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.).

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.

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.

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.

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.

Streptococcus bovis Endocarditis after Colonic Polypectomy.

We describe a case of Streptococcus lutetiensis infective endocarditis occurring in a patient following colonic polypectomy. The patient had multiple risk factors for infective endocarditis including pre-existing mitral valve prolapse and regurgitation. Transoesophageal echocardiography revealed a friable mass on the posterior mitral valve leaflet, confirming the diagnosis. The patient was treated with intravenous antibiotics, successfully underwent mitral valve surgery and was discharged home for outpatient follow-up. This report details an uncommon case presentation, highlights areas for improvement in clinical practice, and summarises the current knowledge available in the literature regarding Streptococcus bovis infective endocarditis. LEARNING POINTS: Infective endocarditis occurring in association with gastrointestinal endoscopy is rare.Clinical suspicion of infective endocarditis after colonic polypectomy or biopsy should be maintained, especially in those with risk factors for infective endocarditis.Antibiotic prophylaxis against infective endocarditis is not recommended for routine gastrointestinal endoscopic procedures.

Acute pericarditis: a review of current diagnostic and management guidelines.

This review examined the relevance of chest pain, pericardial friction rub, pericardial effusion and ECG changes in regard to the diagnosis of acute pericarditis. It also assessed the evidence for the management and therapeutic guidelines, specifically nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. Overall, there appears to be a lack of research into pericarditis. The bulk of high-quality research seems to have been carried out prior to the publication of the European Society of Cardiology guidelines of 2015. Diagnostically, the current combination of symptoms, clinical signs and investigations offer reasonable criteria for diagnosis, but they are not a gold standard. Research into its therapeutic treatment options is required to address the effects of specific nonsteroidal anti-inflammatory drugs (NSAIDs).

Insight into the perioperative management of direct oral anticoagulants: concerns and considerations.

INTRODUCTION: Direct oral anticoagulants (DOACs) have gained momentum in recent years in patients requiring anticoagulation for the prevention and management of venous thromboembolism and thromboembolic events caused by atrial fibrillation. The use of these agents involves potential bleeding complications, particularly during invasive procedures. With increasing use of DOACs, adequate knowledge regarding the perioperative management of patients on DOACs has become indispensable. AREAS COVERED: This review covers the indications, mechanism of action, and pharmacokinetics of DOACs and their management in different perioperative settings based on various current guidelines and practices. The role of bridging therapy with heparin and the recently developed reversal agents are also discussed. EXPERT OPINION: The perioperative management of DOACs is influenced by drug pharmacokinetics, potential comorbidities of the patient and perioperative thrombotic and bleeding risk. In low bleeding risk and minor procedures, continuing DOACs seems to be safe. Interrupting DOACs in high-risk procedures might be necessary and should be based on the elimination half-life of the drug and renal function of the patient. Further research is needed to better clarify the role of recently developed reversal agents in the perioperative setting and to identify specific laboratory tests to guide the perioperative management of DOACs.

Triple antithrombotic therapy in patients with atrial fibrillation undergoing PCI: current evidence and practice.

INTRODUCTION: Patients with atrial fibrillation taking oral anticoagulation and undergoing percutaneous coronary intervention with stent insertion are recommended to receive antithrombotic therapy with aspirin and P2Y12 receptor antagonist. This combinatory regime encompasses triple therapy (TT). Although TT reduces the risk of ischemic events such as stroke and stent thrombosis, it is associated with an increased bleeding risk. Areas covered: The efficacy and safety profile of TT is uncertain with undetermined optimal duration and therapeutic combination. This review summarizes relevant trials evaluating TTs application and introduces exploration of duration and dosage in addition to other contributory factors including stent type and choice of antithrombotic agents. Expert commentary: TT has shown to be effective for reduction of ischemic risk. However, trials have failed to demonstrate the regime's superiority in efficacy over alternatives such as dual therapy (single antiplatelet plus anticoagulant) and continue to denote an increased bleeding risk. Further research driven by a balance between thromboembolic and bleeding end points is required to demonstrate TTs potential beneficence, along with optimal duration identification and antithrombotic choice. Individualized patient risk stratification, along with risk factor optimization should also be incorporated.

Left distal trans-radial access facilitates earlier discharge post-coronary angiography.

AIMS: In 2017, Kiemeneij published a paper on distal trans-radial artery access for coronary angiography in 62 patients. This paper proposed several advantages to this method. Since this paper was published, several other papers have been published describing this technique, with less than 200 cases in total described. We performed a non randomized control study of left distal trans-radial access in patients undergoing coronary angiography in our center. METHODS: We prospectively identified patients presenting for coronary angiography to our center for enrolment in this study. We recruited 94 patients (47 ldTRA, 47 age and sex matched controls). Pre-defined endpoints for the study were as follows: time until radial compression device (RCD) removal, procedural time, radiation dose, fluoroscopy time, and contrast dose. RESULTS: Patient and procedural characteristics did not differ significantly between the two groups. With regard to our primary endpoint, patients undergoing ldTRA required, on average, 69 min less time until removal of the RCD (167.8 ± 30 vs 236.6 ± 63.9 min, P < 0.0001). Procedural length did not vary between groups (28.95 ± 5.89 vs 29.76 ± 8.16 min, P = 0.5824). Similarly, there was no statistically significant difference in radiation dose area product (5032.66 ± 2740 vs 4826 ± 2796 Gy/cm2 , P = 0.7191), contrast dose (82.93 ± 23 vs 92.1 ± 33 mL, P = 0.1215), and fluoroscopy time between the two groups (5.41 ± 3.42 vs 4.82 ± 2.97 min, P = 0.3742). CONCLUSIONS: Our study confirms that ldTRA is a feasible technique for diagnostic coronary angiography in a modern cardiac catheterization laboratory. It results in decreased post-procedure radial artery compression time without increasing procedural time or radiation dose.

A Young Male with Severe Myocarditis and Skeletal Muscle Myositis.

A 34-year-old male presented with retrosternal chest pain, fatigue, shortness of breath, and a history of a previous episode of myocarditis four years prior. He had elevated troponin T, normal skeletal muscle enzymes, and negative inflammatory markers. Cardiac magnetic resonance imaging (MRI) confirmed active myocarditis with extensive myocardial fibrosis and normal left ventricular ejection fraction (LVEF). His myocarditis symptoms resolved with steroids and anti-inflammatory treatment, but on closer questioning, he reported a vague history of long-standing calf discomfort associated with episodes of stiffness, fatigue, and flu-like symptoms. MRI of the lower legs consequently demonstrated active myositis in the calf muscles. Immunomodulatory therapy was commenced with good effect. The patient is undergoing regular follow-up in both cardiology and rheumatology outpatient departments. Repeated MRI of the legs showed significant interval improvement in his skeletal muscle myositis, and repeat cardiac MRI demonstrated the resolution of myocarditis along with persistent stable extensive myocardial fibrosis and preserved LVEF. The patient has returned to full-time work.

Anchor-balloon technique to facilitate stent delivery via the GuideLiner catheter in percutaneous coronary intervention.

AIM: The GuideLiner (GL) is a widely used catheter primarily in complex percutaneous coronary intervention (PCI). Deep seating of the GL and distal stent placement may be facilitated by the anchor-balloon technique (ABT). METHODS: We aimed to prospectively analyze procedural details, technical success, complications and in-hospital outcome in patients who underwent PCI using the GL catheter and the ABT. RESULTS: A total of 118 patients underwent PCI with the aid of the GL and ABT. Procedure success rate was 95% (112/118) and only seven patients (5.9%) encountered complications. ABT was indicated and successfully used in 29 patients (25%). CONCLUSION: GL and ABT successfully aided stent delivery in unfavorable and heavily calcified lesions which otherwise may have been considered unsuitable for PCI.

Significance of High-Sensitivity Troponin T After Elective External Direct Current Cardioversion for Atrial Fibrillation or Atrial Flutter.

External transthoracic direct current (DC) cardioversion is a commonly used method of terminating cardiac arrhythmias. Previous research has shown that DC cardioversion resulted in myocardial injury as evidenced by increased levels of cardiac troponin, even though only minimally. Many of these studies were based on the outdated monophasic defibrillators and older, less sensitive troponin assays. This study aimed to assess the effect of external transthoracic DC cardioversion on myocardial injury as measured by the change in the new high-sensitivity cardiac troponin T (hs-cTnT) using the more modern biphasic defibrillators. Patients who were admitted for elective DC cardioversion for atrial fibrillation or atrial flutter were recruited. Hs-cTnT levels were taken before cardioversion and at 6 hours after cardioversion. A total of 120 cardioversions were performed. Median (twenty-fifth to seventy-fifth interquartile range) cumulative energy was 161 J (155 to 532 J). A total of 49 (41%) patients received a cumulative energy of 300 J or higher. The median hs-cTnT level before cardioversion was 7 ng/L (4 to 11 ng/L) and that after cardioversion was 7 ng/L (4 to 10 ng/L). A Wilcoxon signed-rank test showed no significant difference between pre- and post-cardioversion hs-cTnT levels (Z = -0.940, p = 0.347). In conclusion, external DC cardioversion did not result in myocardial injury within the first 6 hours as measured by high-sensitivity troponin T. Patients who are cardioverted and are found to have a significant increase in cardiac troponin after cardioversion should be assessed for causes of myocardial injury and not assumed to have myocardial injury due to the cardioversion itself.

Erectile Dysfunction and Ischaemic Heart Disease.

Erectile dysfunction (ED) is a common disorder that affects the quality of life of many patients. It is prevalent in more than half of males aged over 60 years. Increasing evidence suggests that ED is predominantly a vascular disorder. Endothelial dysfunction seems to be the common pathological process causing ED. Many common risk factors for atherosclerosis such as diabetes, hypertension, smoking, obesity and hyperlipidaemia are prevalent in patients with ED and so management of these common cardiovascular risk factors can potentially prevent ED. Phosphodiesterase type 5 inhibitors provide short-term change of haemodynamic factors to help initiate and maintain penile erection. They have been shown to be an effective and safe treatment strategy for ED in patients with heart disease, including those with ischaemic heart disease and hypertension.

Spontaneous coronary artery dissection, challenges of diagnosis and management.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome in young patients. No clear factors exist to predict the natural history of the disease and the prognosis of the condition. Furthermore, current management practice of SCAD is based mainly on retrospective data and case series and clear management guidelines are lacking. In this article, we present a series of cases of patients with SCAD and we will discuss the different clinical presentations, the diagnostic approaches and the options of management of this cohort of patients. Our aim is to outline the challenges of diagnosis and management of this interesting and serious pathology.