Symptomatic Coronary Disease Research Articles

Cardioesophageal Reflex. Should it trigger clinician's response?

Cardiologists and gastroenterologists often encounter the coexistence of symptoms and functional abnormalities, but determining causation is more difficult.​​ In 1962 Smith and Papp first coined the term "linked angina". Their statement was preceded by the experiment whereby increase in bile duct pressure elicited the typical chest pain in patients with ischemic heart disease.​ It was demonstrated that dysphagia can be associated with ventricular arrhythmia suggestive of possible cardioesophageal reflex involvement. A potential association between gastroesophageal reflux disease and atrial fibrillation development has been proposed due to the close anatomic vicinity of the esophagus and the left atrium. It has been demonstrated that the patients suffering from prolonged gastro-esophageal acid reflux episodes and coronary spasm may be at higher risk for the development of linked-angina and acute myocardial infarction.​ We believe cardioesophageal reflex is a probable mediator of the linked angina. We recommend early treatment of gastroesophageal disorders in patients with symptomatic coronary arterial disease to alleviate the associated ischemic and arrhythmic burden.

CYP2C19 loss-of-function alleles and use of omeprazole or esomeprazole increase the risk of cardiovascular outcomes in patients using clopidogrel.

Our aim was to investigate in a real-life prospective patient cohort how CYP2C19 loss-of-function (LOF) variants and CYP2C19 inhibitor omeprazole or esomeprazole influence the incidence of cardiovascular events in patients using clopidogrel. Data based simultaneously on these factors are conflicting and sparse. A cohort of prospective patients (n = 1972) with acute coronary syndrome (n = 1302) or symptomatic chronic coronary disease (n = 656) was followed for 365 days after hospitalization with information on purchased prescription drugs, hospital discharge, death, and genotype for CYP2C19*2, CYP2C19*3, and CYP2C19*8 LOF variants. The primary study outcome measurement was cardiovascular death or recurring myocardial infarction or stroke. Altogether, 608 patients (30.8%) carried CYP2C19 LOF alleles. During the 365-day follow-up 252 patients (12.8%) had an ischemic vascular event. Cardiovascular events were significantly more frequent in carriers of CYP2C19 LOF alleles (14.8%, 95% confidence interval [CI], 11.7-17.8) than in non-carriers (10.8%, 95% CI, 9.0-12.6, p = 0.0159). Omeprazole or esomeprazole use was similar among LOF allele carriers (n = 131, 21.5%) and non-carriers (n = 250, 18.3%, p = 0.185). Cardiovascular events were significantly more common in a composite group consisting of all CYP2C19 LOF carriers regardless of proton pump inhibitor use status and non-carriers using omeprazole or esomeprazole than in non-carriers not using omeprazole or esomeprazole (14.8%, 95% CI, 12.2-17.3 vs. 9.9%, 95% CI, 8.0-11.9, p = 0.00173). We observed significantly more cardiovascular events in carriers of CYP2C19 LOF variants and in non-carriers using omeprazole or esomeprazole. For optimal patient care, both genetics and concomitant medication should be considered.

Long-term analysis of ventricular function in patients with symptomatic coronary disease who underwent on-pump or off-pump coronary artery bypass grafting

BackgroundSystemic deleterious effects of cardiopulmonary bypass have been observed in the postprocedural period. Long-term assessment, including ventricular function (VF), is unclear. The objective of this study was to compare the change of left ventricular ejection fractions (LVEFs) during a long-term follow-up of coronary artery disease (CAD) patients who underwent off-pump (OPCAB) or on-pump coronary artery bypass grafting (ONCAB).MethodsThis study is a prespecified analysis of the MASS III trial, which was a single-center and prospective study that enrolled stable CAD patients with preserved VF. The CAD patients in our study were randomized to OPCAB or ONCAB. A transthoracic echocardiogram was performed during follow-up and a LVEF value was obtained. The primary endpoint was the difference between the final LVEF and the baseline LVEF.ResultsOf the 308 randomized patients, ventricular function were observed in 225 over a mean of 5.9 years of follow-up: 113 in the ONCAB group and 112 in the OPCAB group. Baseline characteristics were similar between the two groups, but there was a larger proportion of subjects with 3-vessel disease in the ONCAB group. There was no difference in the LVEF at the beginning (P = 0.08), but there was a slight decrease in the LVEF in the ONCAB and OPCAB groups (P < 0.001 in both groups) at 5.9 years. The decline was not significantly different between the two groups (delta of -6% for ONCAB and -5% for OPCAB; P = 0.78). In a multivariate analysis, myocardial infarction in the follow-up was a predictor of an LVEF < 40%.ConclusionsThere was no difference in the long-term development of ventricular function between the surgical techniques, despite a decline in the LVEF in both groups.Trial registration Clinical Trial Registration Information—URL: http://www.controlled-trials.com. Registration number: ISRCTN59539154. Date of first registration: 10/03/2008.

CYP2C19 loss-of-function alleles and the use of omeprazole or esomeprazole increase the risk of cardiovascular outcomes in patients using clopidogrel – a real-world study

Abstract Background Patients carrying loss-of-function (LOF) variants of CYP2C19 or using the CYP2C19-inhibitors omeprazole or esomeprazole cannot fully bioactivate clopidogrel, and thus are lacking optimal thrombosis prevention. However, clopidogrel is a relevant alternative to ticagrelor due to its lower incidence of hemorrhagic events and lower cost. Purpose The purpose of this study was to investigate in a real-life prospective patient cohort how loss-of-function (LOF) CYP2C19 variants and omeprazole or esomeprazole influence the incidence of cardiovascular events (cardiovascular deaths, reinfarction and strokes) in patients using clopidogrel. Methods A cohort of prospective patients (N=1972) with acute coronary syndrome (ACS) (N=1302) or symptomatic chronic coronary disease (N=670) were followed for 365 days. Information of purchased prescription drugs, hospital discharge, and death registry was available for all patients. The patients were retrospectively genotyped for the CYP2C19*2, CYP2C19*3, and CYP2C19*8 LOF variants. Results A total of 608 (30.8%) patients carried CYP2C19 LOF alleles. During the 365 days follow-up, 252 patients had a recurring ischemic vascular event, either myocardial infarction (N=189), stroke (N=24) or cardiovascular death (N=39). Vascular events were significantly more frequent among carriers of CYP2C19 LOF alleles [14.8% (95% CI 11.7–17.8] than in non-carriers [10.8% (95% CI 9.0–12.6)], p=0.016. Omeprazole or esomeprazole use was similar among the LOF allele carriers and non-carriers, but inclusion of their use in the analysis strengthened the association. Vascular events were significantly more common in a composite group of carriers of CYP2C19 LOF alleles and non-carriers who were using omeprazole or esomeprazole than in non-carriers who were not using omeprazole or esomeprazole 14.8% (95% CI 12.2–17.3) vs 9.9% (95% CI 8.0–11.9) p=0.002. There was a tendency towards lower risk of hemorrhagic complications in carriers of LOF alleles than in non-carriers (p=0.07). Conclusions Patients with impaired clopidogrel bioactivation due to loss-of-function CYP2C19 variants or concomitant omeprazole or esomeprazole use are at increased risk of cardiovascular events. For relevant patient care both genetics and concomitant medication should be considered both in everyday patient care and further randomised studies. Funding Acknowledgement Type of funding sources: None.

IDF21-0196 Study of peripheral arterial disease among type 2 diabetes mellitus patients

Background: Diabetes is a complex chronic metabolic disorder, characterized by persistent hyperglycemia because of lack of insulin secretion, insulin resistance, or both. Peripheral arterial disease (PAD) is one of the major recognised diabetic macro vascular complications. It is a marker of generalised systemic atherosclerosis and is closely associated with symptomatic coronary and cerebrovascular disease, hence significant morbidity and mortality. Aim: To study the various risk factors contributing to development of peripheral arterial disease in adult type2 diabetic patients and vasculopathy profile. Method: This was a retrospective analytical descriptive study conducted at internal medicine department on 13 months. Forty-seven type 2 diabetic patients were included. All patients underwent a detailed history which included age, gender, smoking intake, history of diabetes mellitus with duration and treatment. Biochemical characteristics were studied. Diagnosis of PAD was made by using color Doppler ultrasound. The statistical analysis was carried out using Epi-Info7. Results: The study was conducted on 47type2 diabetic patients with a mean age of 66±10 years with male predominance (77%) compared to females (23%). Mean duration of diabetes mellitus was15±9 years. Majority of patients were on insulin (n=22;46.81%). Eleven patients (23.40%) were on combined insulin and OHA. and ten were on oral hypoglycemic agents (OHA) (21.28%). Sixteen (34%) patients were cigarette smokers. Regarding hypertension status, 24 (51.06%) patients were hypertensive. Metabolic syndrome was prevalent in twenty patients, with mean of BMI 25±5 kg/m2. PAD was prevalent in 38(80.85%) patients. Of these, there were 27(57.45%) obliterating arteriopathy of the lower limbs,20(42.55 %) had mediacalcinosis, 10 (21.28 %) had acute arterial occlusion, 8 (17.02%) stenosis, and 2(4.26 %) arterial thrombosis. The prevalence of neuropathy was 46.81% (n=22) and diabetic foot was present in all patients (n=47) of patients. Regarding biochemical parameters: mean of fasting blood glucose was 1.73±0.76g/l, mean of post prandial blood glucose 2.45±0.77g/l, mean of HBA1C 9±3%, mean of HDLc 0.32±0.14 g/l, mean of triglycerides1.56±1.29g/l, mean of creatinine clearance according MDRD equation was 69±41 ml/min/1.73m2, mean of protein C reactive in this population was 88±80mg/l. Discussion: The increasing burden of diabetes is considered as one of the greatest global public health problem of our time. Diabetic patients with PAD are at high risk of increased morbidity and mortality from cardiovascular diseases and a high rate of lower extremity amputation. Various risk factors like age, gender persistant hyperglycemia, increased glycated hemoglobin, smoking and hypertension, and dyslipidaemia are associated with an increased risk of peripheral artery disease. This study documents a high prevalence of PAD among adult type2 diabetic patients. This strongly calls for aggressive screening for PAD be emphasised.

Kidney Replacement Therapy for Patients Requiring Cardiopulmonary Bypass Support during Cardiac Surgery.

Kidney Replacement Therapy for Patients Requiring Cardiopulmonary Bypass Support during Cardiac Surgery.

Performance and limitations of automated ECG interpretation statements in patients with suspected acute coronary syndrome

BackgroundThe 12‑lead ECG plays an important role in triaging patients with symptomatic coronary artery disease, making automated ECG interpretation statements of “Acute MI” or “Acute Ischemia” crucial, especially during prehospital transport when access to physician interpretation of the ECG is limited. However, it remains unknown how automated interpretation statements correspond to adjudicated clinical outcomes during hospitalization. We sought to evaluate the diagnostic performance of prehospital automated interpretation statements to four well-defined clinical outcomes of interest: confirmed ST- segment elevation myocardial infarction (STEMI); presence of actionable coronary culprit lesions, myocardial necrosis, or any acute coronary syndrome (ACS). MethodsAn observational cohort study that enrolled consecutive patients with non-traumatic chest pain transported via ambulance. Prehospital ECGs were obtained with the Philips MRX monitor from the medical command center and re-processed using manufacturer-specific diagnostic algorithms to denote the likelihood of >>>Acute MI<<< or >>>Acute Ischemia<<<. Two independent reviewers retrospectively adjudicated the study outcomes and disagreements were resolved by a third reviewer. ResultsOur study included 2400 patients (age 59 ± 16, 47% females, 41% Black), with 190 (8%) patients with documented automated diagnostic statements of acute MI or acute ischemia. The sensitivity/specificity of the automated algorithm for detecting confirmed STEMI (n = 143, 6%); presence of actionable coronary culprit lesions (n = 258, 11%), myocardial necrosis (n = 291, 12%), or any ACS (n = 378, 16%) were 62.9%/95.6%; 37.2%/95.6%; 38.5%/96.4%; and 30.7%/96.3%, respectively. ConclusionAlthough being very specific, automated interpretation statements of acute MI/acute ischemia on prehospital ECGs are not satisfactorily sensitive to exclude symptomatic coronary disease. Patients without these automated interpretation statements should be considered further for significant underlying coronary disease based on the clinical context. Trial registrationClinicalTrials.gov # NCT04237688

Spotlight on the April 27 Issue

#### Notable in Neurology This Week This issue features an article that examines the link between lateropulsion and spatial neglect in patients with acute stroke; another investigates the association between cholinesterase inhibitors and cognitive decline in patients with Alzheimer dementia. A featured Views & Reviews examines the incidence and prevalence of drug-resistant epilepsy. ### Association of White Matter Hyperintensity Markers on MRI and Long-term Risk of Mortality and Ischemic Stroke: The SMART-MR Study In a prospective cohort of patients with symptomatic cerebral, coronary, or peripheral arterial disease or an abdominal aortic aneurysm, the volume, type, and shape of white matter changes seen on brain MRI were associated …

Association between apnea-hypopnea index and coronary artery calcification: a systematic review and meta-analysis

Background The present study aimed to evaluate the association between presence and severity of obstructive sleep apnoea (OSA) and the presence of subclinical coronary artery disease (CAD) as assessed by coronary calcium score. Methods Medline, Cochrane, and Google Scholar databases were searched. The presence of coronary artery calcification (CAC) and CAC score were assessed. Results Irrespective of the cut-off value of apnoea-hypopnea index (AHI) (5 or 15 events/h), patients in the OSA group had higher rate of CAC presence and mean CAC score than those in the control group. Subgroup analyses of patients monitored with home sleep apnoea testing (HSAT) or in-hospital/laboratory polysomnography showed that the OSA group had higher rate of CAC presence and mean CAC score than the control group, except in the comparison of mean CAC score between AHI ≥5 vs. <5 events/h for patients using HSAT, which was not significant. Pair-wise comparison showed that CAC score may increase with increased OSA severity. Conclusions In participants without symptomatic coronary disease, the presence of OSA was associated with the presence and extent of CAC. However, potential confounders such as age, gender, and BMI and the diversity of CAC scores may affect the association.

A Commentary on Concomitant Symptomatic Coronary Disease and Carotid Artery Stenosis -The Tufts Medical Center Experience

A Commentary on Concomitant Symptomatic Coronary Disease and Carotid Artery Stenosis -The Tufts Medical Center Experience

A Commentary on Concomitant Symptomatic Coronary Disease and Carotid Artery Stenosis -The Tufts Medical Center Experience

A Commentary on Concomitant Symptomatic Coronary Disease and Carotid Artery Stenosis -The Tufts Medical Center Experience

The effect of combining coronary bypass with carotid endarterectomy in patients with unrevascularized severe coronary disease

ObjectiveManagement of significant carotid stenosis in those with symptomatic coronary disease remains controversial. Staged and combined carotid endarterectomy (CEA) with coronary artery bypass grafting has been described. Yet, an understanding of the additive risks of these approaches is poor. This study sought to assess outcomes in patients with clinically relevant coronary disease undergoing either isolated CEA (ICEA) or combined CEA and coronary artery bypass (concurrent coronary artery bypass [CCAB]). MethodsAll CEAs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. CCABs were identified, as were ICEAs in patients with unrevascularized stable angina, unstable angina, or myocardial infarction (MI) within 6 months of operation. CCABs were compared with ICEAs as well as with a risk-matched cohort of ICEAs. Primary outcomes included perioperative stroke, all-cause death, MI, and these as composite (SDM). Univariate analysis and logistic regression were performed. ResultsThere were 4042 patients identified, including 2582 ICEA patients (64%) and 1460 CCAB patients (36%); 61% were male, 91% were white, and 39% had symptomatic carotid disease. Overall stroke was 3.5%, death 1.8%, and SDM 6.0%. ICEA had higher rates of postoperative MI (1.9% vs 0.9%; P = .01) but lower rates of stroke (2.8% vs 4.7%; P = .002), death (1.0% vs 3.0%; P < .001), and SDM (5.1% vs 7.5%; P = .002). After regression, predictors of SDM were congestive heart failure (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.3-2.4; P < .001), urgent operation (OR, 1.6; 95% CI, 1.2-2.2; P = .001), and CCAB (OR, 1.3; 95% CI, 1.01-1.7; P = .04). After propensity matching, ICEA continued to have higher rates of perioperative MI (2.6% vs 1.0%; P = .01) and lower rates of death (1.0% vs 3.0%; P = .001). However, there were no longer differences in stroke (3.2% vs 4.6%; P = .10) or SDM (6.3% vs 7.8%; P = .18). Within the matched cohort, predictors of SDM included chronic obstructive pulmonary disease (OR, 1.6; 95% CI, 1.1-2.2; P = .01), congestive heart failure (OR, 1.7; 95% CI, 1.1-2.5; P = .01), and symptomatic carotid disease (OR, 1.5; 95% CI, 1.03-2.1; P = .03). CCAB was not significant (OR, 1.3; 95% CI, 0.9-1.8; P = .18). ConclusionsIn patients with unrevascularized, clinically relevant coronary disease, CCAB reduces operative MI but increases risk of stroke and death. After risk adjustment, MI remains higher in ICEA, but differences in 30-day stroke and SDM between ICEA and CCAB are no longer appreciated. These data suggest that CEA risk undertaken in patients with unrevascularized coronary disease is not inconsequential, and outcomes are similar to those of CCAB.

Refractory In-Stent Restenosis: Improving Outcomes by Standardizing Our Approach.

This review will focus on our approach for the treatment of refractory in-stent restenosis. The discovery of bare metal stents over three decades ago set a milestone in the evolution of percutaneous coronary intervention, which is currently the most widely performed procedure for the treatment of symptomatic coronary disease. However, the broad utilization of stents resulted in the new phenomenon of in-stent restenosis (ISR). Over the years, there has been an increase of the incidence of ISR despite continued improvement of drug-eluting stent (DES) technology. The mechanism of ISR is multifactorial, including biological, mechanical, patient, and operator-related factors. The most common factor is aggressive neointimal proliferation and neoatherosclerosis. ISR presentation is not benign, and treatment is challenging, especially in cases of DES-ISR. We review available therapy modalities for ISR, including medical therapy, scoring balloons, atheroablative therapies, repeat DES, vascular brachytherapy, drug-coated balloons, and coronary artery bypass grafting.

Ranolazine in patients with type 2 diabetes and chronic angina: A cost-effectiveness analysis and assessment of health-related quality-of-life

BackgroundType 2 diabetes (T2D) is associated with a high burden of angina. Ranolazine has been shown to reduce angina frequency versus placebo in patients with T2D and stable angina. We sought to estimate the cost-effectiveness of ranolazine when added to standard-of-care (SoC) versus SoC alone in patients with T2D and stable, but symptomatic coronary disease despite treatment with 1–2 antianginals. MethodsA Markov model was developed and evaluated using cohort simulation. The model utilized a US societal perspective, 1-month cycle length and 1-year time horizon and was developed to estimate the cost-effectiveness of ranolazine versus SoC. Patients entered the model in 1 of 4 angina frequency health states based on baseline Seattle Angina Questionnaire Angina Frequency scores (100 = no; 61–99 = monthly; 31–60 = weekly; 0–30 = daily) and could transition between health states (first cycle only) or to death (any cycle) based on probabilities derived from the Type 2 Diabetes Evaluation of Ranolazine in Subjects with Chronic Stable Angina trial. ResultsOur model estimated patients treated with ranolazine lived a mean of 0.728 quality adjusted life years (QALYs) at a cost of $16,654. Those not receiving ranolazine lived a mean of 0.702 QALYs and incurred costs of $15,476. The incremental cost-effectiveness ratio for the addition of ranolazine to SoC was $45,308/QALY. Short Form-36 data suggest improvements in patients' bodily pain drove the gain in QALYs associated with ranolazine (2.73 versus 3.96, p = 0.01). ConclusionOur model suggests the addition of ranolazine to SoC is likely cost–effective from a US societal perspective for the treatment of patients with T2D and stable, symptomatic coronary disease despite treatment with 1–2 antianginals.

The Effect of Combining Coronary Bypass With Carotid Endarterectomy in Patients With Unrevascularized Severe Coronary Disease

Management of significant carotid stenosis in those with symptomatic coronary disease remains controversial. Staged and combined carotid endarterectomy (CEA) with coronary artery bypass (CAB) has been described. Yet, understanding of the additive risks of these approaches is poor. This study sought to assess outcomes in patients with clinically relevant coronary disease undergoing either isolated CEA (ICEA) or combined CEA and CAB (CCAB). All CEAs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. CCABs were identified, as were ICEAs, in patients with unrevascularized stable angina, unstable angina, or myocardial infarction (MI) within 6 months of operation. CCABs were compared with ICEAs as well as with a risk-matched cohort of ICEAs. Primary outcomes included 30-day stroke, death, and MI and these as composite (SDM). Univariate analysis and logistic regression were performed. There were 4042 patients identified, including 2582 ICEAs (64%) and 1460 CCABs (36%); 61% were male, 91% were white, and 39% had symptomatic carotid disease. Overall, stroke was 1.9%; death, 1.8%; and SDM, 4.9%. ICEAs had higher rates of postoperative MI (1.9% vs 0.9%; P = .01) but lower rates of stroke (1.5% vs 2.7%; P = .01), death (1% vs 3%; P < .001), and SDM (4.1% vs 6.4%; P = .001). After regression, predictors of SDM were congestive heart failure (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3-2.5; P < .001), urgent operation (OR, 1.4; 95% CI, 1.01-2.0; P = .04), and CCAB (OR, 1.4; 95% CI, 1.1-1.9; P = .02). After propensity matching, ICEAs continued to have higher rates of perioperative MI (2.6% vs 1.0%; P = .01) and lower rates of death (1% vs 3%; P = .001). However, there were no longer differences in stroke (2% vs 2.8%; P = .21) or SDM (5.2% vs 6.7%; P = .15). Within the matched cohort, predictors of SDM included chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.2-2.5; P = .01), congestive heart failure (OR, 1.6; 95% CI, 1.05-2.4; P = .03), and symptomatic carotid disease (OR, 1.5; 95% CI, 1.04-2.2; P = .03). CCAB was not significant (OR, 1.3; 95% CI, 0.9-1.9; P = .14). In patients with unrevascularized, clinically relevant coronary disease, CCAB reduces operative MI but increases risk of stroke and death. After risk adjustment, MI remains higher in ICEA, but differences in 30-day stroke and SDM between ICEA and CCAB are no longer appreciated. These data suggest that CCAB is not inferior to staged risk of ICEA followed by coronary revascularization.

Healing score of the Xinsorb scaffold in the treatment of de novo lesions: 6-month imaging outcomes.

The objectives of this study are to assess the healing score (HS) and neointimal thickness of the Xinsorb scaffold, and explore the relationships between the implanted patterns, neointimal thickness, and HS. The Xinsorb bioresorbable sirolimus-eluting scaffold is the first domestically designed and fabricated bioresorbable scaffold in China. The 6-month follow-up found it to be safe and effective in the treatment of single de novo coronary lesions. The Xinsorb scaffolds were implanted in 30 patients with symptomatic ischemic coronary disease. A 6-month follow-up was performed in a subset of 19 patients; the HS and neointimal thickness were evaluated by optical coherence tomography. Struts were classified as ApposedCovered, ApposedUncovered, MalapposedCovered, MalapposedUncovered, jailing and presence of intraluminal masses. The implanted pressure, implanted duration, and post-expansion pressure were recorded during the operation. We evaluated the relationship between the HS or neointimal thickness and the implanted pressure, holding time, and post-expansion pressure. The device and procedure success rates were both 100%. No major adverse cardiac or scaffold-thrombus related events occurred. At 6months, 12,295 struts were analyzed to determine the HS (6.23) and neointimal thickness (0.1021 ± 0.05718mm) in the Xinsorb scaffolds. There was a strong negative relationship between the HS and the implantation duration (Pearson r=-0.518, p = 0.023). A significant negative relationship also existed between the HS and post-dilatation (Pearson r=-0.631, p = 0.004). The Xinsorb scaffold HS appears negative correlated with the implanted duration and post-dilatation. We will further evaluate the HS of randomized controlled trial of the Xissorb scaffold.

THE EFFECT OF DEGREE AND TYPE OF LEFT VENTRICULAR HYPERTROPHY ON VENTRICULAR ARRHYTHMIAS IN HYPERTENSION

Finding the arrythmogenic potential in patients with arterial hypertension as well as its correlation with left ventricular hypertrophy (LVH), and its type and degree. The research included 109 hypertensive patients (pts) (54 male and 55 female), 54.2 ± 7.9 years old without symptomatic coronary disease, myocardial infarction and systolic dysfunction. All the pts had a clinical examination, ECG, 24 h Holter monitoring with Lown classification of ventricular arrhythmias, an echocardiogram with left ventricular mass index (LVMI) and a specific type of LVH. QT interval dispersion (QTd) was calculated on 12 leads standard ECG. 75 pts had LVH (LVMI: 172.6 ± 42.95 g/m2) while 35 pts were without LVH (109.3 ± 15.9 g/m2). Non sustained ventricular tachycardia was registered in 13 pts (17.6%) with LVH and 1 female patient without LVH (2.9%). Patients with VT had a considerably higher ILVM (214.9 ± 6.8 vs. 151.9 ± 47.2 g/m2) than the average and higher QTd (73.7 ± 19.1 vs. 55.2 ± 20.2). VT was registered in 3/19 (15.8%) with eccentric nedilated type LVH, 6/38 (15.8%) with concentric LVH, 1/11 (9.1) (disproportional septal LVH) and 3/5 ( 60%) with dilated LVH. Univariate analysis showed a considerable correlation between the degree of arrhythmias and ILVM (p&lt;0.001) and QTd (p=0.012). Ventricular arrhythmias in patients with arterial hypertension are considerably correlated to the degree of LVH expressed in ILVM and QTd.

Cardiac myxomas: an analysis of 39 patients

Objectives . Myxomas are the most common benign primary heart tumors. They have serious complications including intracardiac blood flow obstruction and embolic events. The aim of the study was to assess our experiences related to patients undergoing surgical resection for cardiac myxomas. Methods. The medical records of 39 patients, aged 16 to 76 years (mean, 47.5 years), who were operated on for primary cardiac myxomas between January 1994 and December 2016 at our clinic were retrospectively evaluated. Demographic, clinical, operative and postoperative data were obtained from these hospital medical records. Cardiac myxomas were diagnosed by transthoracic echocardiography. Preoperative coronary angiography was performed in patients over 40 years of age and those with symptoms of coronary disease. In routine follow-up after discharge the patients were checked by echocardiography. Long-term cumulative survival was analyzed using the Kaplan-Meier method. Results . There was no in-hospital mortality. The majority (61.5%) of patients were female. The most common encountered localization of myxoma was the left atrium (76.9%), and the classic posterior approach from interatrial groove was preferred in 32 (82.1%) patients. Mean follow-up was 6.05 ± 3.75 years (range, 1-10 years). Five (12.8%) patients were lost on long-term follow-up. Kaplan-Meier curves, cumulative proportion surviving of patients at 1-, 2-, 5-, and 10-year were 97.4%, 91.7%, 84.7%, and 84.7%, respectively. No hospital mortality was observed in any of the patients. There was no recurrence in our series. Conclusions . Myxoma is the disease that can lead to complications such as embolic events and intracardiac blood flow obstruction. It can be excised with a low rate of morbidity and mortality. S urgical resection should be performed promptly after diagnosis in order to prevent potential complications.

Abstract WP185: Stroke Pre And Post Cardiac Events; A Predictive Or A Prognostic Factor!

Background: Cerebral and cardiovascular events can occur simultaneously in a given patient or in differential timing. There are no comparative studies on the impact of stroke timing difference on the risk and outcome of coronary events. Objective: To describe the association of cerebrovascular and cardiac events and the impact of the order of occurrence of these events on patients’ outcomes. Design: Retrospective longitudinal cohort study Setting: Single tertiary center from 2010 through 2015 Patients: All patients with who underwent coronary angiogram or had a primary admitting diagnosis of stroke. Methods: The two separate databases were crossed matched to identify patients with both diagnoses, and then temporal relationships were identified on both directions (stroke before or after cardiac event). Cardiac events include any suspected acute coronary events that triggered referral for coronary angiogram. Outcome Measures: A composite of death, recurrent stroke and re-hospitalization within 30 days. Results: Among 6300 cardiac patients and 500 stroke patients, 16 patients were identified with both diagnoses. The mean age was 56.9±18.5 years, and 37.5% were females. The most common vascular risk factors were hypertension (94%) diabetes (81%), atrial fibrillation (25%), and renal impairment (6%). When classified based on stroke timing, a quarter (n=4) of patients had stroke pre cardiac event and 75% (n=12) had stroke post cardiac event. The composite endpoint of death, recurrent stroke and re-hospitalization within 30 days was higher in the stroke pre cardiac event group ( p=0.0001) This was primarily driven by increased risk of recurrent stroke in the stroke pre vs. post cardiac event: odds ratio 2.4 (1.2-4.7) vs. 0.4 (0.2-0.8), respectively. The mean time from stroke to cardiac event was 89.5 days compared to 40.5 months from cardiac event to stroke. Conclusions: In this cohort, we observed low co-incidence of stroke with symptomatic coronary disease. Stroke preceding cardiac events carried worse prognosis than its occurrence after a cardiac event. This could imply different vulnerability of the cerebral and coronary vascular beds. Optimization of medical treatment after stroke will reduce future cerebrovascular and coronary events.

Način revaskularizacije miokarda i ishod kod pacijenata sa ishemijskom kardiomiopatijom i višesudovnom koronarnom bolešću

Backgroud: Several studies have compared outcome of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease, but a few were focused on patients with reduced left vetricular function. The aim of the study was to compare effectiveness of PCI and CABG in patients with iscaaemic cardiomyopathy and multivessel coronary disease Methods: This single-center study, included 178 patients, admitted because of symptomatic multivessel coronary disease, ejection fraction of left ventricle (EF) ≤50%, who underwent PCI or CABG, with two-years follow up of adverse cardiac and cerebrovascular events (MACCE), which included mortality, myocardial infarction (MI), target lesion/vessel revascularisation (TLR/TVR) and stroke. Results: There was higher incidence of MACCE in PCI group (18.1% vs. 9.5%, p=0.145). That was mainly because of higher incidence of MI (6% vs. 0%, p=0.021) and TLR/TVR (6% vs. 0%, p=0.021) in PCI group. There was no difference in mortality rate (9.6% in PCI group vs. 9.5% in CABG group, p>0.05). Age, fibrinogen, C-reactive protein were predictors of stent thrombosis, while left ventricular dilatation, EuroSCORE and SYNTAXscore were predictors of mortality in our study. Conclusion: There was no difference in mortality rate during 2-year follow-up after PCI and CABG in studied patients. Incidence of MI and TLR/TVR was higher after PCI comparing with CABG.