Association of GDF-15, hs-cTnT and NT-proBNP with coronary artery disease in patients undergoing elective angiography.

Aim: This study investigated the association between plasma levels of GDF-15, hs-cTnT and NT-proBNP and the presence of coronary artery disease (CAD) in stable patients referred for elective coronary angiography. Methods: The outcome of CAD was defined as an ordinal variable with 3 levels. The association between each biomarker and the outcome was tested using the Winell and Lindbäck method. Results: In unadjusted analysis of 252 patients, GDF-15 and hs-cTnT were associated with the presence and extent of CAD. In multivariate regression analysis including traditional risk factors, this association was no longer significant. Conclusion: NT-proBNP, GDF-15 and hs-cTnT plasma levels do not seem to improve the predictive ability of traditional risk factors for CAD in stable patients referred for coronary angiography.

This study aimed to look at a possible association between blood levels of three molecules (GDF-15, hs-cTnT and N-terminal pro B-type natriuretic peptide [NT-proBNP]) and the presence of coronary artery disease (CAD) in stable patients referred for coronary angiography. Three CAD degrees of severity were identified: no CAD, 1- or 2-vessel CAD and 3-vessel or left main CAD. The association between each of the three blood molecules and CAD was studied using a specific statistical method. In the 252 consecutive patients enrolled, the two molecules GDF-15 and hs-cTnT were significantly associated with the presence and extent of CAD, while NT-proBNP was not. However, when the statistical analysis was adjusted for the traditional risk factors of CAD (age, gender, smoking, diabetes, etc.), the association of GDF-15 and hs-cTnT with CAD was no longer significant. NT-proBNP, GDF-15 and hs-cTnT blood levels do not seem to be independent predictive tools for CAD in stable patients referred for coronary angiography.

A Practical Approach for the Use of High-Sensitivity Cardiac Troponin Assays in the Evaluation of Patients With Chest Pain.

Chest pain is a common clinical presentation, especially in the emergency department. Both rapid identification of patients with myocardial infarction as well as those with noncardiac chest pain is important in order to start therapy in the former and avoid unnecessary investigations and delay in discharge in the latter. Beside electrocardiogram, cardiac biomarkers are a key element in decision making. Conventional creatinine kinase and troponin assays are not sensitive enough and have to be repeated at least 6 to 12 hours after initial evaluation. New high-sensitivity cardiac troponin (hs-cTn) tests are currently available and if used appropriately can substantially improve management. Because of their high sensitivity and accuracy, these tests allow measurement of very low serum troponin levels, such as those present in healthy individuals and can detect small changes in troponin concentration within a short time frame. These tests are thus, very useful for the early diagnosis of myocardial infarction but can also be elevated in several other conditions that result in myocardial injury. A good understanding of the analytical characteristics of these assays is of uppermost importance for their appropriate use in clinical practice.

BENCHMARKING THE DOSE MAP SOFTWARE FOR CLINICAL IMPLEMENTATION AND ESTABLISHMENT OF A LOCAL FOLLOW-UP PROTOCOL FOR THE MANAGEMENT OF SKIN INJURES FOLLOWING COMPLEX INTERVENTIONAL CARDIOLOGY PROCEDURES.

This paper aims to validate the accuracy of the peak skin dose (Dskin,max) computed by the Dose Map software (DMS)-general electric and establish a local follow-up protocol for the management of patient skin injuries following complex interventional cardiology procedures (ICPs). Dskin,max was computed by the DMS and was simultaneously measured by a dense mesh of 72 thermoluminescent dosemeters for 20 ICP. Measured and computed Dskin,max were compared using Lin's concordance coefficient (${\rho}_c$). The implementation of a local follow-up strategy was based on a computed Dskin,max of 2 Gy. After eliminating 2 outliers, the average deviation between the two methods was 6% (range: -36 to +40%). Concordance between the two methods was moderate with ${\rho}_c$ (confidence interval) of 0.9128 (0.8541-0.9486). DMS computes Dskin,max with an acceptable accuracy and can be used to setup an individual follow-up process for patients with high skin exposure and risks.

Lebanese students' motivation in medical school: does it change throughout the years? A cross-sectional study.

BACKGROUND: Students entering medical school are driven by different types of motivation: autonomous motivation, controlled motivation, or amotivation. Motivation types can influence students' performance, outcome and well-being. To our knowledge, this topic has never been studied in Lebanese medical students. This study aims to identify students' motivation types in the first 5 years of medical school at two Lebanese universities (USJ and USEK). It also aims to determine the predominant motivation type of the whole sample. Results may be the first step towards raising awareness about this topic and implementing actions that enhance autonomous motivation. METHODS: A cross-sectional study was performed between January and June 2017. A questionnaire was sent to medical students by e-mail. The students' academic motivation was assessed using the Academic Motivation Scale. RESULTS: A higher mean autonomous motivation score was found in each academic year, as compared to the mean controlled motivation and amotivation scores. The highest mean autonomous motivation score was seen among second year students, whereas the lowest score was noted in fifth year students. The highest scores for controlled motivation and amotivation belonged to the fourth-year students, and the lowest to the first-year students. Students who were still satisfied with medical studies had a higher autonomous motivation score. Finally, USJ students who were satisfied with their second year training had a higher mean autonomous motivation score than those who were not. CONCLUSION: This study showed high levels of autonomous motivation in the first five years of medical school. Autonomous motivation was the predominant type in the whole sample. The highest scores of controlled motivation and amotivation were noted in the fourth year. Moreover, high levels of self-determination were seen in students who enjoyed their early contacts with patients through trainings. Actions should be implemented in medical schools to enhance and maintain autonomous motivation, and consequently students' outcome and health-care quality.

Diabetes without Manifest Cardiovascular Disease: A Novel Approach in Risk Stratification and Treatment Selection.

BACKGROUND: Cardiovascular disease (CVD), the main macro vascular complication of type 2 diabetes (T2D), increases the risk of death significantly in patients with T2D. INTRODUCTION: Most of the patients with T2D do not have obvious CVD symptoms. Due to the paucity of data, CVD screening in asymptomatic patients with T2D remains highly controversial. METHODS: This has driven a panel of experts to establish a novel consensus on how to approach patients with T2D at high CVD risk. The panel formulated a stepwise algorithm by which patients with T2D undergo initial risk stratification into low, intermediate and high risk using the ASCVD calculator. In patients with intermediate risk, coronary artery calcium measurement is used to further stratify those patients into new low and high-risk categories. RESULTS AND CONCLUSION: The panel recommends using standard diabetes care in low risk patients and using SGLT2 inhibitors and GLP1 agonists with cardio protective effect, on top of standard care, in high risk individuals.

Quality of Life and Its Association With Treatment Satisfaction, Adherence to Medication, and Trust in Physician Among Patients With Hypertension: A Cross-Sectional Designed Study.

OBJECTIVE: Patients with hypertension tend to have a lower health-related quality of life (HRQOL) compared to normotensive patients. This study's main objectives are to assess (1) HRQOL and factors that might impact it and (2) association between HRQOL and adherence to treatment, trust in physician, and treatment satisfaction among patients with hypertension. METHODS: A cross-sectional study enrolled 196 patients from medical-care offices in Beirut, North and South Lebanon. Eligible patients signed a consent form and were asked to complete the Trust in Physician Scale, World Health Organization Quality of Life-brief (WHOQOL-brief) questionnaire, and Treatment Satisfaction Questionnaire (TSQM 1.4) as well as questions assessing medication adherence. RESULTS: Better antihypertensive medication adherence was significantly and positively correlated with better HRQOL domains except general health where significance was not reached ( P = .089). Better adherence was also significantly related to better treatment satisfaction (side effects, convenience, and global satisfaction but not to effectiveness) and an increased trust in physicians ( P < .0001). Better treatment satisfaction (TSQM domains) was significantly and positively associated with a better overall HRQOL ( P ≤ .001). Increased trust in physician scores were significantly and positively correlated with a better psychological health, environment, and overall HRQOL domains ( P = .045, .005, and .006, respectively). Finally, TSQM effectiveness, convenience, and global satisfaction were significantly higher when trust in physician was greater ( P = .017, .035, and .002, respectively). CONCLUSION: The results of this study revealed an association between increased adherence to treatment, a higher global satisfaction, and an increased quality of life. An increased patient satisfaction with their antihypertensive treatment and trust in their physician were also correlated with a greater adherence to treatment.

Association Between Adherence to Statins, Illness Perception, Treatment Satisfaction, and Quality of Life among Lebanese patients.

OBJECTIVES: The main objective of this study was to evaluate treatment adherence to statin and health-related quality of life (QOL) in Lebanese patients with dyslipidemia. Secondary objectives were to examine associations between treatment adherence, QOL, treatment satisfaction, and illness perception. METHODS: This cross-sectional study, conducted in 20 community pharmacies from all districts of Lebanon between August 2016 and April 2017, enrolled 247 adult patients taking any statin. RESULTS: The mean age of the participants was 52.63 ± 11.92 years (57.5% males); the mean duration of treatment with a statin was 59.72 months. A significant association was found between adherence and marital status ( P < .0001), educational level ( P = .001), cigarette smoking ( P < .0001), and alcohol drinking ( P < .0001). A negative but significant correlation was found between the adherence score and the duration of dyslipidemia ( r = -0.199). A significant but negative correlation was also found between the side effect score and age ( r = -0.137). The monthly salary, the marital status, the educational level, smoking cigarettes or waterpipes, and drinking alcohol were all associated with the Illness Perception Questionnaire scores ( P < 0.0001 for all variables). Secondary level of education (ß = 13.43), smoking more than 3 waterpipes per week (ß = 14.06), global satisfaction score (ß = 0.32), convenience score (ß = 0.29), and effectiveness score (ß = 0.27) would significantly increase the adherence score. Smoking more than 15 cigarettes per day (ß = -11.15) and a divorced status (ß = -14.81) would however significantly decrease the adherence score. Significant associations were found between the illness perception score, the QOL domains, and the satisfaction domains ( P < .05 for all variables). CONCLUSION: This study showed that global satisfaction with treatment, convenience, and effectiveness are important factors that increase treatment adherence. Patient adherence results in patient satisfaction and improved QOL and is an important criterion for achieving desired therapeutic outcomes.

Snuggle T and protrusion (S-TAP) technique for coronary bifurcation stenting: A step-by-step angiographic and illustration demonstration.

T and small protrusion (TAP) is a stenting technique that is utilized for the management of coronary bifurcation lesions when using a two-stent strategy. This technique is also useful whenever stenting of a main vessel (MV) jeopardizes a side branch (SB) or when a sub-optimal result is encountered in a daughter vessel after starting with one-stent approach. The conversion from one-stent strategy to TAP could be achieved smoothly and often leads to good results. Technically, optimal positioning of the SB stent to achieve the required protrusion into the lumen of the MV remains a challenge. Toward that goal we propose an added step that involves inflating a balloon in the MV to serve as an anvil with simultaneous pullback of the SB stent, to be followed by stent deployment. We refer to this approach as the snuggle T and protrusion (S-TAP) technique owing to close contact between the SB stent and the MV balloon during simultaneous inflation. In this manuscript, we detail this interventional technique and provide a demonstrative case study.

Arterio-venous fistulae: A possible complication of transradial approach with a possible non invasive management.

Arteriovenous fistulae is rarely reported as a complication of percutaneous coronary interventions with trans-radial approach. We report herein a case of radial arteriovenous fistulae that was treated conservatively by applying manual compression and avoiding surgical intervention.

Accordion Phenomenon in the Radial Artery: Should we treat the radial as a coronary artery?

The accordion phenomenon is a well-known finding mechanism in the field of interventional cardiology. It is a benign condition and has mainly been described in tortuous coronary arteries during percutaneous coronary interventions. It is believed to be induced by a stiff guidewire. However, this phenomenon has not been observed previously in the radial artery. We present a case of accordion phenomenon in the radial artery, which was successfully resolved after the catheters and the wire were retrieved, with the pseudolesions found to have completely disappeared in subsequent image findings.

Rotational atherectomy as endovascular haute couture: a road map of tools and techniques for the interventional management of burr entrapment.

OBJECTIVES AND BACKGROUND: Rotational atherectomy (RA) is used as a debulking technique prior to stenting in some specialized cardiac centers for calcified coronary lesions amenable to percutaneous coronary intervention (PCI). A specific possible complication, burr entrapment, is unusual but carries serious risks and may sometimes necessitate surgery as a rescue procedure. However, different modalities using a percutaneous approach were proposed as a bail-out. We aim to propose a framework for possible management for trapped RA burr. METHODS AND RESULTS: A literature review of the most relevant cases of entrapped burr during PCI was performed. Twelve cases were reported and different solutions were discussed. Surgery was needed in only 1 patient to retrieve the trapped burr, and in all the other cases, different percutaneous solutions were successful to retract the trapped device. CONCLUSIONS: These cases illustrate that burr entrapment during RA, albeit rare, may occur and may transform a relatively simple PCI to a procedure failure. Although prevention is better than treatment, the operators should be aware of such serious complication and they should keep in mind that various possible percutaneous solutions may be successful to retrieve the burr and to avoid surgery.

[The percutaneous treatment of pulmonary atresia with intact ventricular septum]. / Traitement percutané de l'atrésie pulmonaire à septum interventriculaire intact.

OBJECTIVE: Describe a mechanical method of perforation-dilatation of the pulmonary valve in pulmonary atresia with intact interventricular septum (PA-IVS), with or without stenting the patent ductus arteriosus (PDA) and medium-term results. METHOD: Since 2007, all patients with PA-IVS and a right ventricle adequate for biventricular repair, benefited from a transcatheter attempt to perforate-dilate the valve with or without stenting the PDA, and were included in this retrospective study. TECHNIQUE: A catheter was percutaneously introduced through the femoral vein and positionned in front of the atretic pulmonary valve. A lasso catheter was introduced through the femoral artery to the other side of the pulmonary valve. The tip of a rigid guidewire was then pushed through the atretic valve and taken with the lasso, creating a loop that allowed for balloon valvuloplasty. If the child remained ductal dependant following PGE1 withdrawal, a stent is placed in the ductus arteriosus. RESULTS: Five patients were included in this series. Four patients were successfully dilated, and two patients necessitated stents. The procedure had to be interrupted in one patient. FOLLOW-UP: One patient with a patent stent was operated at the age of one year and died in the postoperative period. The other patient with a stent is now 16 months old with a patent stent and an oxygen saturation of 98%. The two remaining patients without stent are now 3- and 18-month-old with oxygen saturation of 85% and 96% respectively. CONCLUSION: The percutaneous treatment of PA-IVS is feasible and avoids early high risk surgery. Stenting the ductus arteriosus may replace a Blalock shunt. However, the prognosis is still related to the severity of the anomaly.

Myocardial extraction of intracellular magnesium and atrial fibrillation after coronary surgery.

BACKGROUND: The effects of magnesium loading on the incidence of atrial fibrillation following coronary artery bypass graft surgery (CAGB) are equivocal. None of the previous studies assessed the influence of myocardial extraction of magnesium in these settings. The current trial aims to elucidate whether the incidence of atrial fibrillation following CABG is affected by the preoperative rate of myocardial extraction of magnesium. METHODS: The ethical committee approved the study protocol. 113 patients (94 male, mean age 63 ± 11 years) planned for elective CABG surgery under normothermic cardiopulmonary bypass were prospectively included. Preoperative independent variables included preoperative treatment, electrocardiographic abnormalities, left ventricular ejection fraction estimation, left atrial size, creatinine clearance and assays of plasma and intracellular magnesium, calcium, albumin, potassium and ionized calcium, drawn preoperatively from the coronary sinus and the aortic root. The covariates - including the rate of myocardial extraction of magnesium - were entered in a logistic regression model to predict the odds of atrial fibrillation. RESULTS: The incidence of post operative atrial fibrillation was 16%. A rate of myocardial extraction of intracellular magnesium ≥ 7% increases fivefold the multivariate risk of postoperative atrial fibrillation (p < .01). Advanced age was also significantly associated to postoperative atrial fibrillation. CONCLUSIONS: This study suggests that a preoperative rate of myocardial extraction of intracellular magnesium ≥ 7% could be a new and a potent predictive factor for postoperative atrial fibrillation.

Tako-tsubo cardiomyopathy triggered by misdirection.

Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome or stress-induced cardiomyopathy, is a novel reversible cardiomyopathy mimicking acute myocardial infarction without epicardial coronary artery disease. The exact physiopathology of TTC remains unclear. It is usually precipitated by acute physical or emotional stress and it most commonly affects postmenopausal women. The growing number of clinical cases of TTC have demonstrated a wide field of possible etiologies beyond the emotional stress. We report a case of a 67-year-old postmenopausal woman who was being supplemented by enteral feeding via a nasogastric tube and who developed TTC due to misdirection, probably favored by the mechanical blockade by the nasogastric tube, while swallowing the drug pills.

Comparison of the effects of combination atorvastatin (40 mg) + ezetimibe (10 mg) versus atorvastatin (40 mg) alone on secretory phospholipase A2 activity in patients with stable coronary artery disease or coronary artery disease equivalent.

Secretory phospholipase A2 (sPLA2) is an enzyme that plays an important role in the pathogenesis of atherosclerosis and of adverse cardiovascular events. It is currently the target of emerging therapeutic agents. Our study was designed to investigate the effect of aggressive lowering of low-density lipoprotein (LDL) cholesterol with ezetimibe and atorvastatin on sPLA2 activity. We randomized 100 patients with stable coronary artery disease (CAD) or CAD equivalent (diabetes, stroke, or peripheral vascular disease) to receive ezetimibe 10 mg/day in association with atorvastatin 40 mg/day (combination therapy group) versus atorvastatin 40 mg/day and placebo (monotherapy group). Patients on statin therapy before inclusion were allowed to enter the study as long as the potency of the statin was lower than atorvastatin 40 mg/day. Lipid profile, high-sensitivity C-reactive protein (hs-CRP), and sPLA activity were measured at baseline and after 8 weeks of therapy. The decrease in LDL cholesterol was more significant in the combination therapy group, but the decrease in hs-CRP was similar. sPLA2 activity significantly decreased in the ezetimibe/atorvastatin group from 29 U/ml (interquartile range 23 to 35) to 26 U/ml (23 to 29, p = 0.001) but remained similar in the placebo/atorvastatin group (23 U/ml, 19 to 32, vs 22 U/ml, 19 to 28, p = NS). In a multivariate stepwise linear regression model, change in sPLA2 correlated with change in hs-CRP (p <0.001), baseline LDL cholesterol level (p = 0.001), body mass index (p = 0.003), diabetes mellitus (p = 0.04) and combination therapy with ezetimibe/atorvastatin (p = 0.05). In conclusion, this study demonstrates that coadministration of ezetimibe and atorvastatin decreases sPLA2 activity.

Effect of ezetimibe/atorvastatin combination on oxidized low density lipoprotein cholesterol in patients with coronary artery disease or coronary artery disease equivalent.

Ezetimibe is effective in providing additional low-density lipoprotein (LDL) cholesterol lowering when coadministered with statins, but its effect beyond LDL cholesterol lowering is unknown. Oxidized LDL (ox-LDL) is a better predictor of adverse cardiovascular events than standard lipid parameters. The objective of this study was to investigate the effect of ezetimibe on ox-LDL. A total of 100 patients with coronary artery disease or coronary artery disease equivalent were randomized to atorvastatin 40 mg/day and ezetimibe 10 mg/day or to atorvastatin 40 mg/day and placebo. LDL cholesterol, LDL cholesterol subfractions, and ox-LDL were measured at baseline and after 8 weeks of therapy. The ezetimibe group had a larger reduction in total LDL cholesterol compared to placebo. This was due mainly to a larger reduction in large buoyant LDL (24% vs 10%, p = 0.008). Ox-LDL level did not change in the placebo group (50 +/- 13 vs 51 +/- 13 U/L), while it decreased in the ezetimibe group, from 51 +/- 13 to 46 +/- 10 U/L (p = 0.01 vs baseline and p = 0.02 vs final level in placebo). The change in ox-LDL correlated significantly with those in total LDL and in large buoyant LDL (r = 0.6 and r = 0.5, respectively, p <0.01 for both), but not with that of small dense LDL, high-density lipoprotein, or very low density lipoprotein. In conclusion, this study demonstrates that ezetimibe decreases ox-LDL cholesterol through reductions in total LDL cholesterol and in large buoyant LDL cholesterol.

Effect of high bolus dose tirofiban on the inflammatory response following percutaneous coronary intervention.

BACKGROUND: Tirofiban at the bolus dose of 10 microg/kg does not suppress the inflammatory response following percutaneous coronary intervention (PCI). This may be due to less than optimal inhibition of platelet aggregation. High bolus dose tirofiban (25 microg/kg) allows better inhibition of platelet aggregation but its anti-inflammatory effect remains unknown. HYPOTHESIS: High bolus dose tirofiban exhibits anti-inflammatory activity. METHODS: A total of 100 patients referred for PCI were randomized to receive high bolus dose tirofiban followed by a 24-h infusion or a bolus and an infusion of saline. Patients with elevated troponin or with thrombus in the culprit lesion were excluded. Inflammatory markers were measured at baseline and at 24 h. RESULTS: Levels of soluble CD40 ligand (sCD40L) were not affected by PCI while those of interleukin-6 (IL-6) and of high sensitivity C-reactive protein (hs-CRP) significantly increased. Despite inhibiting platelet's aggregation by > 90%, tirofiban did not suppress the rise of IL-6 and hs-CRP. Median (interquartile range) elevation of IL-6 was 0.6 pg/mL (-1.5-3.6) versus 0.4 pg/mL (-0.7-1.8) and that of hs-CRP was 2.1 mg/L (0.7-5.2) versus 2.4 mg/L (1-4.7) in the tirofiban and the control groups, respectively (p = ns). However, in patients with diabetes mellitus, tirofiban significantly suppressed the rise of hs-CRP by 65% (p = 0.01), but did not significantly affect the rise of IL-6. CONCLUSION: In low-risk patients undergoing PCI, tirofiban did not attenuate the rise of inflammatory markers. However, the significant effect in diabetics suggests that tirofiban may have anti-inflammatory activity in higher risk patients.