Invasive Coronary Interventions Research Articles

Plasma Somatostatin Levels Are Lower in Patients with Coronary Stenosis and Significantly Increase after Stent Implantation.

Background/Objectives: Stimulated capsaicin-sensitive peptidergic sensory nerves release somatostatin (SST), which has systemic anti-inflammatory and analgesic effects, correlating with the severity of tissue injury. Previous studies suggest that SST release into the systemic circulation is likely to serve as a protective mechanism during thoracic and orthopedic surgeries, scoliosis operations, and septic conditions, all involving significant tissue damage, pain, and inflammation. In a severe systemic inflammation rat model, SST released from sensory nerves into the bloodstream enhanced innate defense, reducing mortality. Inflammation is the key pathophysiological process responsible for the formation, progression, instability, and healing of atherosclerotic plaques. Methods: We measured SST-like immunoreactivity (SST-LI) in the plasma of healthy volunteers in different age groups and also that of stable angina patients with coronary heart disease (CHD) using ELISA and tracked changes during invasive coronary interventions (coronarography) with and without stent implantation. Samples were collected at (1) pre-intervention, (2) after coronarography, (3) 2 h after coronarography initiation and coronary stent placement, and (4) the next morning. Results: There was a strong negative correlation between SST-LI concentrations and age; the plasma SST-LI of older healthy volunteers (47-73 years) was significantly lower than in young ones (24-27 years). Baseline SST-LI in CHD patients who needed stents was significantly reduced compared to those not requiring stents. Plasma SST-LI significantly increased two hours post stent insertion and the next morning compared to pre-intervention levels. Conclusions: Age-related SST decrease might be a consequence of lower gene expression within specific hypo-thalamic nuclei as has been previously demonstrated in rodent animals. Reperfusion of ischemic myocardium post-stent implantation may trigger SST release, potentially offering protective benefits in coronary heart disease. Investigating this SST-mediated mechanism could offer valuable insights for future therapies.

Effect of invasive therapeutic coronary interventions on endothelial cell activation and thrombin generation in patients with chronic total coronary occlusion

BackgroundPercutaneous coronary intervention (PCI) is commonly used treatment for chronic total occlusion (CTO). PCI can be performed in two different ways using wire escalation (WE) or subintimal dissection and reentry (DR) technique. During both procedures patients are treated with anticoagulants, however a substantial activation of coagulation cascade is expected, which may affect clinical outcome. ObjectivesOur aim was to compare the impact of WE and DR techniques regarding endothelial cell activation and thrombin formation. MethodsFifty patients after CTO-PCI were enrolled into this study. Blood samples were obtained before PCI, at 48 h and 3–6 months after the intervention to measure soluble endothelium-specific markers and to investigate thrombin generation. ResultsTwenty-nine patients were treated with WE, 21 received DR. In the DR group, soluble VCAM-1 (vascular cell adhesion molecule-1) and ICAM-1 (intercellular cell adhesion molecule-1) concentrations were gradually elevated and remained significantly increased at 3–6 months (p = 0.006 and p = 0.037, respectively) compared to pre-PCI. Furthermore, significant decrease in lagtime (p = 0.004) and time to peak (p = 0.002) with a substantial increment in peak thrombin (p = 0.001) were observed in these patients. In contrast, no significant alteration was found in the WE cohort. Clinical complications (myocardial infarction, stroke, thrombosis, revascularization) did not occur in the first 9 months of follow-up period in either group. ConclusionAlthough DR intervention induces more thrombin generation with a larger degree of endothelium activation compared to WE, this technique does not cause more clinical complications.

Dexmedetomidine in anesthesia for planned endovascular myocardial revascularization

Introduction. Endovascular stenting of coronary arteries is an effective, minimally invasive and rapidly developing method of coronary heart disease (CHD) treatment. The question regarding the choice of a drug for adequate and safe monitoring sedation in patients during this type of surgical procedures remains open. The aim of the study was to discuss a clinical case of dexmedetomidine in elective endovascular stenting of coronary arteries. Materials and methods. A clinical case of dexmedetomidine in anesthesia during elective stenting of the right coronary artery and its analgesic effect in the development of right coronary artery (RCA) dissection are described. Results. Patient S., 72 years old, after planned endovascular stenting of the right coronary artery with 3 stents at the time of his admission to the intensive care unit (ICU) had no angina pains and sternal discomfort. The patient was transferred to the specialized department 8 hours after stenting in a stable condition. Serum cardiospecific troponin T level was less than 0.2 ng/ml 6 hours after RCA stenting. No negative dynamics was described on the control ECG after surgical intervention. Discussion. Dexmedetomidine has a proven analgesic effect due to its direct effect on the peripheral nervous system. Conclusion. The use of dexmedetomidine has its place in periprocedural sedation in patients with coronary heart disease during planned endovascular coronary artery stenting, including patients with significant (over 90%) and extended coronary artery stenoses. The clinical use of dexmedetomidine in elective minimally invasive coronary interventions requires closer attention and study.

Morphological and functional diagnostics of coronary artery disease by computed tomography

Computed tomography coronary angiography (cCTA) is asafe option for the noninvasive exclusion of significant coronary stenoses in patients with a low or moderate pretest probability for coronary artery disease (CAD). Furthermore, it also allows functional and morphological assessment of coronary stenoses. The European Society of Cardiology (ESC) guidelines on the diagnosis and management of chronic coronary syndrome published in 2019 have strengthened the importance of cCTA in this context and for this reason it has experienced a considerable upgrade. The determination of the Agatston score is aclinically established method for quantifying coronary calcification and influences the initiation of drug treatment. With technologies, such as the introduction of electrocardiography (ECG)-controlled dose modulation and iterative image reconstruction, cCTA can be performed with high image quality and low radiation exposure. Anatomic imaging of coronary stenoses alone is currently being augmented by innovative techniques, such as myocardial CT perfusion imaging or CT-fractional flow reserve (FFR) but the clinical value of these methods merits further investigation. The cCTA could therefore develop into agatekeeper with respect to the indications for invasive coronary diagnostics and interventions.

The effect of sexual counseling on depression, anxiety, stress, sexual knowledge and sexual quality of life in men who have undergone invasive coronary interventions: An RCT.

BackgroundSexual dysfunctions are common in men with ischemic heart disease, especially in men undergoing therapeutic interventions.ObjectiveThis study intended to assess the effect of counseling on depression, anxiety, stress, sexual knowledge and sexual quality of life in men after invasive coronary interventions in the post catheterization department of Kashan Shahid Beheshti Hospital during 2018.Materials and MethodsThe study population consisted of 54 male participants who had undergone an invasive coronary intervention. The intervention group received counseling and the control group underwent the standard ward routine. Data were collected using the depression anxiety stress scales, Abraham's sexual quality of life, and the Yi-Hung Sexual Knowledge questionnaires before discharge and also two months later.ResultsWithin two months, the intervention group's mean score of sexual knowledge significantly increased, compared with the control group, from 12.37 to 14.81 (p 0.001). The intervention group's mean score of sexual quality of life also significantly increased, compared with the control group, from 48.2 to 60.7 (p 0.001). Moreover, the mean anxiety score changed in the intervention group from 11.18 to 5.25, again a significant difference compared with the control group (p = 0.01). But, the differences in the depression and stress scores were not significant.ConclusionOur findings suggest that sexual counseling may improve sexual knowledge, sexual quality of life and anxiety in men following invasive coronary intervention, but might not reduce their stress or depression. Further studies are needed to confirm these findings.

Ischemic Stroke as a Manifestation of Cholesterol Embolization Syndrome Following Percutaneous Coronary Intervention

Cholesterol embolization syndrome (CES) is one of the major, yet underdiagnosed cause of morbidity and mortality following invasive coronary interventions. The major risk factors are elderly, male, atherosclerotic disease, anticoagulation and femoral access route. This multisystem disease affects skin, kidney, brain, eye and gastrointestinal tract. Only few cases of cholesterol embolization syndrome manifesting as an ischemic stroke are reported. We present a case of an elderly man, admitted to our ICU after percutaneous coronary intervention (PCI) who developed neurological deficits along with skin changes and renal failure. cholesterol embolization syndrome was suspected based upon the presence of cardiovascular risk factors, invasive cardiovascular intervention and clinical signs. The diagnosis of ischemic stroke made through plain MRI brain, revealed multiple areas of lacunar infarcts. He was treated with intermittent hemodialysis, statins and anti-platelet agents. On follow up, skin lesions and renal functions were improved; but slurring of speech and paresis persisted.

Self-Care Behaviors of Rural Women Post-Invasive Coronary Interventions

Purpose: Self-care is an essential component of secondary prevention of coronary artery disease (CAD) for rural women after undergoing invasive coronary interventions (ICI). The purpose of the study was to describe self-care behavior experiences of rural women with CAD post-ICI. The specific aims were: to identify and describe self-care behaviors initiated by rural women post-ICI; and to identify and describe barriers to and facilitators of self-care behavior adoption. The language used to describe self-care can be different between health care providers, who are guided by the American Heart Association (AHA), and rural women whose descriptions are based on their life experiences.
 Methods: Qualitative descriptive methods were used to purposefully sample women (N=10) from two rural Arizona counties. Data were collected using semi-structured face-to-face interviews, lasting approximately 25minutes. Atlas.ti Mac Version 1.5.2 (462) was used for data analysis.
 Findings: Aim 1: Healthy diet was the most common self-care behavior described by rural women. When describing self-care behaviors, rural women used a different language, which was in alignment with AHA guidelines for self-care behaviors. Aim 2: Themes identified and described for barriers were: residential environment, health and physical ailments, family conditions, and personal characteristics; and for facilitators were relationships, available resources, and personal outcomes.
 Conclusions: Regardless of poor health-promoting environment, such as unavailability of fresh food stores and access to exercise opportunities rural women took advantage of what they had to keep healthy. They performed self-care behaviors that they described as good for their health and made them happy without associating them the expected self-care behaviors to prevent reoccurrences and complications post-ICI. Rural health care providers must recognize these challenges, acknowledge the positive assets wihin rural women, and incorporate them into the programs for self-care behavior modification strategies.
 Keywords: Self-care, rural women, coronary artery disease, invasive coronary interventions
 DOI: http://doi.org/10.14574/ojrnhc.v20i2.629

The role of public health versus invasive coronary interventions in the decline of coronary heart disease mortality

Purpose: There has been considerable debate on the extent to which the decline in coronary heart disease (CHD) mortality has been caused by better control of coronary risk factors in the general population or is the result of invasive coronary interventions in symptomatic individuals. MethodsUsing the Myocardial Infarction Data Acquisition System, a statewide database of all cardiovascular hospital admissions in New Jersey, we examined time trends in incidence of death from CHD in the Years 2000–2014 in persons with a history of hospitalization for CHD in the previous 10 years and those without such a history. ResultsOver the 10-year study period, there was a marked decline in CHD-related mortality in both persons with a history of CHD and persons without a history of CHD. The decline occurred across all gender, racial, and age groups and was higher in those without a prior history of CHD. ConclusionsThis adds more evidence that the decline in CHD was not only because of advanced invasive medical and surgical treatments but also equally because of improved lifestyle, pharmacologic treatment of risk factors for CHD, and public health interventions.

TransRadial versus transUlnar artery approach for elective invasive percutaneous coronary interventions: a randomized trial on the feasibility and safety with ultrasonographic outcome - RAUL study.

IntroductionTransradial access (TRA) for coronary angiography (CAG) and percutaneous coronary intervention (PCI) is superior to transfemoral access (TFA). Transulnar access (TUA) is an alternative to TRA.AimTo compare the efficacy and safety of TRA vs. TUA in patients scheduled for CAG or PCI.Material and methodsThis was a prospective, single-center, randomized study conducted between 2013 and 2016. Two hundred patients referred for the first elective CAG were included in the study. Eligible patients were then randomly assigned to the TRA or TUA group. Before and after the invasive procedure, all patients underwent ultrasonographic measurements of the right upper limb arteries.ResultsThe primary endpoint was efficacy, defined as a successful CAG without a crossover of vascular access. The secondary endpoint was safety, assessed as the number of vascular complications. Successful coronary angiography via the access site was 95% vs. 75% in the TRA vs. TUA groups, respectively (p < 0.001). It depended on the anatomy of UA and the operator experience. No differences were observed in early and late follow-up complications.ConclusionsTRA was superior to TUA with regard to efficacy. TUA occurred a safe approach for CAG and PCI and could be used as an alternative method of forearm access.

An Ex Vivo Vessel Injury Model to Study Remodeling

Objective: Invasive coronary interventions can fail due to intimal hyperplasia and restenosis. Endothelial cell (EC) seeding to the vessel lumen, accelerating re-endothelialization, or local release of mTOR pathway inhibitors have helped reduce intimal hyperplasia after vessel injury. While animal models are powerful tools, they are complex and expensive, and not always reflective of human physiology. Therefore, we developed an in vitro 3D vascular model validating previous in vivo animal models and utilizing isolated human arteries to study vascular remodeling after injury. Approach: We utilized a bioreactor that enables the control of intramural pressure and shear stress in vessel conduits to investigate the vascular response in both rat and human arteries to intraluminal injury. Results: Culturing rat aorta segments in vitro, we show that vigorous removal of luminal ECs results in vessel injury, causing medial proliferation by Day-4 and neointima formation, with the observation of SCA1+ cells (stem cell antigen-1) in the intima by Day-7, in the absence of flow. Conversely, when endothelial-denuded rat aortae and human umbilical arteries were subjected to arterial shear stress, pre-seeding with human umbilical ECs decreased the number and proliferation of smooth muscle cell (SMC) significantly in the media of both rat and human vessels. Conclusion: Our bioreactor system provides a novel platform for correlating ex vivo findings with vascular outcomes in vivo. The present in vitro human arterial injury model can be helpful in the study of EC-SMC interactions and vascular remodeling, by allowing for the separation of mechanical, cellular, and soluble factors.

P756TransRadial versus transulnar artery approach for elective invasive percutaneous coronary interventions - Randomized feasibility and safety trial with ultrasonographic outcome

P756TransRadial versus transulnar artery approach for elective invasive percutaneous coronary interventions - Randomized feasibility and safety trial with ultrasonographic outcome

Abstract 16639: Low Yield of Additional Non-invasive Testing in Moderate Worst Stenosis by cCTA in Acute Chest Pain Patients - Results From a Clinical ED cCTA Registry

Introduction: Coronary computed tomography angiography (cCTA) allows efficient triage of low-intermediate risk patients with suspected acute coronary syndrome (ACS); appropriate management of patients with moderate stenosis by cCTA is unknown. We evaluated the yield of downstream testing in moderate stenosis patients in a clinical ED cCTA registry. Methods: All consecutive ED patients with acute chest pain undergoing cCTA as part of routine care between October 2012 and July 2014 were screened. Patients with moderate as their worst stenosis (50-69% stenosis) on cCTA were included. Plaque characteristics, resting left ventricular function (by cCTA), results of any functional downstream non-invasive testing, invasive coronary angiography (ICA) and interventions, and discharge diagnosis were reported. ACS was defined as acute myocardial infarction (MI) or unstable angina pectoris (UAP) and adjudicated by an independent committee. Ischemia was defined as clear, territorial abnormality by myocardial perfusion scintigraphy imaging (MPI) or rest or stress echocardiogram, significant dynamic ST-T shift by exercise treadmill test (ETT) and stenosis &gt;70% on ICA or fractional flow reserve (FFR) &lt;0.75. Results: 586 patients underwent cCTA, with 7.2% (n=42) deemed moderate stenosis. Rate of ACS was 14.2% (n=6) with all adjudicated as UAP. Of these, 83% had stenosis caused by lipid-rich plaque; 33% had wall motion abnormalities on cCTA. The majority (n=28; 66%) underwent downstream non-invasive testing. Overall, n=2 (6%) of the non-invasive tests were positive for ischemia while n=3 (42%) of the invasive tests were diagnosed as positive for ischemia (all revascularized) (Figure 1). Conclusions: Unstable angina but not myocardial infarction is frequent among acute chest pain patients with moderate stenosis by cCTA. cCTA findings of lipid-rich plaque and resting functional abnormalities had a relatively higher yield vs. other non-invasive tests to detect ischemia.

PATIENTS WITH ACUTE CORONARY SYNDROME AND ELEVATED ST SEGMENT AT THE HOSPITAL HAVING NO OPPORTUNITIES TO PERFORM INVASIVE CORONARY INTERVENTIONS: ANALYSIS OF MEDICAL TACTICS AND HOSPITALIZATION OUTCOMES

Aim. To give recommendations concerning optimization of treatment at the hospital having no opportunities to perform invasive coronary interventions for patients with acute coronary syndrome and elevated ST segment. Materials and methods. Medical tactics was analyzed in 190 patients with acute coronary syndrome and elevated ST segment at the Unit of Urgent Cardiology of Smolensk Emergency Hospital. Results. Disadvantages in treatment tactics concerning patients with acute coronary syndrome and elevated ST segment were revealed. Thrombolytic therapy was carried out only in 18,42% of patients. Intrahospital mortality was 17,99%, acute heart failure was diagnosed in 19,48% of patients. Conclusion. Patients with acute coronary syndrome and elevated ST segment treated at «invasive» hospitals have a high risk of unfavourable outcomes. It was recommended by the results of this study to follow modern guidelines regarding management of patients with acute coronary syndrome and elevated ST segment, to use widely thrombolytic therapy, low-molecular heparins, up-to-date antiplatelet and hypolipidemic drugs.

Registration of &lt;formula formulatype="inline"&gt;&lt;tex Notation="TeX"&gt;$3{\rm D}+{\rm t}$&lt;/tex&gt;&lt;/formula&gt; Coronary CTA and Monoplane &lt;formula formulatype="inline"&gt;&lt;tex Notation="TeX"&gt;$2{\rm D}+{\rm t}$&lt;/tex&gt;&lt;/formula&gt; X-Ray Angiography

A method for registering preoperative 3D+t coronary CTA with intraoperative monoplane 2D+t X-ray angiography images is proposed to improve image guidance during minimally invasive coronary interventions. The method uses a patient-specific dynamic coronary model, which is derived from the CTA scan by centerline extraction and motion estimation. The dynamic coronary model is registered with the 2D+t X-ray sequence, considering multiple X-ray time points concurrently, while taking breathing induced motion into account. Evaluation was performed on 26 datasets of 17 patients by comparing projected model centerlines with manually annotated centerlines in the X-ray images. The proposed 3D+t/2D+t registration method performed better than a 3D/2D registration method with respect to the accuracy and especially the robustness of the registration. Registration with a median error of 1.47 mm was achieved.

Statistical coronary motion models for 2D+t/3D registration of X-ray coronary angiography and CTA

Accurate alignment of intra-operative X-ray coronary angiography (XA) and pre-operative cardiac CT angiography (CTA) may improve procedural success rates of minimally invasive coronary interventions for patients with chronic total occlusions. It was previously shown that incorporating patient specific coronary motion extracted from 4D CTA increases the robustness of the alignment. However, pre-operative CTA is often acquired with gating at end-diastole, in which case patient specific motion is not available. For such cases, we investigate the possibility of using population based coronary motion models to provide constraints for the 2D+t/3D registration. We propose a methodology for building statistical motion models of the coronary arteries from a training population of 4D CTA datasets. We compare the 2D+t/3D registration performance of the proposed statistical models with other motion estimates, including the patient specific motion extracted from 4D CTA, the mean motion of a population, the predicted motion based on the cardiac shape. The coronary motion models, constructed on a training set of 150 patients, had a generalization accuracy of 1mm root mean square point-to-point distance. Their 2D+t/3D registration accuracy on one cardiac cycle of 12 monoplane XA sequences was similar to, if not better than, the 4D CTA based motion, irrespective of which respiratory model and which feature based 2D/3D distance metric was used. The resulting model based coronary motion estimate showed good applicability for registration of a subsequent cardiac cycle.

Iatrogenic femoral pseudoaneurysms - a simple solution of inconvenient problem?

A femoral artery pseudoaneurysm - is the most common complication associated with invasive coronary interventions. The aim of the study was to analyze the effectiveness of various methods used for femoral pseudoaneurysm treatment and to assess how routine use of radial approach leads to reduction of these site complications. The study comprised 1854 consecutive patients who were hospitalized in years 2005-2008 and underwent coronary angiography (with or without angioplasty) via femoral artery access. Since 2009 routine radial approach has been introduced for both coronary angiography and angioplasty. In patients with symptoms suggesting entry site complications Doppler ultrasound was performed. Femoral access site complications requiring additional procedures were observed in 63 patients (3.4%): in 56 femoral pseudoaneurysms (88.8%) and in 7 arteriovenous fistulas (11.1%) were diagnosed (all appeared after coronary angioplasty). The patients were treated in following ways: standard compression with an elastic bandage prolonged to 12 hours - in 14 cases (25%), ultrasound guided compression - in 13 patients (23.2%), finger compression followed by standard compression with an elastic bandage prolonged to 12 hours or ice compress - in 10 patients (17.8%), surgical treatment - in 3 patients (5.3%). Only 2 patients required thrombin injection (3.6%). Since the time routine radial approach was introduced extreme reduction in the rate of local complications was registered. Although iatrogenic femoral pseudoaneurysms following invasive percutaneous coronary interventions are still important complications, most of them can be treated conservatively. It seems that radial access completely eliminates the risk of this complication.

Revascularisation and mortality rates following acute coronary syndromes in people with severe mental illness: comparative meta-analysis

High levels of comorbid physical illness and excess mortality rates have been previously documented in people with severe mental illness, but outcomes following myocardial infarction and other acute coronary syndromes are less clear. To examine inequalities in the provision of invasive coronary procedures (revascularisation, angiography, angioplasty and bypass grafting) and subsequent mortality in people with mental illness and in those with schizophrenia, compared with those without mental ill health. Systematic search and random effects meta-analysis were used according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies of mental health and cardiovascular procedures following cardiac events were eligible but we required a minimum of three independent studies to warrant pooling by procedure type. We searched Medline/PubMed and EMBASE abstract databases and ScienceDirect, Ingenta Select, SpringerLink and Online Wiley Library full text databases. We identified 22 analyses of possible inequalities in coronary procedures in those with defined mental disorder, of which 10 also reported results in schizophrenia or related psychosis. All studies following acute coronary syndrome originated in the USA. The total sample size was 825 754 individuals. Those with mental disorders received 0.86 (relative risk, RR: 95% CI 0.80-0.92, P<0.0001) of comparable procedures with significantly lower receipt of coronary artery bypass graft (CABG; RR = 0.85, 95% CI 0.72-1.00), cardiac catheterisation (RR = 0.85, 95% CI 0.76-0.95) and percutaneous transluminal coronary angioplasty or percutaneous coronary intervention (PTCA/PCI; RR = 0.87, 95% CI 0.72-1.05). People with a diagnosis of schizophrenia received only 0.53 (95% CI 0.44-0.64, P<0.0001) of the usual procedure rate with significantly lower receipt of CABG (RR = 0.69, 95% CI 0.55-0.85) and PTCA/PCI (RR = 0.50, 95% CI 0.34-0.75). We identified 6 related studies examining mortality following cardiac events: for those with mental illness there was a 1.11 relative risk of mortality up to 1 year (95% CI 1.00-1.24, P = 0.05) but there was insufficient evidence to examine mortality rates in schizophrenia alone. Following cardiac events, individuals with mental illness experience a 14% lower rate of invasive coronary interventions (47% in the case of schizophrenia) and they have an 11% increased mortality rate. Further work is required to explore whether these factors are causally linked and whether improvements in medical care might improve survival in those with mental ill health.

The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

Introduction Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality. Patients and methods Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets). Results The mean perioperative blood loss was 899 ± 496 ml for patients not on clopidogrel, 1091 ± 654 ml for patients on clopidogrel ( p = 0.005) and 1312 ± 686 ml for those on combined clopidogrel and aspirin ( p = 0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation ( p = 0.0012) and prolonged surgical time ( p = 0.0002). There were no cases of mortality in the early postoperative period. Conclusions Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.

Glucocorticoids and the Cardiovascular System: State of the Art

Glucocorticoids (GC) are drugs commonly used, by approximately 1% of the total adult population as anti-inflammatory and immunosuppressive therapies for asthma, inflammatory bowel disease, dermatological, ophthalmic, neurological, and rheumatic autoimmune diseases. Supporting evidence exists of GC use in both immune mediated and non-immune mediated heart disease. The molecular mechanisms by which GC induces immune-modulation and direct cardioprotection, are complex and not fully understood. We review herein, the current knowledge of GC use in various immune-mediated or non-immune mediated cardiovascular conditions. GC have been investigated in autoimmune, inflammatory and idiopathic heart diseases such as atrio-ventricular conduction abnormalities, rheumatic fever, myocarditis, dilated cardiomyopathy, Churg-Strauss syndrome, Kawasaki disease and sarcoidosis. GC therapy has been studied in non-autoimmune and non-inflammatory indications such as acute myocardial infarction, angina, postpericardiotomy syndrome and other pericardial diseases, endocarditis and cardiac amyloidosis, as well as in invasive cardiology, coronary interventions, and cardiopulmonary-bypass surgery. Despite GC's role as natural, physiologic regulators of the immune system, cardiovascular adverse outcomes may occur. Some of the well-known side effects of GC therapy involve bone, metabolic, and cardiovascular systems and include osteoporosis, fractures, dyslipidemia, diabetes, obesity, and hypertension.

Present status of outcome prediction of invasive coronary treatment by using genetic markers

A growing number of studies suggest that the outcome after invasive coronary treatment may be in part genetically determined. Here, we review the present status of outcome prediction of invasive coronary treatments by using genetic markers. Although some studies found an association between one or another genetic marker with one or another clinical endpoint, many other studies found no such relations; to date, none of the genetic markers that have been investigated in association studies are used in routine clinical practice to prospectively assess the prognosis following invasive coronary treatment or to decide upon therapeutic strategies. Many associations between genetic markers and certain clinical endpoints were initially reported in small studies but could not be confirmed in larger ones. Some of these discrepancies may be explained by publication bias. Some genetic variants may have true effects on clinical endpoints, which, albeit biologically interesting, do not bear much clinical relevance. On the other hand, many-if not most-studies that have been published to date are more or less grossly underpowered and very rarely report on the results of an a priori power analysis. Thus, there is still a need for further high-quality studies designed to investigate the specific contribution of genetic factors to the outcome after invasive coronary interventions.