Does individualized guided selection of antiplatelet therapy improve outcomes after percutaneous coronary intervention? A systematic review and meta-analysis

Background: The potential benefits of individualized guided selection of antiplatelet therapy over standard antiplatelet therapy in improving outcomes in patients undergoing percutaneous coronary intervention (PCI) have not been established. Therefore, we pooled evidence from available clinical trials to assess the effectiveness by comparing the two regimens in patients undergoing PCI.Methods: We queried two electronic databases, MEDLINE and Cochrane CENTRAL, from their inception to April 20, 2021 for published randomized controlled trials in any language that compared guided antiplatelet therapy, using either genetic testing or platelet function testing, versus standard antiplatelet therapy in patients undergoing PCI. The results from trials were presented as risk ratios (RRs) with 95% confidence intervals (CIs) and were pooled using a random-effects model.Results: Eleven eligible studies consisting of 18,465 patients undergoing PCI were included. Pooled results indicated that guided antiplatelet therapy, compared to standard therapy, was associated with a significant reduction in the incidence of MACE [RR 0·78, 95% CI (0·62-0·99), P = 0·04], MI [RR 0·73, 95% CI (0·56-0.96), P = 0·03], ST [RR 0·66, 95% CI (0·47-0.94), P = 0·02], stroke [RR 0·71, 95% CI (0·50-1.00), P = 0·05], and minor bleeding [RR 0·78, 95% CI (0·66-0.91), P = 0·003].Conclusions: Individualized guided selection of antiplatelet therapy significantly reduced the incidence of MACE, MI, ST, stroke, and minor bleeding in adult patients when compared with standard antiplatelet therapy. Our findings support the implementation of genetic and platelet function testing to select the most beneficial antiplatelet agent

Impact of COVID-19 pandemic on cardiovascular testing in Asia: the IAEA INCAPS-COVID study

BACKGROUND The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known. OBJECTIVES This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia. METHODS The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison. RESULTS Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020. CONCLUSIONS The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Late Aminophylline Reversal of Regadenoson Stress Testing in Patients with End Stage Renal Disease

Regadenoson is a widely used and well-tolerated vasodilator agent for pharmacologic stress myocardial perfusing imaging. In patients at higher risk of adverse reactions such as those with end stage renal disease, it can be reversed with early administration of aminophylline. However, little is known about late administration of aminophylline. This case report describes the efficacy of late aminophylline use in patients with end stage renal disease. Possible explanations for the prolonged pharmacodynamic effect of regadenoson in this group are discussed

Effect of Recommendations on Interobserver Consistency of Diastolic Function Evaluation

ObjectivesWe sought the impact of recent recommendations on observer concordance on interpretation of diastolic stage and assessment of filling pressure.BackgroundWorsening stages of diastolic dysfunction are associated with worsening outcome. However, the echocardiographic classification of diastolic function is complex, and parameters may be discordant. The interobserver agreement of diastolic assessment is undefined.MethodsA complete diastolic evaluation (transmitral flow, left atrial volume, tissue Doppler, pulmonary venous flow, mitral flow propagation, and left ventricular images) was obtained in 20 patients and interpreted by 14 experts in 8 countries (280 case reads). Each investigator was asked to interpret diastolic class and left ventricular filling pressure. Brain natriuretic peptide level was drawn on the same day of the echocardiogram to corroborate filling pressures obtained by the echocardiogram. Concordance was assessed as kappa, and accuracy was compared with specific application of the recommendations by 2 investigators.ResultsFor recognition of raised filling pressure, the sensitivity and specificity of readers for raised filling pressure defined by the reference read were 66 ± 37% and 88 ± 26%, respectively. Complete agreement among all readers was obtained in 10 of 20 cases. Diagnosis of normal and categories of abnormal filling was correct in 71% to 95%, with the lowest values obtained for normal and pseudonormal filling. There was no difference between U.S. and international readers. Not all patients in each diastolic stage showed all of the changes that are typical of that stage, and variations appeared to be attributable to differences in weighting of conflicting observations. Overall, kappa values for filling pressure and diastolic class were 0.71 (range 0.60 to 0.80) and 0.68 (range 0.54 to 0.86).ConclusionsCorrect results for estimation of filling pressure were obtained by a high proportion of readers. Classification of diastolic stages continues to be variable and might be addressed by provision of a uniform hierarchy of observations

Multiple Symptomatic Giant Coronary Aneurysms

We present a rare case of symptomatic giant coronary artery aneurysms due to Kawasaki disease in an elderly patient. Giant coronary aneurysms are uncommon; even more is their association with ischemic symptoms and left coronary system involvement. Treatment can be challenging, and we discuss the management taken in this case.</jats:p