Setting Of Acute Coronary Syndrome Research Articles

Self-expanding stent for complex percutaneous coronary interventions: A real life experience.

Self-expanding stents represent a re-emerging option for percutaneous coronary interventions. Their application covers a wide spectrum of angiographic situations, i.e., coronary bifurcations, acute coronary syndromes with large thrombotic burden and stenosis of ectatic coronaries. We review our experience with self-expanding stents for different clinical and angiographic indications, with long clinical follow-up. From 2011 to 2013 we used self-expanding STENTYS® stents in 40 consecutive patients followed-up for death from any cause and from cardiovascular cause, myocardial infarction, target lesion revascularization (TLR), stent thrombosis (mean 21±13months). We also revised rate of procedural outcomes, acute stent thrombosis and TLR in patients treated with conventional stents for similar clinical/angiographic situations, in the same period at our institution. We identified three anatomical settings of STENTYS® use: coronary bifurcations with proximal/distal main branch diameter discrepancy (55% of cases), massive thrombotic burden in the setting of acute coronary syndrome (35% of cases) and stenosis of ectatic coronaries (15%). We observed one death related to acute heart failure and 1 case (2.5%) of acute stent thrombosis (2.5% in the control group). During follow-up 2 cases of stent restenosis leading to TLR (5%) occurred (6.25% in the control group). According to our real life experience, self-expanding STENTYS® stents appear to be an effective tool for different angiographic situations in which they may be preferable to balloon-expandable stents, showing a low rate of complications and good results at long term follow-up.

ST-segment elevation in lead aVR in the setting of acute coronary syndrome

Objectives The purpose of our study was to assess the value of aVR ST-segment elevation (STE) during acute non ST-segment elevation myocardial infarction (NSTEMI) or unstable angina. Background STE in lead aVR has been associated with severe coronary lesions in patients with acute coronary syndromes. However, there are conflicting data regarding the prognostic significance of this finding.Methods We evaluated the initial electrocardiogram (ECG) in 129 patients admitted to our hospital with acute NSTEMI or unstable angina without STE in leads other than aVR or V1. STE in aVR lead was measured and echocardiography and coronary angiography were performed within 48-72 hours after hospitalization. Results Overall, 40.3% (52 patients) had more than 0.05 mv STE in lead aVR. These patients had an increased prevalence of ST ≥ 1 mm in lead V1, a more frequent and extensive ST-segment depression (STD) in other leads, a higher prevalence of anterior and lateral STD and a lower frequency of isolated negative T waves. It was also strongly associated with cardiac enzyme rising and a trend toward higher 3-month mortality. Furthermore, patients with STE in lead aVR were more likely to have three-vessel or multivessel disease, higher Gensini score of the coronary arteries, lower left ventricular ejection fraction (LVEF) and higher incidence of mitral regurgitation (MR).Conclusions Our study showed that among ECG markers, the sole criterion STE in lead aVR was independently associated with atherosclerosis severity and decreased LVEF. Also, it was significantly associated with the presence of MR.

Plasma-derived and synthetic high-density lipoprotein inhibit tissue factor in endothelial cells and monocytes.

HDL (high-density lipoproteins) exert anti-thrombotic activities by preventing platelet adhesion and activation and by stimulating the protein C pathway and fibrinolysis. The aim of the present study was to assess the effect of plasma-derived and synthetic HDL on endothelial and monocyte expression of TF (tissue factor), the primary initiator of coagulation. HDL inhibited TF expression and activity in stimulated endothelial cells and monocytes in a dose-dependent way. Synthetic HDL fully retain the ability to inhibit TF expression in a dose-dependent manner; lipid-free apoA-I (apolipoprotein A-I) was not effective and neither was sphingosine 1-phosphate involved. HDL-mediated TF inhibition was due to a modulation of cellular cholesterol content through the interaction with SR-BI (scavenger receptor BI); downstream, HDL inhibited the activation of p38 MAPK (mitogen-activated protein kinase) and the repression of the PI3K (phosphoinositide 3-kinase) pathway responsible for TF expression. In vivo, human apoA-I-transgenic mice displayed a reduced aortic TF expression compared with wild-type animals and TF plasma levels were increased in subjects with low HDL-C (HDL-cholesterol) levels compared with high HDL-C subjects. Thus the anti-thrombotic activity of HDL could also be mediated by the inhibition of TF expression and activity in endothelial cells and monocytes; synthetic HDL retain the inhibitory activity of plasma-derived HDL, supporting the hypothesis that synthetic HDL infusion may be beneficial in the setting of acute coronary syndrome.

Elevated serum fibrinogen levels and risk of contrast-induced acute kidney injury in patients undergoing a percutaneous coronary intervention for the treatment of acute coronary syndrome.

Contrast-induced acute kidney injury (CI-AKI) is a common complication of diagnostic and therapeutic catheterizations, especially in the setting of acute coronary syndrome (ACS). Fibrinogen is a well-known cardiovascular risk factor. We evaluated whether serum fibrinogen level is associated independently with CI-AKI in patients with ACS who underwent a percutaneous coronary intervention (PCI). Patients (n=710, aged 61 ± 13, 69% men) were classified into two groups: CI-AKI and non-CI-AKI. CI-AKI was defined as an increase of at least 0.5 mg/dl or at least 25% in the serum creatinine level within 72 h following PCI. CI-AKI occurred in 75 (10.6%) patients. We found significantly higher serum fibrinogen levels in patients who developed CI-AKI than in those who did not (498 ± 152 vs. 386 ± 96 mg/dl, P<0.001). Multivariate logistic regression analysis showed that serum fibrinogen level (odds ratio 1.006, 95% confidence interval 1.003-1.009, P<0.001), age, glomerular filtration rate, female sex, and white blood cell count were correlated with the development of CI-AKI. Serum fibrinogen level is associated independently with a higher risk of CI-AKI in patients with ACS undergoing PCI.

The evolution of dual antiplatelet therapy in the setting of acute coronary syndrome: ticagrelor versus clopidogrel

ABSTRACTReview of: Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Eng J Med 2009; 361(11): 1045–1057.For acute coronary syndrome (ACS), a dual antiplatelet regimen comprised of treatment with aspirin and either P2Y12 adenosine diphosphate receptor antagonists, clopidogrel, prasugrel or ticagrelor is usually employed. This article compares clopidogrel with ticagrelor for the prevention of vascular events and death in broad population of ACS patients ranging from UA, NSTEMI to STEMI, utilizing planned strategies of medical or invasive treatment strategy.

Acute high-density lipoprotein therapies.

Increasing interest has focused on the strategies that target the atheroprotective properties of HDL in order to reduce cardiovascular risk. The potential impact of strategies to acutely promote HDL functionality will be reviewed. Population and animal studies suggest that HDLs have a protective impact on atherosclerotic plaque. However, the failure of recent clinical trials of HDL cholesterol-raising agents has raised concerns that this may not be a viable strategy to reduce cardiovascular risk. Increasing attention has highlighted the importance of the functional quality, as opposed to quantity, of HDL with evidence of impaired HDL function in the setting of acute coronary syndromes (ACSs). The finding that infusing HDL in patients with recent acute ischemic events promotes the rapid regression of coronary atherosclerosis suggests a potentially useful strategy for ACS patients, although this remains to be fully established in large clinical outcome trials. Infusing HDL has favorable effects on coronary atherosclerosis in ACS patients, suggesting a potentially beneficial therapeutic strategy to acutely promote HDL functionality.

Abstract 12850: Complex Lesion Characteristics Would be the Potential Risk Factors for Ventricular Fibrillation With Acute Coronary Syndrome

Background: In the setting of acute coronary syndrome (ACS), ventricular fibrillation (VF) was serious and fatal complication. However, even though ischemia was well known as the risk for occurrence of VF, what influential factors of ACS patients related to VF were still unclear. We performed extracorporeal cardiopulmonary resuscitation for VF with ACS patients taken to our institute and performed coronary angiography to make definite diagnosis. Accordingly, We sought to the risk factors for VF with ACS. Methods: Consecutive 246 ACS patients hospitalized and underwent emergent coronary revascularization from September 2010 to September 2014 were enrolled. In these, patients with VF were categorized into VF group, and patients without VF were into non-VF group. We reviewed patients’ characteristics, including medications, past histories and laboratory findings, and CAG findings (lesion characteristics with ACC/AHA classification, number of disease vessels, existence of chronic total occlusion (CTO) and left-main coronary artery (LMCA) lesion) retrospectively. Results: Fifty-seven patients developed ACS with VF (VF group), and 189 patients were without VF (non-VF group). Comparing between the groups, the morbidity of previous angina pectoris or coronary artery bypass grafting were significantly higher in VF groups (32.1%-16.0%, p=0.01, 14.3%-1.1%, p&lt;0.001, respectively). The prevalence of Complex lesion characteristics, such as multi vessel disease, CTO and LMCA lesion, was also higher in VF group (71.9%-42.8%, 43.9%-13.9%, 15.8%-6.3%, all p &lt; 0.025, retrospectively). Moreover, multiple logistic regression analysis revealed multi vessel disease and existence of CTO lesion were independent factors for VF. Conclusion: VF group had more complex characteristics of coronary artery disease. Complex lesion characteristics, such as multi vessel disease, CTO and LMCA lesion, would be potential risk factors of VF with ACS patients.

Impact of Nonalcoholic Fatty Liver Disease on Myocardial Perfusion in Nondiabetic Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Limited data exist on the role of nonalcoholic fatty liver disease (FLD) as a potential independent risk factor in the setting of acute coronary syndromes. The aim of this study was to evaluate the impact of FLD on myocardial perfusion and inhospital major adverse cardiac events (MACE) in the setting of ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We examined 186 consecutive nondiabetic patients (mean age 58 ± 11 years and 76% men) who underwent primary PCI for STEMI by ultrasound within 72 hours of admission. FLD was graded according to a semiquantitative severity score as mild (score <3) or moderate to severe (score ≥3). Myocardial perfusion was determined by measuring myocardial blush grade (MBG) and ST-segment resolution (STR) analysis. Patients were divided into 2 groups according to FLD score (<3 or ≥3). There were no differences with regard to postprocedural Thrombolysis In Myocardial Infarction 3 flow grade between the 2 groups (89% vs 83%, p = 0.201). Patients with FLD score ≥3 were more likely to have absent myocardial perfusion (MBG 0/1, 37% vs 12%, p <0.0001), absent STR (27% vs 9%, p = 0.001), and higher inhospital MACE rate (31% vs 8%, p <0.0001). By multivariate analysis, FLD ≥3 score was found to be an independent predictor of absent MBG 0/1 (odds ratio [OR] 2.856, 95% confidence interval [CI] 1.214 to 6.225, p = 0.033), absent STR (OR 2.862, 95% CI 1.242 to 6.342, p = 0.031), and inhospital MACE (OR 2.454, 95% CI 1.072 to 4.872, p = 0.048). In conclusion, we found that despite similar high rates of Thrombolysis In Myocardial Infarction 3 after primary PCI, patients with FLD score ≥3 are more likely to have impaired myocardial perfusion which may contribute to adverse inhospital outcome.

REAL-WORLD CLINICAL OUTCOMES ACCORDING TO DUAL ANTI-PLATELET THERAPY REGIMEN AMONG PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: SINGLE CENTER EXPERIENCE IN CANADA

Newer anti-P2Y12 inhibitors (i.e. ticagrelor and prasugrel) have demonstrated superiority over clopidogrel in the setting of acute coronary syndromes (ACS) in randomized controlled trials. However such results have not been reported in routine clinical practice. Data were systematically and prospectively collected in our institutional interventional database between April 1st 2013 and March 30th 2014. We analyzed in-hospital outcomes of patients undergoing PCI on the basis of different dual anti-platelet therapy (DAPT) regimens consisting in clopidogrel versus ticagrelor or prasugrel in addition to aspirin. Over the study period, 1835 patients were included: 333 were treated with BVS, 1009 with DES and 490 with BMS. In addition to aspirin, patients were pre-treated with clopidogrel in 65% of the cases and ticagrelor or prasugrel in 35%. In-hospital MACE (death, myocardial infarction or urgent PCI) occurred in 1.2% of the patients on ticagrelor or prasugrel and in 3.0% of the patients on clopidogrel (HR=2.49; 95% CI [1.1-5.7]; p=0.03). Sub-group analysis of patients with ACS showed also a significantly lower incidence of MACE in patients pre-treated with ticagrelor of prasugrel (HR=2.54; 95% CI [1-6,3]; p=0.049) When considering only patients treated with drug-eluting devices (i.e. BVS or metallic DES) and after logistic regression modeling, treatment with ticagrelor or prasugrel versus clopidogrel was independently associated with a lower incidence of in-hospital MACE (HR=3.29 [1.25-8.66]; p=0.016). There was no significant correlation between the type of drug eluting device used and the incidence of MACE. In this contemporary, real-world all-comer patient population treated with PCI, using multiple types of stents in a real-life context; DAPT regimen with ticagrelor or prasugrel pre-treatment in addition to aspirin was associated with a significantly lower incidence of in-hospital MACE among patients undergoing PCI as compared with clopidogrel.

Ticagrelor-induced dyspnoea

Background Ticagrelor, a reversible P2Y12 receptor antagonist, is superior to clopidogrel in decreasing major adverse cardiac events in the setting of acute coronary syndrome. However, a high rate of drug discontinuation secondary to ticagrelor-induced dyspnoea has been observed. Clinical details This is a case of persistent and intolerable ticagrelor-induced dyspnoea in a patient requiring drug discontinuation. A review of the literature on the plausible mechanisms is also provided. Conclusion Dyspnoea is a relatively common side effect of ticagrelor, usually mild and not associated with alteration in pulmonary function. However, in cases of persistent and intolerable dyspnoea, drug discontinuation should be considered. It is imperative that healthcare professionals regularly monitor patients receiving ticagrelor therapy with the aims of maintaining medication adherence and providing appropriate alternatives if dyspnoea becomes intolerable.

Aspirin dosing in cardiovascular disease prevention and management: an update.

Aspirin has been in use for prevention and management of cardiovascular diseases for several decades. Clinical and epidemiological literature suggests that while net benefits of aspirin in primary prevention of CVDs are less clear, the benefits of aspirin in acute scenarios and secondary prevention settings are well established. However, its optimum dosing requirements have been up for debate especially in various settings of acute coronary syndrome and stable ischemic heart disease. The role of clinician in stratifying individual risk score to achieve net clinical benefit is an important determinant of initiating aspirin therapy. The purpose of this article is to review association of aspirin and CVD in general, and to review its dosing regimens in acute settings as well as primary and secondary prevention as suggested by various established guidelines. We also aim to provide the readers an update on recent changes and current evidence based practice trends.

Dual antiplatelet therapy use by Canadian cardiac surgeons

BackgroundDual antiplatelet therapy is the cornerstone treatment for patients with acute coronary syndrome. Recent Canadian Guidelines recommend the use of dual antiplatelet therapy for 1 year after coronary artery bypass grafting in patients with acute coronary syndrome, but considerable variability remains. MethodsWe performed a survey of 75 Canadian cardiac surgeons to assess the use of dual antiplatelet therapy. ResultsWhereas 58.6% of respondents indicated that the benefits of dual antiplatelet therapy were seen irrespective of how patients were managed after acute coronary syndrome, 36.2% believed that the benefits of dual antiplatelet therapy were limited to those treated medically or percutaneously. In regard to the timing of dual antiplatelet therapy administration, 57% of respondents indicated that dual antiplatelet therapy should be given upstream in the emergency department, whereas 36.2% responded that dual antiplatelet therapy should be given only once the coronary anatomy has been defined. The majority surveyed (81%) weighed bleeding risk as being more important than ischemic risk reduction. In stable patients after acute coronary syndrome, the majority of surgeons would wait approximately 4 days after the last dose of P2Y12 antagonist before coronary artery bypass grafting. Only 44.6% indicated that they routinely use dual antiplatelet therapy postrevascularization in the setting of acute coronary syndrome. Rather, most surgeons use dual antiplatelet therapy for select patients, such as those with a stented vessel without a bypass graft, endarterectomy, or off-pump coronary artery bypass grafting. ConclusionsCardiac surgeons exhibit variation in their attitudes and practice patterns toward dual antiplatelet therapy after coronary artery bypass grafting, and in approximately half of cases, their practice does not adhere to current guideline recommendations. New trials focusing on coronary artery bypass grafting cases in their primary analysis and educational initiatives for surgeons that focus on guideline recommendations may be warranted.

Beyond FAMOUS-NSTEMI

Fractional flow reserve (FFR) is a well-established method of assessing haemodynamically significant coronary artery stenoses that has demonstrated improved outcomes when used to guide revascularization decisions in patients with stable coronary artery disease. However, the role of FFR in the setting of acute coronary syndrome (ACS) remains uncertain. The recently published FAMOUS-NSTEMI trial was a pilot study that demonstrated the safety of routine FFR in ACS patients as well as its impact upon refining management decisions in patients with stenoses of varying severity in nonculprit arteries. The goal of this review is to summarize the current literature of the utility of FFR in the ACS population and highlight the role that the results of FAMOUS-NSTEMI may have on future study and management in this area.

Old and New Drugs for Treatment of Stable Angina: New Anti-Anginal Drugs and Coronary Revascularization.

Since the first human catheterization performed by Forssman in 1929 angioplasty equipment and medical therapies have undergone considerable evolution and technical improvement allowing interventionalists to perform more complex procedures and solving most of the percutaneous limitations. While percutaneous coronary intervention (PCI) has dramatically changed the outcome in the Acute Coronary Syndrome (ACS) setting, its role in the treatment of chronic stable angina is still debated. Stable coronary artery disease (SCAD) is a major public health issue and its prevalence is still increasing in the industrialized world. The correct treatment sees a multi-strategy approach aimed to a relief of symptoms, prevention of future cardiac events and survival improvement. In so forth, treatment strategies include optimal medical therapy (OMT) alone or combined with percutaneous or surgical coronary revascularization. Despite this, angina remains poorly controlled in the vast majority of CAD patients. Traditional agents such Beta-blockers or Calcium channel blockers or short and long acting nitrates have been used as first-line anti-anginal therapy for several years. Nowadays newer and more effective drugs usually used on top of older medical treatment have become available.

Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome

BackgroundSYNTAX score II (SS II) integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality. AimsWe sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes (ACS) population with severe coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). MethodsFrom August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 (13.6%) showed severe CAD (three-vessel disease and/or left main involvement). Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization. ResultsThe median SS II was 29 (range, 14–59). Overall, MACCE occurred in 25% of patients (cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%). The 1-year MACCE-free survival was significantly lower in patients with SS (⩾29), than in those with SS II (<29) (64.2% vs. 87.2%, respectively; p=0.007). In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval (CI): 1.02–5.85; p=0.031] and SS II ⩾29 (hazard ratio 2.74, 95% CI: 1.30–8.21; p=0.011) were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 (95% CI: 0.58–0.81). For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 (p=0.09). ConclusionSS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI.

Women with Rheumatoid Arthritis: The Unspoken Risk Factor

Women with Rheumatoid Arthritis: The Unspoken Risk Factor

The Utility of Systolic and Diastolic Echocardiographic Parameters for Predicting Coronary Artery Disease Burden as Defined by the SYNTAX Score.

Early identification of high-grade ischemia based on echocardiographic diastolic abnormalities may be clinically useful in the acute coronary syndrome (ACS) setting. This could provide the clinician with an awareness of the burden of coronary artery disease (CAD) before angiography is performed to allow for early intervention of suspected ischemic lesions. The objective of the study was to assess whether 2D transthoracic echocardiography (TTE)-derived tissue Doppler imaging parameters can predict the severity of CAD in comparison with the cardiac catheterization-derived SYNTAX score. A retrospective study of 74 stable angina or patients with ACS was performed in 2012 at a single tertiary care center. In all study subjects, TTE and angiography were performed within 6 months of each other without revascularization in the interim. The study population included a total of 74 patients (mean age 67 ± 12 years) with 77% presenting with an ACS. The median SYNTAX score was 24.0 (6.0-35.0). The E-wave velocity was higher, and deceleration time (DT) was lower in the high SYNTAX group in comparison with the low/intermediate SYNTAX group (P = 0.045 and P = 0.001, respectively). Septal mitral annular S' was lower in the high SYNTAX group (P = 0.02). After multivariate analysis, E/A ratio (OR 0.03, 95% 0.00-0.36, P = 0.0067), DT (OR 0.93, 95% CI 0.89-0.97, P = 0.0001) and septal annular S'-wave velocity (OR 0.34, 95% CI 0.16-0.71, P = 0.0038) remained strong predictors of a high SYNTAX score. Early identification of systolic and diastolic dysfunction based on echocardiographic parameters may be of important clinical significance for predicting CAD burden prior to invasive angiography.

Cost Effectiveness of Antiplatelet and Antithrombotic Therapy in the Setting of Acute Coronary Syndrome: Current Perspective and Literature Review.

Acute coronary syndromes (ACS) are associated with high rates of morbidity and mortality. The advances of antiplatelet and anticoagulation therapy over several years time have resulted in improved in cardiac outcomes, but with increased health care costs. Multiple cost-effectiveness studies have been performed to evaluate the use of available antiplatelet agents and anticoagulation in the setting of both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Early on, the use of glycoprotein IIb/IIIa receptor inhibitors (GPIs) proved to be economically attractive in the management of ACS; however, the introduction of P2Y12 receptor antagonists limited their use to a bail out agents in complex interventions. Generic clopidogrel is probably still an economically attractive P2Y12 receptor antagonist choice, especially in low-risk ACS, while both ticagrelor and prasugrel present an economically attractive alternative option, especially in high-risk ACS and patients at risk for stent thrombosis. While enoxaparin presents an economically dominant alternative to heparin in NSTE-ACS, its role in STEMI in the contemporary era is unclear. During percutaneous coronary intervention (PCI), bivalirudin monotherapy was shown to be an economically dominant alternative to the combination of heparin and GPI in ACS. However, new studies may suggest that using heparin monotherapy may offer an attractive alternative. The comparative and cost effectiveness of different combinations of antiplatelet and antithrombotic therapy will be the focus of future expected clinical and economic assessments.

Peripheral frequency of CD4+ CD28- cells in acute ischemic stroke: relationship with stroke subtype and severity markers.

CD4+ CD28− T cells also called CD28 null cells have been reported as increased in the clinical setting of acute coronary syndrome. Only 2 studies previously analyzed peripheral frequency of CD28 null cells in subjects with acute ischemic stroke but, to our knowledge, peripheral frequency of CD28 null cells in each TOAST subtype of ischemic stroke has never been evaluated. We hypothesized that CD4+ cells and, in particular, the CD28 null cell subset could show a different degree of peripheral percentage in subjects with acute ischemic stroke in relation to clinical subtype and severity of ischemic stroke.The aim of our study was to analyze peripheral frequency of CD28 null cells in subjects with acute ischemic stroke in relation to TOAST diagnostic subtype, and to evaluate their relationship with scores of clinical severity of acute ischemic stroke, and their predictive role in the diagnosis of acute ischemic stroke and diagnostic subtypeWe enrolled 98 consecutive subjects admitted to our recruitment wards with a diagnosis of ischemic stroke. As controls we enrolled 66 hospitalized patients without a diagnosis of acute ischemic stroke. Peripheral frequency of CD4+ and CD28 null cells has been evaluated with a FACS Calibur flow cytometer.Subjects with acute ischemic stroke had a significantly higher peripheral frequency of CD4+ cells and CD28 null cells compared to control subjects without acute ischemic stroke. Subjects with cardioembolic stroke had a significantly higher peripheral frequency of CD4+ cells and CD28 null cells compared to subjects with other TOAST subtypes. We observed a significant relationship between CD28 null cells peripheral percentage and Scandinavian Stroke Scale and NIHSS scores. ROC curve analysis showed that CD28 null cell percentage may be useful to differentiate between stroke subtypes.These findings seem suggest a possible role for a T-cell component also in acute ischemic stroke clinical setting showing a different peripheral frequency of CD28 null cells in relation of each TOAST subtype of stroke.

Subacute thrombosis after primary percutaneous coronary intervention with bioresorbable vascular scaffold implantation

Everolimus-eluting bioresorbable vascular scaffold (BVS) is a promising new technology recently applied in the treatment of coronary artery lesions that might overcome the limitations of the currently used drug eluting stents. There were no scaffold thromboses reported in the first-in-human trials with BVS implantation. However, the current body of evidence on its safety and incidence of early thrombotic complications in the setting of acute coronary syndromes is still limited. We present the case of a 58-year-old male who was admitted to a coronary care unit due to typical (two-hour long) chest pain with electrocardiographic signs of anterior wall ST segment-elevation myocardial infarction. Coronary angiography revealed critical stenosis of the proximal left anterior descending artery (Fig. 1A). Subsequent primary angioplasty with manual aspiration thrombectomy, balloon predilatation, and implantation of BVS (ABSORB, 3.5/28 mm, 12 atm.) was performed, with good angiographic result (TIMI 3 flow) (Fig. 1B). Optical coherence tomography (OCT) confirmed good scaffold expansion and complete strut apposition (Fig. 1C–F). Further in-hospital course was uneventful and the patient was discharged after five days of hospitalisation. On the ninth day after BVS implantation he presented again with acute severe chest pain and anterior ST-segment elevation in electrocardiogram. The patient confirmed that he discontinued both antiplatelet drugs (aspirin and clopidogrel) after discharge. Repeat coronary angiography revealed a subacute scaffold thrombosis (Fig. 2A). Manual aspiration thrombectomy, abciximab infusion, and plain old balloon angioplasty was performed (Fig. 2B), with good final angiographic result (TIMI 3) (Fig. 2C). Echocardiography revealed an impaired left ventricular ejection fraction of 38%, compared to 50% directly after the primary index procedure. As there was appropriate scaffold expansion and strut apposition in OCT directly after the index procedure, the most likely cause of scaffold thrombosis was the cessation of antiplatelet therapy. Figure 2. A. Occlusion of the proximal left anterior descending artery in the place of bioresorbable vascular scaffold implantation (arrow); B. Plain old balloon angioplasty performed in the occluded left anterior descending artery; C. Good final angiographic result of the treatment of scaffold thrombosis (TIMI 3) Figure 1. A. Coronary angiography revealing critical stenosis of the proximal left anterior descending artery (arrow); B. Good angiographic result of primary angioplasty with bioresorbable vascular scaffold implantation (TIMI 3); C–F. Good scaffold expansion and complete strut apposition in optical coherence tomography A