History Of Acute Coronary Syndrome Research Articles

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience.

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

Assessment of Carotid Plaque Enhancement on Contrast-Enhanced Ultrasound as a Predictor for Severe Coronary Artery Disease

Abstract Background and Aim Contrast-enhanced ultrasound (CEUS) can reliably identify vulnerable plaques. As atherosclerosis is a systemic disease, we evaluated whether contrast enhancement of carotid plaque (CECP) can predict severe coronary artery disease (CAD) by comparing CECP in patients who have had acute coronary syndromes (ACS) recently with asymptomatic individuals. Settings and Design This case–control study was done at a tertiary care center during 2022. Materials and Methods Fourteen participants were recruited in each group, after screening in-patients for carotid plaques and inclusion and exclusion criteria. Those who had history of ACS were enrolled as cases, while those who did not were enrolled as controls. All these patients underwent grayscale, Doppler, and CEUS examination for characterization of the carotid plaque. For cases, findings on CEUS were also compared with the severity of CAD on catheter coronary angiography. Statistical Analysis Diagnostic parameters including sensitivity, specificity, and diagnostic accuracy were calculated and proportions were compared by using Fisher's exact test. Results Eight out of 28 patients showed CECP. CECP and CAD were positively associated with p-Value of 0.033. Eighty-three percent patients with triple vessel disease and 50% patients with double vessel disease on coronary angiography showed CECP. Sensitivity and specificity of CECP for prediction of CAD were 50 and 92.9%, respectively. Conclusion CECP on CEUS can predict CAD and is a more reliable indicator of severe CAD than plaque characteristics on grayscale and Doppler imaging; making it useful for screening of patients at risk of having CAD.

Elevated neutrophyl-to-lymphocyte ratioand smoking are associated with chronic total occlusion in patients with ST elevation myocardial infarction

BackgroundAtherosclerosis is a progressive disease characterized by the build-up of lipids and connective tissue in the large arteries. Some patients experience chronic total occlusion (CTO). Inflammation plays a key role in the development and complications of atherosclerosis. Neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with the development of acute coronary syndrome (ACS). We aimed to assess the relationship between NLR and CTO in ACS patients with ST elevated myocardial infarction (STEMI) in Indonesia.MethodsThis cross-sectional study was performed with secondary data obtained from patient medical records at Cipto Mangunkusumo National Central Hospital, Jakarta. Inclusion criteria were patients with ACS and STEMI who underwent coronary angiography in 2015–2018.ResultsA total of 98 patients were enrolled in the analysis. Most subjects with CTO were male, elderly (> 60), smoking, had no history of diabetes mellitus (DM) or hypertension, no family history of coronary heart disease (CHD), but had a history of ACS and had never consumed statin or antiplatelet medications. Bivariate logistic regression analysis revealed that male gender (PR = 1.820; 95%CI 0.871–3.805; p = 0.025) and smoking (PR = 1.781; 95%CI 1.028–3.086; p = 0.004) were significantly correlated with CTO. Receiver operator characteristic (ROC) curve revealed that higher NLR (≥ 6.42) could predict a CTO diagnosis with positive predictive value (PPV) of 91%. Multivariate analysis revealed that NLR was correlated with an 11.2-fold increase in occurrence of CTO (95%CI 3.250-38.303; p < 0.001). Additionally, smoking was correlated with a 7-fold increase in CTO (95% CI 1.791–30.508; p = 0.006).ConclusionNLR value of ≥ 6.42 is potentially useful as a marker of CTO in STEMI patients. In addition, smoking increases the risk of CTO in ACS/STEMI patients.

Coronary artery disease in older adults with congenital heart defects: risk factors and pharmacotherapy.

With advancing age, adults with congenital heart disease (ACHD) are at a higher risk of developing atherosclerotic coronary artery disease (CAD). We aimed to determine the prevalence of CAD, its risk factors, and use of guideline‑directed pharmacotherapy among older patients with ACHD. Patients and methods: We studied all ACHD patients aged 60 years or older hospitalized in our department between the years 2013 and 2020. CAD was defined as a history of acute coronary syndrome or coronary revascularization, or more than 50% diameter stenosis on coronary angiography. Data regarding the underlying heart defect, prevalence of cardiovascular risk factors, and drug prescriptions were collected. A total of 198 patients with known coronary artery status (mean [SD] age, 66.2 [5.3] years; 43.3% men) were included in the analysis. Of them, 54 (27.3%) had CAD. The individuals with CAD were more often men, and they were more likely to have a mild heart defect, dyslipidemia, and a history of hypertension and tobacco use. Multivariable analysis showed that male sex (P = 0.001), dyslipidemia (P = 0.003), and hypertension (P = 0.04) were positive independent predictors of CAD, whereas overweight / obesity was identified as a negative independent predictor (P = 0.04). The proportion of CAD patients on antiplatelet and / or anticoagulant drugs was 92.6%. β‑Blockers were prescribed to 87% of the patients, and a lipid‑lowering agent to 96% of the study population. CAD is common in older patients with ACHD. Our results underline the importance of identification and treatment of modifiable CAD risk factors in individuals with ACHD. The obesity paradox might also play a role in this population. The rate of guideline‑recommended pharmacotherapy implementation seems to be satisfactory.

Hibernation of the Conduction System and Atrioventricular Block Reversibility Following Revascularization in Patients without Acute Coronary Syndrome.

Although myocardial infarction (MI) is a reversible cause of atrioventricular (AV) block, the association of ischemia other than MI with AV block is unclear. The purpose of this study is to investigate this relationship. Among patients nominated for pacemaker implantation due to AV block in two centers from 2017-2020, 120 patients with significant coronary artery disease (CAD) in angiography were included in the study. Patients were divided into two equal groups based on their CAD treatment approach: drug therapy and revascularization. Coronary lesions were divided into three types based on location: left anterior descending artery (type 1), dominant coronary with AV node branch (type 2), and a combination of both (type 3). After coronary disease treatment, all patients were followed up with for 14 months, and AV block reversibility was assessed. There were 7 cases of block reversibility in the revascularization group (11.7%) and 1 case in the medical group (1.7%), which differed significantly (P = .02). A history of acute coronary syndrome, smoking, opium use, chronic kidney disease, hypertension, age, sex, and chronic obstructive pulmonary disease were not significantly associated with reversible block. Also, the type of coronary obstruction had no significant relationship with block reversibility (P = .3, .5, and .8 for type 1, type 2, and type 3, respectively). Hibernation due to ischemia can be a reversible cause of an AV blockage. Therefore, it is recommended that significant coronary artery lesions be revascularized before pacemaker implantation.

Can the Use of Cardiology Medical Record to Deliver Educational Intervention Improve Care? On Behalf of TAPP Program: Thinking Approach Towards Physician Support in Patient Management

Background: Despite clear and concise practice guidelines, strategies for lowering LDL-C are often poorly adopted in clinical practice, and many patients fail to reach guideline-recommended levels despite physician education and quality improvement programs. We studied whether physician focussed, guideline-based practice level educational intervention can improve lipid lowering management. Methods: Cardiologists or internal medicine specialists from the province of Ontario, Canada who were using a cardiology specific EMR (CEREBRUM, WELL Health Technologies Corporation) were invited to participate. Practice level data of patients with history of acute coronary syndromes (ACS) and lipid profile were studied. Physicians were alerted when patients in their practice were not treated according to recommendations. The primary endpoint was proportion of patients achieving the recommended LDL-C level of below 1.8 mmol/L. Results: Of the invited 378 specialists, 178 agreed to participate and shared their practice involving 7,683 ACS patients who were 70.4 ± 10.3 years of age and 27.2% were women. Overall, 57.7% of patients had LDL-C &lt; 1.8 mmol/L at the start of the program (1.84 ± 0.87 mmol/L) and 63.0% (1.75 ± 0.79 mmol/L) at the end of the program (p&lt;0.0001). With respect to the lipid lowering therapy, statin therapy was used in 52.9% of patients at the start of the program and increased to 72.1% at the end (p&lt;0.0001). The use of ezetimibe increased from 12.6% to 19.0% (p&lt;0.0001) and the use of PCSK9i from 1.2% to 2.4% (p&lt;0.0001). Conclusion: The results indicate the feasibility of using EMR as a platform to deliver educational intervention and overcoming treatment inertia and improving LDL-C lowering.

SICI-GISE/SICOA Consensus document: Clinical follow-up of patients after acute coronary syndrome or percutaneous coronary intervention

In the last decades, advances in percutaneous coronary intervention (PCI) strategies have significantly reduced the risk of procedural complications and in-hospital mortality of patients with acute coronary syndromes (ACS), thus increasing the population of stable post-ACS patients. This novel epidemiological scenario emphasizes the importance of implementing secondary preventive and follow-up strategies. The follow-up of patients after ACS or elective PCI should be based on common pathways and on the close collaboration between hospital cardiologists and primary care physicians. However, the follow-up strategies of these patients are still poorly standardized. This SICI-GISE/SICOA consensus document was conceived as a proposal for the long-term management of post-ACS or post-PCI patients based on their individual residual risk of cardiovascular adverse events. We defined five patient risk classes and five follow-up strategies including medical visits and examinations according to a specific time schedule. We also provided a short guidance for the selection of the appropriate imaging technique for the assessment of left ventricular ejection fraction and of non-invasive anatomical or functional tests for the detection of obstructive coronary artery disease. Physical and pharmacological stress echocardiography was identified as the first-line imaging technique in most of cases, while cardiovascular magnetic resonance should be preferred when an accurate evaluation of left ventricular ejection fraction is needed. The standardization of the follow-up pathways of patients with a history of ACS or elective PCI, shared between hospital doctors and primary care physicians, could result in a more cost-effective use of resources and potentially improve patient's long-term outcome.

Statin Therapy After Myocardial Infarction in Patients With Renal Failure: The Longer, the Merrier!

Among the ongoing clinical challenges for cardiologists in the 21 th century, there is the necessity of being able to cope with multimorbidity and polypharmacy. Irrespectively, beneficial drugs should be continued long-term, to ensure mortality and morbidity benefits continue to be accrued. This is evidently the case for the use of statins to improve long-term outcomes in chronic kidney disease (CKD) patients with acute coronary syndromes (ACS), as the combination of CKD and ACS represents a veritable crucible of adverse risk factors. Furthermore, statins have pleiotropic effects, including anti-inflammatory, antioxidant and endothelial-protective effects. Even though these effects are debated in CKD patients, it is biologically plausible that statins may reduce the inflammatory burden and improve glomerular hemodynamics. Awaiting for further clinical studies, for instance focused on the identification of possible biomarkers of statins action on renal function, it is pivotal to maintain our CKD patients with history of ACS on lifesaving medications such as statins.

Vitamin D deficiency in persons over 50 years of age with and without carotid artery atherosclerosis: a cross-sectional outpatient study

Highlights. The association between vitamin D levels and estimated glomerular filtration rate and triglyceride levels was revealed in people with cardiovascular risk factors aged older than 50 years. Vitamin D deficiency was more frequently noted in patients with acute coronary syndrome. They also were more likely to have abdominal obesity and type 2 diabetes mellitus, indicating the association between vitamin D deficiency and metabolic syndrome. The high prevalence of both vitamin D deficiency and metabolic syndrome in the population necessitates further larger-scale studies to identify the relationship between vitamin D levels and cardiovascular risk factors.Aim. To assess the level of vitamin D in people older than 50 years with the presence/ absence of carotid artery atherosclerosis.Methods. The single-stage observational study was conducted, the study included 70 outpatients over 50 years of age, of which 17 (24%) were men and 53 (76%) were women. The mean age of the patients was 66 (60; 72) years. All examined patients underwent history taking, anthropometry, biochemical examination of blood plasma with the determination of lipid spectrum, glucose, creatinine and estimated glomerular filtration rate, echocardiographic examination. The presence of carotid atherosclerosis was determined by ultrasound examination of the carotid arteries. The study of the level of 25-OH vitamin D in blood serum was carried out by enzyme immunoassay (25-OH vitamin D ELISA).Results. It was found that about half (46%) of the examined persons have insufficient levels of vitamin D in the blood plasma, while its deficiency (less than 20 ng/mL) was determined in 9% of patients. Individuals with carotid atherosclerosis had slightly lower levels of vitamin D than those without it, but the differences did not reach statistical significance. In acute coronary syndrome survivors, there was a statistically significant decrease in vitamin D levels, the vast majority of these patients had diabetes mellitus and abdominal obesity. Statistically significant moderate relationships were found between vitamin D levels and triglyceride levels (r = –0.33; p&lt;0.05) and estimated glomerular filtration rate (r = 0.26; p&lt;0.05), which confirms the association of vitamin D deficiency with metabolic syndrome. No statistical regularity was found between the level of vitamin D and other laboratory biochemical parameters, as well as morphological changes in the heart and blood vessels.Conclusion. Insufficient content of vitamin D in blood plasma is more common in individuals with a history of acute coronary syndrome, among them diabetes mellitus and abdominal obesity are more often detected, which confirms the relationship of vitamin D deficiency with metabolic syndrome.

Implementation of recommendations on the check of risk factors for cardiovascular diseases in patients undergoing coronary re-interventions

MethodThe study involved 905 patients after coronary interventions, qualified for invasive diagnosis due to symptomatic coronary disease.AimThe aim of this study was to check the implementation of recommendations on the control of risk factors for cardiovascular diseases in patients undergoing re-interventions.ResultsCompared to elderly persons, younger people more often increased their physical activity (62 vs. 65 years, p = 0.009), stopped smoking (61 vs. 65 years, p < 0.001) and reduced alcohol consumption (62 vs. 65 years, p = 0.001). People with secondary and higher education increased their physical activity more often than those with primary education (51%, 31% vs. 23%, p = 0.006). Men more often than women decided to limit their alcohol consumption (48% vs. 37%, p = 0.007). Patients with a history of acute coronary syndrome were more likely to quit smoking and reduce their alcohol consumption than those without such a history (47% vs. 37%, p = 0.003 and 42% vs. 34%, p = 0.020, respectively). Only 2% of the subjects achieved the recommended LDL cholesterol values. Forty-eight percent were qualified for reinvasive procedures on the coronary arteries. Less than half of the patients undertook health-promoting behaviors that required modification of existing habits.ConclusionAge, gender, and education level influence pro-health behaviors. The majority of patients do not achieve the levels of LDL cholesterol and triglycerides consistent with the ESC guidelines in the secondary prevention of coronary disease. Inadequate check of risk factors may result in faster disease progression and coronary re-interventions.

Significance of Rate-Pressure Product and Duke Treadmill Score in Predicting Disease Severity in Patients with Coronary Artery Disease: A Cross-sectional Study

Introduction: Exercise electrocardiography is a well-established and cost-effective investigation for evaluating Coronary Artery Disease (CAD). The Rate-pressure Product (RPP), which is the product of maximal Systolic Blood Pressure (SBP) and peak Heart Rate (HR) during exercise, is a widely accepted parameter reflecting cardiac work and evaluating ventricular function. The use of Duke Treadmill Score (DTS) improves the diagnostic accuracy of exercise-induced ST-segment depression and has been observed to provide independent prognostic information. It has been shown that DTS provides information about the complexity of coronary artery lesions assessed by invasive coronary artery testing. Aim: To determine the significance of RPP and DTS in predicting the severity and complexity of angiographic lesions in patients with Stable Ischemic Heart Disease (SIHD) and a positive Treadmill Test (TMT). Materials and Methods: This study involved 100 consecutive patients with a positive TMT but no prior history of Acute Coronary Syndrome (ACS) who underwent coronary angiography at Government Medical College, Kottayam, Kerala, India, between March 2018 and March 2019 after obtaining ethical clearance from the Institutional Review Board. The DTS and RPP were calculated for these patients. All patients then underwent coronary angiography, and their SYNTAX scores were calculated. Correlation analysis was performed to assess the relationship between DTS, RPP, and SYNTAX score using Spearman's correlation coefficient. The Kruskall-Wallis test was used to compare risk factors among groups. Results: A total of 100 patients were evaluated, ranging in age from 40 to 74 years with an average age of 57 years. The average SYNTAX score was 15, ranging from 2 to 56. The average Duke TMT score was -5.2, ranging from 6 to -22. There was a significant negative correlation between DTS and angiographic severity determined by SYNTAX score (r=-0.702, p=0.001). The average RPP was 22174, ranging from 14000 to 37620. The study showed a significant negative correlation between RPP and SYNTAX score (r=-0.201, p=0.04). Diabetic patients had a significantly higher SYNTAX score compared to non-diabetics (r=-0.602, p=0.013). Additionally, a significant negative correlation was observed between the Metabolic Equivalents (METs) attained, duration of exercise, and the SYNTAX score. Conclusion: DTS and RPP derived from the exercise treadmill test have a significant negative correlation with the severity and complexity of CAD as determined by the SYNTAX score in coronary angiography.

Conflicts hurt: Social stress modulates proinflammatory cytokines’ link with pain and sadness

Several parameters of heart rate variability (HRV) have been shown to predict the risk of sudden cardiac death (SCD) in cardiac patients. There is consensus that risk prediction is increased when measuring HRV during specific provocations such as orthostatic challenge. For the first time, we provide data on reproducibility of such a test in patients with a history of acute coronary syndrome.Sixty male patients (65 ± 8 years) with a history of acute coronary syndrome on stable medication were included. HRV was measured in supine (5 min) and standing (5 min) position on 2 occasions separated by two weeks. For risk assessment relevant time-domain [standard deviation of all R-R intervals (SDNN) and root mean squared standard differences between adjacent R-R intervals (RMSSD)], frequency domain [low-frequency power (LF), high-frequency power (HF) and LF/HF power ratio] and short-term fractal scaling component (DF1) were computed. Absolute reproducibility was assessed with the standard errors of the mean (SEM) and 95% limits of random variation, and relative reproducibility by the intraclass correlation coefficient (ICC).We found comparable SEMs and ICCs in supine position and after an orthostatic challenge test. All ICCs were good to excellent (ICCs between 0.636 and 0.869).Reproducibility of HRV parameters during orthostatic challenge is good and comparable with supine position.

Coronary angioplasty or medical treatment in patients with aortic stenosis and coronary artery disease undergoing transcatheter aortic valve implantation: a real world analysis

Abstract Backgroud Patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic stenosis have a high prevalence of coronary artery disease (CAD). As many of them have high surgical risk, CAD treatment in this group usually has been carried out with optimal medical treatment alone or associated with percutaneous coronary intervention (PCI). However, the best approach in this scenario is not well established. Purpose We aimed to compare the incidences of major adverse cardiovascular outcomes in patients with aortic stenosis and chronic CAD treated with medical treatment alone or medical treatment plus PCI before or during TAVI, using data from a large multinational electronic health record network (TriNetX). Methods Patients aged ≥18 years with severe aortic stenosis and CAD who underwent TAVI in the last 10 years before the analysis were considered eligible. Patients who underwent PCI before or during TAVI were named the PCI-TAVI group and no coronary intervention patients were named isolated TAVI group. Patients with a past history of acute coronary syndrome, stroke or coronary artery bypass graft before TAVI were excluded from the analysis. The primary outcome was major adverse cardiovascular events (MACE) including the composite of death, unstable angina or myocardial infarction and ischemic stroke. We used propensity score matching to balance the cohorts. The 5-year cumulative incidences for MACE, Kaplan Meier curves and hazard ratios were calculated. Results We identified 13,171 patients undergoing isolated TAVI and 1,884 patients undergoing TAVI and PCI. Using propensity score matching, 1,884 patients in each group were compared. The 5-year incidence of MACE was 23.1% in the isolated TAVI group vs 24.7% in the PCI-TAVI group. The probability of survival without MACE was not significantly different between the isolated TAVI group vs PCI-TAVI group (47.4% vs 50.3%, Log-rank test p=0.718) (Figure 1). The hazard ratio (HR) between the 2 groups was also not significant (HR 1.027, CI 95% 0.89–1.18). Conclusions In a real-world cohort of patients with severe aortic stenosis and chronic coronary artery disease, the 5-year probability of major adverse cardiovascular events was not different between patients undergoing isolated TAVI versus patients undergoing PCI before or during TAVI. Funding Acknowledgement Type of funding sources: None.

Impact of de novo tachyarrhythmias in patients with prior acute coronary syndrome.

Although the incidence of acute coronary syndrome (ACS) has increased over the decades, the overall prognosis has improved with newer stents, tailored medication, and better intervention techniques. Atrial fibrillation (AF) and ventricular arrhythmia at the time of ACS diagnosis are known indicators of a poor acute prognosis. However, there is a lack of data regarding the long-term arrhythmic impact of ventricular tachyarrhythmia (VA) on mortality in ACS patients. This study sought to elucidate the impact of tachyarrhythmia on mortality during long-term follow-up in patients with a history of ACS. This retrospective study was conducted in a single university hospital, and it evaluated the clinical outcomes, especially regarding cardiovascular mortality and readmission. The enrolled patients underwent percutaneous coronary intervention (PCI) for ACS between February 2004 and March 2018. Clinical information was attained by a thorough chart review. We retrospectively analyzed 560 ACS patients. We reviewed all electrocardiograms (ECGs) before and immediately after PCI, during hospitalization, and within 3 months of the index PCI. Three months after the index PCI procedure, any Holter monitoring or ECG was also reviewed for arrhythmia diagnosis. During follow-up, 91 patients were diagnosed with AF and 36 patients were diagnosed with VA. Overall mortality was related to the presence of anemia, low body mass index, low left ventricular ejection fraction after PCI, late-diagnosed AF, and any VA during follow-up. Readmission was higher in patients with chronic kidney disease and newly diagnosed AF during the follow-up. Diagnosis of late tachyarrhythmia during follow-up was associated with increased mortality in post-ACS patients.

Pre-existing Psychiatric Morbidity Is Strongly Associated to Takotsubo Syndrome: A Case-Control Study.

BackgroundTakotsubo syndrome (TTS) is an emerging disease characterized by an acute and reversible myocardial dysfunction which may have an influence on clinical status and prognosis. Despite extensive research, its pathophysiology has not been completely elucidated; among other hypothesis, a heart-brain interaction has been proposed.MethodsThe aim of this study was to assess the impact of psychiatric disorders and of some personality types on the pathogenesis of TTS. We conducted a retrospective observational case-control study. We enrolled a total of 50 patients, 25 with a previous diagnosis of TTS and 25 patients with a history of acute coronary syndrome (ACS), that underwent a comprehensive lifetime psychiatric assessment.ResultsWe found no significant difference between TTS and ACS patients in cardiovascular risk profile. The frequency of lifetime psychiatric disorders was significantly greater in TTS. In particular, in the univariate analysis, TTS group showed a higher prevalence of mood disorders (Major Depressive Disorder, Bipolar Disorder, Dysthymia; 16 vs. 2, P < 0.001) and anxiety disorder (Generalized Anxiety Disorder, Panic Disorder, Agoraphobia; 20 vs. 8, P = 0.001) compared with ACS group. There was also a significant tendency in TTS patients to psychotropic medication use, substance abuse, and psychologist or psychiatrist consulting. However, there was no difference between the groups in previous stressful events and Type D personality. Moreover, the multivariate analysis showed that mood disorders were independently associated with TTS (OR 16.9, 95% CI, 2.2–127).ConclusionOur study demonstrated that pre-existing anxiety disorders and mostly mood disorders were significantly higher in TTS patients than in ACS group, suggesting the role of psychiatric disorders as possible pathophysiological substrate of TTS.

Efficacy and Safety of Atorvastatin 40 mg versus Rosuvastatin 20 mg in Patients with Type 2 Diabetes Mellitus and Previous Acute Coronary Syndrome: A Randomized Clinical Trial

Background: The purpose of this study was to compare the efficacy and safety of high-dose atorvastatin (40 mg) versus high-dose rosuvastatin (20 mg) in Egyptian patients with type 2 diabetes and previous acute coronary syndrome history. Materials and methods: This open-labeled prospective, randomized clinical trial compared once daily atorvastatin 40 mg (Ator®) versus once daily rosuvastatin 20 mg (Crestor®). The primary outcome was the 50% reduction in low-density lipoprotein cholesterol levels at 12 weeks. The secondary outcome was the achievement of low-density lipoprotein cholesterol level &lt; 55 mg/dL. Results: A total number of 108 patients had a significant percentage of improvement in atorvastatin arm (n = 59) and rosuvastatin arm (n = 49) in low-density lipoprotein cholesterol, total cholesterol, triglycerides, and high-density lipoprotein-cholesterol achieved (p ≤ 0.05). In atorvastatin arm, 32.2% of patients achieved fifty percent reduction in low-density lipoprotein cholesterol while 34.7% of patients in rosuvastatin arm (p &gt; 0.05). Twenty percent of patients achieved low-density lipoprotein cholesterol &lt; 55 mg/dL in atorvastatin group compared to eighteen percent only in rosuvastatin group (p &gt; 0.05). Regarding safety, the mean difference in liver transaminases was non-significant between the two groups (p &gt; 0.05). Muscular symptoms were experienced by 1.7% patients receiving atorvastatin 40 mg and 10.2% of those receiving rosuvastatin 20 mg (p &gt; 0.05). Conclusions: In Egyptian context, both high doses statin therapy were comparable regarding efficacy and safety in patients with type 2 diabetes and previous history of acute coronary syndrome. The Clinicaltrial.gov registration ID is: NCT05306990.

Myocardial infarction in pregnancy: Current topical issues in diagnostics and treatment

Lately due to the increase of childbearing age of women, high prevalence of cardiovascular diseases, and, presumably, due to the usage of some medications, there was an increase in myocardial infarction (MI) cases in pregnant women. Risk factors and pathophysiological mechanisms of MI in pregnant women differ from the general population, and are heterogeneous. Pregnancy and childbirth can be defined as ‘physiological stress’ for the cardiovascular system, which can cause MI. Abrupt changes in hemodynamics and increased coagulation state during pregnancy, in childbirth or in the early postpartum period can provoke sudden constriction (vasospasm) of a coronary artery (CA), as well as non-atherosclerotic spontaneous CA dissection, which leads to a critical decrease in the supply of oxygen to the heart muscle. The frequency of hemodynamically significant atherosclerosis of CA is also increasing. The incidence of maternal, perinatal mortality and obstetric complications is higher than in women without history of acute coronary syndrome. Over the past few decades, the diagnosis and treatment of myocardial infarction improved, the number of primary percutaneous coronary interventions in pregnant women increased, and there is now less inpatient mortality. However, due to the absence of large randomized clinical trials on the MI in pregnant women it is impossible to develop a unified algorithm for the management and preventive measures for this condition, thereby it is difficult to select an optimal treatment tactic, and hard to predict subsequent cardiovascular events. In this article we analyzed current data on MI during pregnancy, childbirth, and the postpartum period.

Evaluating the occurrence of increased postoperative cardiac enzymes in patients with coronary atherosclerotic obstruction.

Percutaneous transluminal coronary angioplasty (PTCA) has been accepted as the elective treatment in many patients with coronary atherosclerotic obstruction. A slight increase in cardiac markers after the percutaneous coronary intervention (PCI) has been commonly reported. Some researchers have suggested that it predicts mortality and long-term complications. This study aimed to evaluate the occurrence of increased postoperative cardiac enzymes and determine the relationship between such an increase and clinical angiographic and technical variables. For this purpose, the descriptive study was performed in Hospital's cardiac ward from 2020-to 2021. One hundred twenty-two patients with stable coronary artery disease were studied for elective PTCA implanted with successful and uncomplicated stenting. Blood samples were taken from all patients to measure cardiac markers 20 hours after surgery. The normal range was CTnI ≤ 2ng/ml and CKMB ≤ 24 IU/L. Plasma levels of myocardial infarction and their relationship with clinical variables (including age, sex, risk factors for coronary artery disease, the severity of symptoms based on ccs class and previous history of acute coronary syndromes), angiographic including (lesion type, severity of stenosis) or related to the operation (operation on one or two vessels and direct stenting versus PTCA + stenting) were recorded in a questionnaire and observation sheets. The collected data were processed using descriptive statistics, frequency distribution tables, Chi-square, and student t-tests. Abnormal values of myocardial infarction were observed in 46.72% (57 patients). An increase in CTnI was observed in 39 patients (31.96%) and an increase in CKMB was seen in 31 patients (25.40%). Although the rise in CTnI exceeded the CKMB, the difference between the two was not statistically significant. The increased CTnI was significantly higher in older people, and the increase in CKMB was significantly higher in hypertensive individuals (p = 0.01). Based on the findings of this study, there is an increase in enzymes after successful and uncomplicated PCI selection. Increased CTnI occurs more frequently than CKMB. There is no relationship between enzyme enhancement and other clinical, angiographic, and technical variables.

Prognostic value of exercise stress echocardiography in patients with known coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Exercise stress echocardiography (EE) is useful for diagnosis and risk stratification in patients (pts) with suspected coronary artery disease (CAD). Pts with known CAD carry a high risk of events. Our aim was to assess the utility of EE in predicting outcomes in this population. Methods Single center retrospective study of consecutive pts with known CAD who performed an EE between 2018 and 2019. The primary endpoint was a composite of admission for acute coronary syndrome (ACS), coronary revascularization and cardiovascular death during the follow-up. Results A total of 76 pts were included (mean age 59±9 years; 87% male). Fifty-nine (78%) pts had history of ACS, 51 (67%) of percutaneous coronary intervention (PCI) and 14 (18%) of coronary artery bypass graft. The majority of pts had 2 or more vessel disease (42 pts; 55%). The main reason for performing EE was new onset of chest pain (38 pts; 50%) followed by functional assessment of coronary stenoses after incomplete revascularization (29 pts; 38%). The majority of pts had a preserved left ventricular ejection fraction (67; 88%). The exam was performed under beta-blocker effect in 35 (46%) pts. The results of EE were positive for myocardial ischemia in 7 (9%) pts, negative in 37 (49%) pts and inconclusive in 32 (42%) pts. Mean exercise time was 8±3 minutes and mean METs achieved was 9.4±2.6. ST-segment depression fulfilling electrocardiographic criteria for ischemia occurred in 17 (22%) pts. Eleven (14%) pts complained of chest pain during the exam. During a median follow up of 22 months (IQR 15-26), the primary endpoint occurred in 9 pts (admission for ACS in 5 pts; revascularization for chronic coronary syndrome in 4 pts). No cardiovascular death occurred. The positive predictive value of EE for the primary endpoint was 57.1% and the negative predictive value (NPV) 97.3%. In a survival analysis, the predictors of the primary endpoint were lower exercise time, lower METs achieved, untreated significant coronary lesions and a positive EE (figure). After adjustment in a multivariate analysis, a positive EE was an independent predictor of the primary endpoint (HR 4.6, 95%CI: 1.1-16.7, p=.044). Conclusion In pts with known CAD, EE had a high NPV and a positive result was an independent predictor of future cardiovascular events.

INTRAPROCEDURAL STENT THROMBOSIS DURING PERCUTANEOUS CORONARY INTERVENTION: HOW TO PREDICT

Background: Intraprocedural stent thrombosis (IPST) during percutaneous coronary intervention (PCI) is an uncommon event that results in a poor outcome including STEMI and sudden cardiac death. Concerns about an increased risk of stent thrombosis with drug-eluting stents (DES) continue, even though the incidence, timing, and predictors of stent thrombosis with DES have not been identified. Objective: This study aimed to describe the diagnosis and management of Intraprocedural Stent Thrombosis. Case presentation: We will discuss a 49 year-old male brought to our hospital because of chest pain while doing moderate activity. One month prior to admission, he had history of acute coronary syndrome and 1 DES on right coronary artery was placed. Ticagrelor and aspirin were routinely consumed as dual antiplatelet therapy. The patient was diagnosed with intraprocedural stent thrombosis during PCI with the evidence of intra-catheter thrombosis and ST segment elevations seen in the ECG monitor. We treat the patient with Ticagrelor 180 mg loading dose and intracoronary unfractionated heparin (UFH) during procedure continued with continuous infusion until 24 hours. No event of subsequent acute coronary syndrome was observed. Conclusion: Intraprocedural Stent Thrombosis was a strong predictor of mortality in STEMI patients. This case showed that the present widespread use of DES instead of BMS for coronary implantation although decreased the future risk of repeat revascularization, increased the risk of thrombosis. Prior risk stratification, potent early antiplatelet treatment and anticoagulant of choice with UFH might be used to reduce the risk of thrombosis in STEMI patients undergoing stent implantation.