Outcome of very elderly (octogenarians) patients with coronary artery disease, all diagnosed by coronary angiography

Background: Women with ischemic heart disease (IHD) typically present less severe coronary artery atherosclerosis. Despite that, as compared with men, women maintain a worse outcome. This female susceptibility seems to be mainly related to older age of clinical presentation and heavier risk factors burden. Purpose: To investigate whether sex differences exist in the real-world management and clinical outcome of elderly patients with suspected IHD. Methods: Retrospective analysis of IHD elderly (≥ 80 years) patients undergoing coronary angiography for acute coronary syndrome (ACS) or stable angina (SA). Management strategy, including invasive revascularization or a conservative medical approach, and outcome were evaluated. Results: A total of 1420 (41% women; mean age: 83.1 ± 2.8) IHD patients referring for ACS (43%) and SA (57%) were analyzed. Men more likely accessed for SA (59.6% vs 52.5%, p<0.001) whereas ACS was the most frequent reason for angiography in women (28.8% vs 21.5%, p<0.001). No significant sex differences in the burden of obstructive epicardial disease were observed in both ACS and SA patients. No sex disparities in antiplatelet therapy, specifically clopidogrel, were detected. Compared with SA men patients, female ones received more likely a conservative therapy (p=0.049). After a median (IQR) follow-up time of 39.0 (16-71) months, a total of 514 (36%) patients died. No sex differences in cardiac death (p=0.139) was observed. Nevertheless, the Kaplan Meier curves showed a trend in lower all-cause mortality in female group(p=0.093). Conclusions: In the very elderly population, an invasive strategy is superior to a conservative one in terms of survival rate. However, a dilution of the efficacy occurs with increasing age and comorbidities, and for male patients the benefit of the invasive strategy is not clear. Prospective studies are warranted to evaluate the net benefit of an invasive or a conservative approach in older population

Ticagrelor Monotherapy or Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation: Per-Protocol Analysis of the GLOBAL LEADERS Trial.

Background In the GLOBAL LEADERS trial, ticagrelor monotherapy beyond 1 month compared with standard antiplatelet regimens after coronary stent implantation did not improve outcomes at intention-to-treat analysis. Considerable differences in treatment adherence between the experimental and control groups may have affected the intention-to-treat results. In this reanalysis of the GLOBAL LEADERS trial, we compared the experimental and control treatment strategies in a per-protocol analysis of patients who did not deviate from the study protocol. Methods and Results Baseline and postrandomization information were used to classify whether and when patients were deviating from the study protocol. With logistic regressions, we derived time-varying inverse probabilities of nondeviation from protocol to reconstruct the trial population without protocol deviation. The primary end point was a composite of all-cause mortality or nonfatal Q-wave myocardial infarction at 2 years. At 2-year follow-up, 1103 (13.8%) of 7980 patients in the experimental group and 785 (9.8%) of 7988 patients in the control group qualified as protocol deviators. At per-protocol analysis, the rate ratio for the primary end point was 0.88 (95% CI, 0.75-1.03; P=0.10) on the basis of 274 versus 325 events in the experimental versus control group. The rate ratio for the key safety end point of major bleeding was 1.00 (95% CI, 0.79-1.26; P=0.99). The per-protocol and intention-to-treat effect estimates were overall consistent. Conclusions Among patients who complied with the study protocol in the GLOBAL LEADERS trial, ticagrelor plus aspirin for 1 month followed by ticagrelor monotherapy was not superior to 1-year standard dual antiplatelet therapy followed by aspirin alone at 2 years after coronary stenting. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435

320-slice CT and myocardial bridge

A 29-year-old professional athlete was referred for cardiac evaluation after a syncope occurring during strenuous exercise.Twelve-lead ECG showed Brugada-like pattern ( fi gure 1 ), but both fl ecainide and genetic tests were negative. ECG Holter and echocardiogram were normal. ECG stress test showed no signifi cant ST-segment changes. A CT scan showed two typical myocardial bridges of the left anterior descending artery, with intramural tracts of 10 mm in the mid-segment and of 15 mm in the distal segmen

Acute profound abciximab induced thrombocytopenia: a correct management of a methodological error

Thrombocytopenia is a rare complication of glycoprotein IIb/IIIa treatment. We report a case of an acute profound abciximab induced thrombocytopenia and its successful management. The patient, presenting with unstable angina, underwent percutaneous coronary intervention with implantation of three drug eluting stents without receiving a clopidogrel loading dose according to guidelines. The rapid drop in the platelet count after abciximab elastomeric pump infusion was treated with drug discontinuation and platelet transfusion. The high risk of stent thrombosis was avoided by a timely readministration of the dual antiplatelet treatment

Very late bare metal stent thrombosis with concomitant patent drug eluting stent in the same vessel: a case for a suggestive hypothesis

We report a case of very late stent thrombosis of a bare metal stent with a concurrent drug eluting stent’s patency in the same coronary vessel, in a patient undergoing primary angioplasty who discontinued his clopidogrel regimen a few weeks after successful deployment of the stents

Rosuvastatin was effective in acute heart failure and slow coronary flow: A hypothesis-generating case report

Slow coronary flow phenomenon (SCFP) is characterized by angiographically normal coronary arteries with delayed run-off of contrast medium across the vasculature. Its etiology and clinical significance are still not completely known; however, acute congestive heart failure (CHF) is rare in this context. A 71 year-old woman with SCFP presented with acute CHF complicated by ventricular tachycardia. Treated with rosuvastatin (20 mg/day for 6 days) and inotropic drug infusion she had a complete recovery of left ventricular function and normalization of serum levels of the high-sensitivity C-reactive protein (hs-CRP), which were increased (3.6 mg/L) during the acute phase. This case illustrates that the anti-inflammatory properties of rosuvastatin may deserve specific clinical tests not only during the chronic phase but also in the acute phase of CHF patients. © Arrivi et al

Acute Aortic Dissection Mimicking STEMI in the Catheterization Laboratory: Early Recognition Is Mandatory

Coronary malperfusion due to type A aortic dissection is a life-threatening condition where timely recognition and treatment are mandatory. A 77-year-old woman underwent an acute evolving type A aortic dissection mimicking acute myocardial infarction. Two pathophysiologic mechanisms are discussed: either thrombosis migrating from a previously treated giant aneurism of proximal left anterior descending or a local arterial complication due to left main stenting. Recognition of these occurrences in the catheterization laboratory is important to look immediately for surgery

Idiopathic, Serial Coronary Vessels Dissection in a Young Woman with Psychological Stress: A Case Report and Review of the Literature

Spontaneous coronary artery dissection (SCAD) is a very rare disease, associated with high mortality rate, whose etiology and pathogenesis are poorly understood. Its sporadic nature and the varied angiographic extent make firm recommendations regarding revascularization impossible. The case described is that of a young, otherwise healthy woman, without a known underlying condition which may lead to SCAD, but with a history of intense psychological stress. We managed the patient with a conservative approach based on watchful waiting, medical therapy, and plain old balloon angioplasty (POBA) with low inflation atmospheres

Dipyridamole versus verapamil for treatment of no-reflow during primary angioplasty

Background: No previous study has assessed the possible role of dipyridamole for treatment of no-reflow during acute myocardial infarction (AMI). Methods and Results: Forty-six consecutive patients (age 64 ± 13 years, 37 men) with no reflow during primary percutaneous coronary intervention were randomized to initial treatment with either dipyridamole (0.56 mg/kg i.c.) or verapamil (1 mg i.c.). Patients with unsuccessful response to the first drug were then switched to the second one (from dipyridamole to verapamil and vice versa). Angiographic end-points were similar in the two groups: TIMI flow was 2.9 ± 0.3 versus 2.8 ± 0.4 (P = 0.28), corrected TIMI frame count (cTFC) 26.4 ± 8.8 versus 31.6 ± 11.4 (P = 0.14) and TIMI myocardial perfusion grade (TMPG) 2.1 ± 1.2 versus 1.7 ± 1.2 (P = 0.12) in dipydidamole and verapamil group, respectively. Optimal myocardial perfusion (TMPG-3) was achieved by 56% of patients with dipyridamole and 39% with verapamil (P = 0.38). In patients with persistent no-reflow administration of dipyridamole on top of verapamil resulted in a significant further improvement of cTFC (from 31.6 ± 11.4 to 24.6 ±5.7 P = 0.009) and of TMPG (from 1.7 ± 1.2 to 2.6 ± 0.7, P = 0.007). Conversely, verapamil did not induce a significant improvement in coronary flow (cTFC changed from 26.4 ± 8.8 to 24.5 ± 8.5, P = 0.28 and TMPG from 2.1 ± 1.2 to 2.4 ± 1.2, P = 0.13). There were no significant side effects induced by dipyridamole, while verapamil caused AV block in 9% of cases. Conclusions: Dipyridamole is a safe and effective first-line drug for treatment of no-reflow. Dipyridamole can also be successfully used in patients with incomplete response to verapamil. © 2010 Wiley-Liss, Inc