTnT levels were also significantly higher in those who died within 1 year compared with those who survived (10 319 ng/L vs 4622 ng/L, respectively; p=0.003). The left anterior descending artery was associated with the highest hs-cTnT and was the most common culprit in those who died at 1 year. An inverse relationship was demonstrated between peak hs-cTnT and LVEF (Pearson's R=0.379; p<0.00001). CONCLUSIONS: In STEMI, those who died at 30 days and 1 year had significantly higher peak troponin levels than those who survived. Peak troponin is also inversely proportional to LVEF with higher troponins associated with lower LVEF.

Intravascular lithotripsy during percutaneous coronary intervention: current concepts.

INTRODUCTION: Coronary artery calcification (CAC) is commonly encountered by interventional cardiologists. Severe CAC may impair stent delivery or result in stent underexpansion, stent thrombosis and/or in-stent restenosis (ISR). Multiple tools have been developed to help overcome the challenges associated with CAC and improve outcomes for these patients. Intravascular shockwave lithotripsy (IVL) is a novel therapy that uses acoustic pressure waves for the modification of CAC. AREAS COVERED: This review discusses the growing body of evidence to support the safety and efficacy of IVL in the setting of de novo severely calcified coronary arteries prior to stenting. We also discuss international real-world experience with the coronary IVL system. This includes the use of IVL in the setting of acute coronary syndrome (ACS), ISR and in combination with other tools for calcium modification. EXPERT OPINION: IVL is a safe and effective therapy that results in the fracture of coronary calcium and facilitates optimal stent delivery and expansion. Longer term follow-up is essential to shed light on the durability and late outcomes of an IVL strategy. Randomized control trials are warranted to compare IVL to alternative methods of calcium modification and to explore further the use of IVL for ACS.

Activation of PPCI team in the octogenarian and nonagenarians population: real-world single-centre experience.

OBJECTIVE: Advancement in healthcare provision has led to increasing octogenarian ST elevation myocardial infarction (STEMI) presentation to hospital for early revascularisation therapies. Limited literature to date exists to suggest octogenarian STEMI population; with majority of trials excluding these age group patients. Due to an ageing population, we expect increasing rates of STEMI in the octogenarian and nonagenarian population in the future. This study seeks to identify the outcomes of patients over the age of 80 presenting with STEMI and determine the factors associated with better or worse outcome. PATIENTS AND METHODS: This study is a single-centre retrospective observational study involving patients' age 80 or older presenting with STEMI between January 2014 and December 2019. Patient data were collected by chart review and analysis of the local STEMI database. Standard Bayesian statistics were employed for analysis. RESULTS: 1301 patients presented with STEMI during this period. 159/1301 (12.2%) were 80 years or older that fulfilled STEMI criteria, 35/159 (22.1%) were medically managed. 107/124 (86.29%) had angiographic evidence of acute total or partial thrombotic occlusion, and 97/107 were treated with primary percutaneous coronary intervention (PPCI). The activation ECG most commonly exhibited an anterior STEMI, while inferior STEMI ECGs had the strongest positive predictive value. PPCI group had a 30-day mortality rate of 20% (p=0.07) and 1-year mortality was 22.4%. Highest mortality was observed with cardiogenic shock, low ejection fraction, higher high sensitivity cardiac troponin T and creatinine at presentation. Conservatively managed patients had significant higher mortality rate (48% vs 22.4%, p=0.005) at 1 year. CONCLUSION: Patients over the age of 80 who present with STEMI and undergo PPCI have a significantly lower mortality rate at 1 year. These patients have a 77.6% survival at 1 year, with 92.4% likelihood of discharge to home (without need for long-term nursing home care). Cardiogenic shock in this group was associated with a 1-year mortality of 87.5%. Despite the advanced age, we suggest favourable outcomes described in the absence of patients presenting with cardiogenic shock.

Interhospital and interindividual variability in secondary prevention: a comparison of outpatients with a history of chronic coronary syndrome versus outpatients with a history of acute coronary syndrome (the iASPIRE Study).

BACKGROUND: Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes. METHODS: We studied outpatients who had an index CHD event in the preceding 6-24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods. RESULTS: Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation. CONCLUSIONS: Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

Impact on percutaneous coronary intervention for acute coronary syndromes during the COVID-19 outbreak in a non-overwhelmed European healthcare system: COVID-19 ACS-PCI experience in Ireland.

AIMS: To evaluate temporal trends of acute coronary syndromes (ACS) treated via percutaneous coronary intervention (PCI) throughout the COVID-19 outbreak in a European healthcare system affected but not overwhelmed by COVID-19-related pathology. METHODS AND RESULTS: We performed a retrospective multicentre analysis of the rates of PCI for the treatment of ACS within the period 2 months pre and post the first confirmed COVID-19 case in Ireland, as well as comparing PCI for ST-elevation myocardial infarction (STEMI) with the corresponding period in 2019. During the 2020 COVID-19 period (29 February-30 April 2020), there was a 24% decline in PCI for overall ACS (incidence rate ratio (IRR) 0.76; 95% CI 0.65 to 0.88; p<0.001), including a 29% reduction in PCI for non-ST-elevation ACS (IRR 0.71; 95% CI 0.57 to 0.88; p=0.002) and an 18% reduction in PCI for STEMI (IRR 0.82; 95% CI 0.67 to 1.01; p=0.061), as compared with the 2020 pre-COVID-19 period (1 January-28 February 2020). A 22% (IRR 0.78; 95% CI 0.65 to 0.93; p=0.005) reduction of PCI for STEMI was seen as compared with the 2019 reference period. CONCLUSION: This study demonstrates a significant reduction in PCI procedures for the treatment of ACS since the COVID-19 outbreak in Ireland. The reasons for this decline are still unclear but patients need to be encouraged to seek medical attention when cardiac symptoms appear, in order to avoid incremental cardiac morbidity and mortality due to a reduction in coronary revascularisation for the treatment of ACS.

Rheumatic pericarditis: a rare cause of constrictive pericarditis.

Constrictive pericarditis is a relatively uncommon form of cardiac failure and presents due to scarring and consequent loss of the normal elasticity of the pericardial sac. This results in abnormal/limited ventricular filling and symptoms of heart failure. The aetiology is varied, from infective causes to idiopathic causes, or can manifest after cardiothoracic surgery. This case involves a 46-year-old man presenting with acute group A beta haemolytic streptococcus infection, and over the subsequent 6 months develops constrictive pericarditis due to what is believed to be a rheumatic aetiology. The patient subsequently underwent pericardiectomy and had restoration of normal filling dynamics confirmed on follow-up echocardiography. This case provides a subject matter for the review of the features of constrictive pericarditis and its investigation and management. This case is that it highlights the fact that pericarditis is not a benign condition. Emerging evidence suggests that pericarditis is due to a failure in inflammatory regulatory mechanisms, and patients suffering this condition have a preponderance to 'autoinflammation'. Pericarditis should be recognised early and treated fully with anti-inflammatory agents.

Diagnosing, fast and slow.

Diagnostic error is increasingly recognised as a source of significant morbidity and mortality in medicine. In this article, we will attempt to address several questions relating to clinical decision making; How do we decide on a diagnosis? Why do we so often get it wrong? Can we improve our critical faculties?We begin by describing a clinical vignette in which a medical error occurred and resulted in an adverse outcome for a patient. This case leads us to the concepts of heuristic thinking and cognitive bias. We then discuss how this is relevant to our current clinical paradigm, examples of heuristic thinking and potential mechanisms to mitigate bias.The aim of this article is to increase awareness of the role that cognitive bias and heuristic thinking play in medical decision making. We hope to motivate clinicians to reflect on their own patterns of thinking with an overall aim of improving patient care.

High-sensitivity troponin assays: development and utility in a modern health-care system.

Introduction: The introduction of cardiac troponin (cTn) assays have revolutionized the diagnosis and management of acute myocardial infarction in Emergency Departments worldwide. Its success has led to significant research and development investment in this area culminating in the development of newer high-sensitivity cardiac troponin assays (hs-cTn). While these newer assays allow for more rapid diagnosis by decreasing the time interval between serial data points, there is an inevitable trade off between increasing sensitivity and specificity. This review examines in detail the introduction and implementation of hs-cTN and its implications for clinical practice.Areas covered: This article reviews the history and development of high-sensitivity troponin assays and their application to clinical practice and current evidence base. It also discusses both the positive and negative aspects of the continuing increasing sensitivity of biochemical assays and the translation of this into clinical practice. Potential future developments are also discussed.Expert commentary: It is clear that there are many benefits to detecting extremely low concentration of cardiac troponin including the development of rapid rule out algorithms and the cost and time-saving advantages associated with the quicker movement of patients through the health-care system. It is important to note however that detecting troponin at very low concentrations also dramatically increases the false-positive rates and leads to a potentially large increase in invasive testing and diagnosis of myocardial infarction.

Outcomes of nurse-led clinic for patients treated with percutaneous coronary intervention: A retrospective analysis.

BACKGROUND: With an increasing prevalence of coronary heart disease, secondary prevention forms a major cornerstone of management. A dedicated nurse-led clinic for patients post percutaneous coronary intervention (PCI) offers a great opportunity to address risk factors in order to reduce cardiovascular events. PURPOSE: To determine the impact of a nurse-led clinic follow up of patients post PCI in relation to the 30 day mortality rate and re-admission, and patient satisfaction. Risk factor assessment, compliance with dual antiplatelet therapy (DAPT), and interventions at the clinic visit were also assessed. METHODS: A retrospective review of parameters recorded at clinic appointments from January 2015-December 2017. The data of patients were examined for baseline characteristics, risk factor assessment, and interventions at the clinic visit. Thirty day mortality and re-admission rates and patient satisfaction were major outcomes. RESULTS: 1325 individual patient records were retrospectively reviewed in our clinic. Mean age was 64 and 78% were males. The indications for PCI were STEMI (22.7%), NSTEMI (21.9%), and unstable and stable angina (43.1%). 5 patients (0.4%) died and 132 patients (10%) were re-admitted within 30 days after the follow-up visit. However, only 24 (1.8%) of the re-admissions were due to cardiac reasons. At the clinic appointment, 852 (64.3%) patients had non-pharmacological intervention and 473 (35.7%) patients had a pharmacological intervention. 712 (53.7%) patients had LDL-C above target and their statin therapy was amended accordingly. CONCLUSION: Nurse-led PCI clinics provide satisfactory assessment and management of risk factors achieving high patient satisfaction rates without increased risk of poor outcomes.

Coronary no-reflow in the modern era: a review of advances in diagnostic techniques and contemporary management.

Introduction: Atherosclerotic coronary artery disease, in particular acute myocardial infarction (AMI), is a leading cause of morbidity and mortality globally. Percutaneous coronary intervention (PCI) is the mainstay of treatment for obstructive coronary artery disease and AMI through the restoration of TIMI III flow. Despite good macrovascular flow, the myocardium can remain hypoperfusion due to poor microvascular perfusion, and this is referred to as 'no-reflow'. Various treatments have been studied with variable success in both prevention and treatment of no-reflow. Areas covered: This review outlines the cutting-edge diagnostic investigations which have been explored in no-reflow, allowing a deeper understanding of mechanism and microvascular pathological processes involved in its genesis. These include utility of novel MRI techniques and perfusion echo in conjunction with traditional approaches. Detailed review has been undertaken of both pharmacological and non-pharmacological techniques to prevent and manage microvascular dysfunction associated with no-reflow. Particular attention was paid to the evolution and successes of various mechanical protection devices. Expert opinion: Most promising innovations in the diagnosis and management of no-reflow are evaluated, and future outlook is explored. Emerging advances in acute coronary syndrome have their findings applied a role in modifying the pathophysiology of no-reflow.

Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis.

Purpose: We sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy. Background: Direct oral anticoagulants have become a popular choice for the prevention of thromboembolism. Risk factors for thromboembolism are common among cardiovascular conditions and indications for direct oral anticoagulant therapy as well as coronary angiography often overlap in patients. It has been hypothesised that uninterrupted direct oral anticoagulant therapy would increase haemorrhagic and access site complications, however data in this area is limited. Methods: This was a prospective observational analysis of 49 patients undergoing elective diagnostic coronary angiography while receiving uninterrupted anticoagulation with direct oral anticoagulants. This population was compared with a control group of 49 unselected patients presenting to the cardiology service for elective diagnostic coronary angiography. Continuous variables were analysed using the independent samples t-test and categorical variables using Pearson's χ2 test. Results: The mean duration of radial compression for the control group was 235.8±62.8 min and for the uninterrupted direct oral anticoagulant group was 258.4±56.5 min. There was no significant difference in mean duration of radial compression (p=0.07; 95% CI=-1.4 to 46.5). There was also no difference in the complication rate between the two groups (p=1). Conclusions: We observed similar complication rates and radial artery compression time postangiography in both groups. This small prospective observational study suggests that uninterrupted continuation of direct oral anticoagulants during coronary angiography is safe. Larger randomised control studies in this area would be beneficial.