Long-term dual antiplatelet therapy and nuisance bleeding: impact on quality of life.

Long term dual antiplatelet therapy (LTDAPT), with ticagrelor 60 mg and low-dose aspirin, is indicated after acute coronary syndrome (ACS) for the secondary prevention of atherothrombotic events in high-risk patients with a history of ACS of at least 1 year. LTDAPT had a good tolerability and safety profile, but the risk of TIMI major bleeding was increased. However, even non-significant bleeding may be important because it has an effect on the quality of life and therefore may lead to treatment discontinuation. We, therefore, evaluated patients' experiences with LTDAPT and the impact of nuisance bleeding on quality of life and treatment adherence. We retrospectively reviewed 225 patients in follow-up after ACS with at least one high-risk condition, treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The outpatient follow-up program after hospitalization provides a visit on day 30 after discharge, then after 3 months, continuing with six-monthly checks. We assessed the presence and intensity of bleeding, as well as health-related quality of life (HRQoL), at each visit. The TIMI score was used to determine the severity of the bleeding. Any overt bleeding event that did not meet the major and minor criteria was labeled "minimal" and could be framed as "nuisance bleeding." The HRQoL was assessed by the EuroQol-5 and Dimension (EQ-5D) visual analog scale (VAS) score. Minimal bleedings were present in 49 patients (21%), but only in one case (by decision of the patient) there was a cause for discontinuation of therapy. However, 39 (79%) subjects had asked for opinions on stopping the therapy during the telephone consultation. Factors influencing LTDAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from the hospital. All adverse events, judged to be "not serious" in trials, may have an effect on the quality of life and therefore may lead to treatment discontinuation. The authors underline the importance of careful outpatient follow-up and ongoing counselling, to check out compliance and possible adverse effect of LTDAPT.

Long term dual antiplatelet therapy after myocardial infarction: retrospective analysis in an outpatient population.

Long term treatment with ticagrelor 60 mg and low-dose aspirin are indicated after acute coronary syndrome (ACS). We retrospectively reviewed aggregate data of 187 patients (155 M and 38 F) (mean age 63.8±9 years) in follow up after ACS with at least one high risk condition (Multivessel disease, diabetes, GFR<60 mL/min, history of prior myocardial infarction, age >65 years) treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The results were compared with findings (characteristics of the patients at baseline, outcomes, bleeding) of PEGASUS-TIMI 54 trial and Eu Label. The highrisk groups were represented as follows: multivessel disease 105 pts (82%), diabetes 63 pts (33%), GFR< 60 mL/min 27 pts (14%), history of prior MI 33 pts (17%), >65 year aged 85 pts (45%). Treatment was withdrawn in 7 patients: 3 cases showed atrial fibrillation and were placed on oral anticoagulant drugs, one developed intracranial bleeding, in three patients a temporary withdrawal was due to surgery (1 colon polyposis and 2 cases of bladder papilloma). Chest pain without myocardial infarction occurred in 16 patients (revascularization was required in 9 patients). Dyspnea was present in 15 patients, but was not a cause for discontinuation of therapy. Long term treatment with ticagrelor 60 mg twice daily plus aspirin 100 mg/day showed a favourable benefit/risk profile after ACS.  In this study all patients had been given ticagrelor 90 mg twice daily for 12 months and the 60 mg twice daily dosage was started immediately thereafter, unlike PEGASUS-TIMI 54 trial in which it was prescribed within a period ranging from 1 day to 1 year after discontinuation of the 90 mg dose. This makes our results more consistent with current clinical practice. However, a careful outpatient follow-up and constant counseling are mandatory to check out compliance to therapy and adverse side effects.

Work-related outcome after acute coronary syndrome: Implications of complex cardiac rehabilitation in occupational medicine.

OBJECTIVES: Coronary heart disease is frequent in the working-age population. Traditional outcomes, such as mortality and hospital readmission, are useful for evaluating prognosis. Fit-for-work is an emerging outcome with clinical as well as socioeconomic significance. We describe the possible benefit of a cardiac rehabilitation (CR) program for return to work (RTW) after acute coronary syndrome (ACS). MATERIAL AND METHODS: We evaluated 204 patients with recent ACS. They were divided into 4 groups on the basis of their occupational work load: very light (VL), light (L), moderate (M), and heavy (H). Work-related outcomes were assessed with the Work Performance Scale (WPS) of the Functional Status Questionnaire and as "days missed from work" (DMW) in the previous 4 weeks. The variables considered for outcomes were percent ejection fraction, functional capacity expressed in metabolic equivalents (METs), and participation or non-participation in the CR program (CR+ and CR-). RESULTS: One hundred thirty (66%) patients took part in the CR program. Total WPS scores for CR+ and CR- subgroups were VL group: 18±4 vs. 14±4 (p < 0.001), L group: 18±3 vs. 14±3 (p < 0.0001), M group: 19±3 vs. 16±3 (p < 0.003), and H group: 20±4 vs. 17±3 (p < 0.006). Fewer DMW were reported by the CR+ group. CONCLUSIONS: Non-participation in CR was a consistent cause of poorer work-related outcomes. Our findings indicate that CR and occupational counseling play a very important role in worker recovery and subsequent reintegration in the workplace, in particular among clerical workers.

[Choice of antithrombotic therapy in patients with Non Valvular Atrial Fibrillation in real life]. / Scelta della terapia antitrombotica in pazienti con fibrillazione atriale non valvolare nella reale pratica clinica.

INTRODUCTION: Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia and it is associated with a 5-fold increase in risk of ischemic stroke. Although clinical guidelines recommend antithrombotic therapy for stroke prevention in patients at moderate or high risk for stroke, little is known on the extent to which the increase of the risks influence the choice of the therapy. AIM: The aim of the study was to assess the level of adherence to the guidelines for the prevention of thromboembolic risk in patients with NVAF. METHODS: A population-based cohort study was conducted using administrative data from a local health authority in the Campania Region (~1,000,000 inhabitants). NVAF was defined as one or more claims for atrial fibrillation between July, 2013 and June, 2014 where none of the claims were associated with cardioversion or cardiac ablation during the identification period and there was no evidence of valve-related diagnoses or procedures. The cohort was classified according to the first drug dispensing during 6 months from the discharge date for atrial fibrillation. Patients were categorized in low ischemic stroke risk (LR, score = 0), moderate-risk (MR, score = 1), high-risk (HR, score≥2) according to the CHA2DS2-VASc score. Multivariable logistic regression was used to evaluate the associations between ischemic stroke risk with the choice of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) therapy. RESULTS: A total of 1963 patients were identified: 4.9% LR, 7.6% MR and 87.5% HR patients. Overall, 36.4% of patients were not treated (LR: 56.7%, MR: 55.0%, HR: 33.7%patients). The Vitamin K antagonists were prescribed to 17% of the patients (LR: 10.3%, MR: 12,1%, HR: 17,8%), NOAC to 12,7% (LR: 10,3%, MR: 8,1%, HR: 13,2%), low-dose aspirin to 17.5% (LR: 13,4%, MR: 15,4%, HR: 17,9%), other antiplatelet to 12,3% (LR: 7,2%, MR: 6,0%, HR: 13,2%). The ischemic stroke was not significantly associated with the choice of anticoagulant drug. CONCLUSIONS: High proportion of NVAF patients with CHA2DS2-VASc score of 2 or greater not received oral anticoagulant as recommended. In contrast with recent guidelines, aspirin was commonly prescribed even in HR patients. The stroke risk stratification did not influence the choice of anticoagulant drug.

Single coronary artery originating from the right sinus Valsalva presenting as typical angina pectoris.

A single coronary artery (SCA) ostium is a rare finding. In the general population, the incidence of SCA is approximately 0.024%. We introduce a case of a warehouseman presenting with chest pain after a morning work. The exercise ECG showed ST segment depression in the V 1-4 leads. The coronary angiography procedure and the CT demonstrated an SCA dividing into the right coronary artery and left main coronary artery. We identified a borderline lesion in the distal left anterior descending artery with fractional flow reserve of 0.85. In our case, the coronary anomaly was considered at low risk of arrhythmia and sudden death, and the patient was, therefore, treated conservatively.

Single coronary artery originating from the right sinus Valsalva and ability to work.

We present a case of a 56-year-old male electrician who was admitted to the hospital with atrial fibrillation, atypical chest pain and dyspnea. He gave a history that on the morning he had working for almost 4 hours carrying out various activities with considerable physical effort. After cardioversion, conventional coronary angiography revealed a suspect of single coronary vessel (SCA) arising from the right sinus of Valsalva. The patient underwent multislice computed tomography that showed a SCA arising from the right sinus Valsalva and dividing in Right Coronary Artery (RCA) and Left Main coronary artery (LM). The finding of posterior course of the LM without atherosclerotic has proved crucial for the expression of an opinion of working capacity even with limitation.

Onset of recent exertional dyspnoea in a firefighter with left bundle-branch block.

BACKGROUND: The presence of a left bundle-branch block (LBBB) among firefighters raises questions about stratifying risk of subsequent cardiovascular events as this conduction disorder may mask underlying coronary artery disease. This report describes the case of a firefighter with a history LBBB with exertional dyspnoea of recent onset after work activity. CASE REPORT: A 39-year-old male firefighter with LBBB developed exertional dyspnoea after a prolonged session of work. ECG and treadmill test only showed a permanent LBBB; echocardiography and myocardial scintigraphy did not add to this. However, multislice CT (MSCT) showed a significant stenosis in the mid-left anterior descending artery (LAD). Coronary angiography confirmed the stenosis with subsequent placement of a coronary stent. CONCLUSIONS: An occupational physician should take into account that factors such as age and low cardiovascular risk do not always exclude heart disease, especially when there are conduction system abnormalities that can mask possible coronary artery disease.

A novel fluoroscopic method of measuring right-to-left interlead distance as a predictor of reverse left ventricular remodeling after cardiac resynchronization therapy.

PURPOSE: In spite of technological breakthroughs, the choice of a suitable location for the coronary sinus (CS) lead in biventricular implants is still mostly empiric. The aim of this study was to investigate the utility of a radiological index-the distance between the right ventricular (RV) and CS lead tips on fluoroscopic recordings, measured by means of a new method-as a tool for selecting the most profitable left ventricular (LV) lead position. METHODS: Forty-nine consecutive patients (36 male, 13female; mean age 63 ± 19 year), in whom the LV electrode was implanted in a lateral/postero-lateral position in the CS, were evaluated immediately after implantation. The fluoroscopic distances between the RV and LV lead tips were calculated off-line in antero-posterior (2DAP) and latero-lateral (2DLL) projections by means of integrated software. RESULTS: On 1-year follow-up evaluation, 53 % patients were classed as responders (R) (>15 % reduction in LV end-systolic volume) and 47 % as non-responders (NR). On receiver-operating curve analysis, 2DAP and 2DLL showed cut-off values of 81 mm and 51 mm, respectively. In discriminating between R and NR, 2DAP >81 mm displayed 95 % specificity and 74 % sensitivity, while 2DLL >51 mm displayed 74 % specificity and 92 % sensitivity. On multivariate analysis, the cut-off values of 2DAP and 2DLL were significantly predictive of R to CRT. CONCLUSIONS: In our single-center prospective experience, RV-LV interlead distance measured by means of a novel method on fluorographic recordings correlated with CRT response. The use of this method as an intra-operative guide to identifying suitable lead placement in the CS needs evaluating on-line and on a large scale.

Separate origin of left anterior descending artery and left circumflex artery from left aortic sinus of Valsalva: visualization by multislice computed tomography before and after coronary artery bypass graft.

A 59-year-old woman was admitted to our hospital because of atypical chest pain. Stress ECG test was inconclusive. The patient underwent contrast-enhanced 16-slice computed tomography which demonstrated the absence of left main, and separate but adjacent ostia of the left anterior descending artery (LAD) and the left circumflex artery (CX) from the left coronary aortic sinus of Valsalva and severe narrowing of their proximal tracts. Conventional coronary angiography confirmed the diagnosis. Some time later, the patient underwent coronary artery bypass graft by left internal mammary artery graft to the LAD and Y-saphenous vein bypass to the obtuse marginal branch of CX. Multislice computed tomography (MSCT) scan, 1 year later, revealed the patency of grafts. MSCT, with the aid of postprocessing techniques, is an accurate and precise, noninvasive tool for the visualization of coronary artery anatomy, identification of coronary stenoses and evaluation of coronary artery bypass grafts.

Right coronary artery arising from pulmonary trunk: assessment with conventional coronary angiography and multislice computed tomography coronary angiography.

We present a case of a 59-year-old man who was admitted to the hospital because of atypical chest pain and dyspnea. Conventional coronary angiography showed an anomalous origin of the right coronary artery from the pulmonary trunk. The patient underwent multislice computed tomography in order to clarify the origin and course of the anomalous vessel. The aim of this report is to emphasize the role of multislice computed tomography as an accurate noninvasive imaging tool in the evaluation of coronary artery anomalies.

[Anomalous origin of the circumflex artery from the right aortic sinus: assessment with conventional coronary angiography and multislice computed tomography]. / Origine anomala dell'arteria circonflessa dal seno di Valsalva destro: valutazione mediante tomografia computerizzata multistrato ed angiografia coronarica convenzionale.

Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly. This anomaly is thought to be of little clinical significance without the presence of severe narrowing of the vessel. A 43-year-old woman was referred to our institution for evaluation of atypical chest pain and equivocal results of the exercise stress test. We decided to perform multislice computed tomography coronary angiography before any other invasive studies. The scan was performed with a 16-row scanner (Aquilion 16 CFX, Toshiba Medical Systems, Tokyo, Japan) after intravenous administration of non-ionic contrast material. Scans revealed that the circumflex coronary artery originated from the right sinus of Valsalva; the initial course was retro-aortic until it reached its target in the atrioventricular groove; peripheral distribution of the circumflex coronary artery was then normal. The anomalous vessel presented a significant stenosis in its proximal tract. Coronary angiography confirmed that the origin of the circumflex coronary artery was from the right aortic sinus and the significant stenosis of the proximal portion of this vessel. This case confirms the full capability and accuracy of multislice computed tomography with the aid of post-processing techniques in the identification and evaluation of the ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva, displaying accurately the origin, size, course, and relationship of the anomalous vessel with respect to surrounding structures.

Usefulness of multislice computed tomography to assess patency of coronary artery stents versus conventional coronary angiography.

BACKGROUND: The aim of the present study was to assess the in-stent restenosis and occlusion of coronary artery stents by multislice computed tomography (MSCT) compared with conventional coronary angiography in patients with atypical chest pain and not practicable/non-conclusive stress test. METHODS: Between December 2004 and March 2006, 81 patients were scheduled and of these 72 (65 men, mean age 61 years) with 90 stents underwent MSCT angiography using a 16-slice scanner, Toshiba Aquilion 16, 8-12 months after stent placement. RESULTS: Of the 90 stents, 71 (79%) could be assessed and 19 (21%) were excluded because the image quality at the stent level was incompatible with diagnostic assessment. This results in sensitivity, specificity, and positive and negative predictive values for all assessable stents in the identification of occlusion and/or in-stent restenosis of 82, 96, 87, and 94%, respectively. When the 19 uninterpretable stents were included in the analysis, the diagnostic accuracy of MSCT in detecting in-stent restenosis and occlusion resulted in a sensitivity of 82%, specificity of 71%, positive predictive value of 40%, and negative predictive value of 94%. CONCLUSION: The results of the study suggest that MSCT angiography is a useful method for evaluating patency/occlusion of large (>or=3 mm) coronary stents in symptomatic patients with atypical chest pain and concomitant not practicable/non-conclusive exercise or stress imaging test.

Pulsed Doppler tissue imaging and myocardial function in thalassemia major.

Few studies are available on left ventricular diastolic function in beta-thalassemia major, and these have conflicting results. Our aim in this study was to analyze myocardial systolic and diastolic functions in patients with beta-thalassemia major using, for the first time, pulsed Doppler tissue imaging (DTI), and compare data with standard Doppler echocardiography. We studied 30 young patients with beta-thalassemia major (age

Does the angiotensin II receptor antagonist losartan improve cognitive function?

Newer classes of antihypertensive agents, such as angiotensin II receptor antagonists, may offer benefits to patients in addition to their ability to lower blood pressure. It is accepted that chronic hypertension contributes to the development of cerebrovascular and cardiovascular disease, and several studies have demonstrated a link between hypertension and reduced cognitive function, especially in patients not receiving antihypertensive medication. In an initial clinical trial, the angiotensin II receptor antagonist losartan was shown to improve cognitive function in patients with hypertension, including in those who were elderly (up to 73 years of age). This effect cannot be explained by a reduction in blood pressure alone and is likely to involve interactions with the diverse biological actions of the renin-angiotensin system. Improving or maintaining cognitive function in patients with hypertension may translate into economic benefits beyond those expected due to blood pressure control, and would result in considerable quality-of-life benefits for the aging population.

The heart in neurofibromatosis type 1: an echocardiographic study.

BACKGROUND: Comprehensive data are unavailable for cardiac abnormalities in patients with neurofibromatosis type 1 (NF1). The goal of this study was to evaluate the prevalence of cardiovascular abnormalities with echocardiography with color Doppler scan (ECHO) in a large, consecutive series of patients with NF1. METHODS: We studied 48 patients with NF1 (mean age, 10 years). Thirty healthy subjects comparable for age and sex served as the control group. All ECHO studies were performed by the same cardiologist and reviewed by a second cardiologist blinded to the physical findings of the subjects. RESULTS: Cardiac abnormalities were found in 13 of the 48 young patients (27%). A secundum atrial septal defect with a left to right shunt was found in 2 children. ECHO evidence of mild left pulmonary artery stenosis was found in 1 participant. A moderate coarctation of the thoracic aorta was found in 1 patient. ECHO criteria for mitral valve prolapse and evidence of trivial mitral regurgitation with myxomatous mitral valve was present in 1 case. Mild mitral regurgitation was found in 2 patients. A regurgitant mild flow signal was detected from the aortic valve in 2 subjects. Atrial septal aneurysm was found in 2 patients without patent foramen ovale. Two patients had septal to posterior left ventricular free wall ratio greater than 1.5, suggesting hypertrophic cardiomyopathy. CONCLUSION: This is the first attempt to evaluate the prevalence of cardiovascular abnormalities in patients with NF1 with ECHO. The study's most striking finding is the high prevalence of cardiovascular abnormalities. Congenital lesions have potential long-term hemodynamic consequences that justify an early diagnosis. Thus, a cardiologic assessment at regular intervals, including ECHO study, is mandatory for patients with NF1.