A young male with severe myocarditis and skeletal muscle myositis

A 34-year-old male presented with retrosternal chest pain, fatigue, shortness of breath, and a history of a previous episode of myocarditis four years prior. He had elevated troponin T, normal skeletal muscle enzymes, and negative inflammatory markers. Cardiac magnetic resonance imaging (MRI) confirmed active myocarditis with extensive myocardial fibrosis and normal left ventricular ejection fraction (LVEF). His myocarditis symptoms resolved with steroids and anti-inflammatory treatment, but on closer questioning, he reported a vague history of long-standing calf discomfort associated with episodes of stiffness, fatigue, and flu-like symptoms. MRI of the lower legs consequently demonstrated active myositis in the calf muscles. Immunomodulatory therapy was commenced with good effect. The patient is undergoing regular follow-up in both cardiology and rheumatology outpatient departments. Repeated MRI of the legs showed significant interval improvement in his skeletal muscle myositis, and repeat cardiac MRI demonstrated the resolution of myocarditis along with persistent stable extensive myocardial fibrosis and preserved LVEF. The patient has returned to full-time work.</p

Mechanical chest compressions and intra-aortic balloon pump combination for refractory ventricular fibrillation during primary PCI

This case highlights the successful resuscitation of a 43-year-old man with ST-segment elevation myocardial infarction and refractory ventricular fibrillation by using a combination of mechanical chest compressions and intra-aortic balloon pump insertion. This bailout strategy facilitated primary multivessel percutaneous coronary intervention in a center without on-site extracorporeal membrane oxygenation. (Level of Difficulty: Advanced.)</p

A distinctive posterior mitral valve infective endocarditis and a large mycotic aneurysm

Case presentationA 72-year-old man with a background of hypertension and atrial fibrillation presented with confusion, lumbar back pain and pyrexia. Clinical examination identified a pansystolic murmur radiating to the left axilla.</p

Pre-percutaneous coronary intervention TIMI flow grade in STEMI patients treated with pre-hospital ticagrelor loading

Aim We hypothesised that pre-hospital ticagrelor loading would result in a higher proportion of STEMI patients presenting with pre percutaneous coronary intervention TIMI flow grade (ppTFG) 3 than had previously been reported in the clopidogrel era.Methods Retrospective observational analysis of all STEMI patients attending our centre from 01/01/2016 to 31/12/2019. Patients presenting with STEMI were required to have received pre-hospital load-ing with 180 mg ticagrelor. The coronary angiography images were assessed for each patient to determine the ppTFG in the infarct related artery.Results 590 patients met the inclusion criteria. 125 patients (21.2%) presented with ppTFG 3 on pre-PCI angiography with the remaining 465 patients (78.8%) presenting with ppTFG ≤ 2. In-hospital mor-tality was comparable between the two groups (4% vs 5.6%, p=0.48).Conclusion In STEMI patients loaded with ticagrelor in the field, over one-fifth present with ppTFG 3 on angi-ography pre-PCI. This data is comparable to data from the clopidogrel era.</p

COVID-19 and STEMI: A snapshot analysis of presentation patterns during a pandemic

The coronavirus disease 2019 (COVID-19) pandemic has emerged as a major global public health emergency [1]. Many countries, including the Republic of Ireland, have instituted restrictions on their citizens in order to reduce the transmission of the virus [2,3], colloquially referred to as ‘lockdown’. Concern has been raised regarding an observed decrease in the number of ST elevation myocardial infarction (STEMI) presentations during this period [4,5]. Numerous theories have been proposed regarding this phenomenon [4]. The most concerning hypothesis is that patients with symptoms of acute myocardial ischemia may not be presenting to medical attention due to lockdown measures or concern regarding COVID-19.</p

Revascularisation of left main stem disease: a prospective analysis of modern practice and outcomes in a non-surgical centre

Purpose In this study, we sought to prospectively analyse the management and long term outcomes associated with revascularisation of left main stem disease via percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in our centre.Methods This prospective study enrolled all patients with unprotected left main stem disease undergoing revascularisation from January 2013 to June 2014. Baseline characteristics, hospital presentation and hospital stay length were collected. Patients were followed up at 1, 2 and 3 years. Primary outcomes of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) were defined as death, Q wave myocardial infarction, stroke, repeat revascularisation and readmission within 30 days.Results 56 patients with significant left main stem coronary artery disease were identified from the clinical registry. 27 patients underwent PCI (median age 67.7) and 29 CABG (median age 68.6). PCI patients had a higher surgical risk as measured by mean euroSCORE (4.95±5.8 vs 3.11±3.85). At 3 years, total MACCE occurred in 29.6% of the PCI cohort and 27.5% of the CABG cohort. Death occurred in three patients in the PCI group within the first 6 months. Death occurred in one patient in the CABG group over 2 years postprocedure. Two patients in the CABG cohort presented with Transient Ischemic Attacks (TIAs) at 2-year follow-up. At 3 years, revascularisation occurred in three patients in the PCI cohort. There were no revascularisation events in the CABG cohort.Conclusions PCI with modern drug eluting stents is a reasonable treatment option for unprotected left main stem disease in a non surgical centre.</p

Streptococcus bovis endocarditis after colonic polypectomy

We describe a case of Streptococcus lutetiensis infective endocarditis occurring in a patient following colonic polypectomy. The patient had multiple risk factors for infective endocarditis including pre-existing mitral valve prolapse and regurgitation. Transoesophageal echocardiography revealed a friable mass on the posterior mitral valve leaflet, confirming the diagnosis. The patient was treated with intravenous antibiotics, successfully underwent mitral valve surgery and was discharged home for outpatient follow-up. This report details an uncommon case presentation, highlights areas for improvement in clinical practice, and summarises the current knowledge available in the literature regarding Streptococcus bovis infective endocarditis.</p

Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis

Purpose We sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy. Background Direct oral anticoagulants have become a popular choice for the prevention of thromboembolism. Risk factors for thromboembolism are common among cardiovascular conditions and indications for direct oral anticoagulant therapy as well as coronary angiography often overlap in patients. It has been hypothesised that uninterrupted direct oral anticoagulant therapy would increase haemorrhagic and access site complications, however data in this area is limited. Methods This was a prospective observational analysis of 49 patients undergoing elective diagnostic coronary angiography while receiving uninterrupted anticoagulation with direct oral anticoagulants. This population was compared with a control group of 49 unselected patients presenting to the cardiology service for elective diagnostic coronary angiography. Continuous variables were analysed using the independent samples t-test and categorical variables using Pearson’s χ2 test. Results The mean duration of radial compression for the control group was 235.8±62.8min and for the uninterrupted direct oral anticoagulant group was 258.4±56.5min. There was no significant difference in mean duration of radial compression (p=0.07; 95% CI=-1.4 to 46.5). There was also no difference in the complication rate between the two groups (p=1). Conclusions We observed similar complication rates and radial artery compression time postangiography in both groups. This small prospective observational study suggests that uninterrupted continuation of direct oral anticoagulants during coronary angiography is safe. Larger randomised control studies in this area would be beneficial</p

Systematic review and meta-analysis of remote ischaemic preconditioning in percutaneous coronary intervention

A body of evidence suggests that myocardial infarctions (MI) that are associated with percutaneous coronary intervention (PCI) have prognostic significance but it is uncertain whether remote ischaemic preconditioning (RIPC) offers periprocedural cardioprotection at the time of PCI. Medline, Embase, the Cochrane Central Register of Controlled Trials and conference records were searched (January 1986 to August 2013) for randomised trials that evaluated the effect of RIPC induced by limb ischaemia–reperfusion versus no RIPC in patients who were undergoing PCI. All outcomes were considered for inclusion in the systematic review. Relevant data were extracted and summarised. Pooled odds ratios determined the effect of RIPC compared to control on three prespecified outcomes: troponin positive events in elective PCI, periprocedural MI incidence in elective PCI and acute kidney injury (AKI) incidence in emergency or elective PCI. Eight trials (1119 patients) were found of which six (983 patients) had primary outcomes that were significantly in favour of RIPC. There was no difference in troponin positive events between RIPC and control groups (pooled OR 0.529, 95%CI 0.206–1.358, p = 0.185) (three studies, 377 patients). There was a significant reduction in periprocedural MI incidence with RIPC (pooled OR = 0.577, 95%CI 0.400–0.833, p = 0.003) (four studies, 636 patients). There was no difference in AKI incidence (pooled OR = 0.672, 95%CI 0.252–1.787, p = 0.425) (two studies, 407 patients). Primary outcomes favoured RIPC in most of the studies. RIPC significantly reduced the incidence of periprocedural MI. Included studies were heterogeneous in methodology and quality</p

Peak troponin T in STEMI: a predictor of all-cause mortality and left ventricular function

Background The clinical significance of peak troponin levels following ST-elevation myocardial infarction (STEMI) has not been definitively established. The purpose of this study was to examine the relationship between peak high-sensitivity cardiac troponin T (hs-cTnT) and all-cause mortality at 30 days and 1 year, and left ventricular ejection fraction (LVEF) in STEMI. Methods A single-centre retrospective observational study was conducted of all patients with STEMI between January 2015 and December 2017. Demographics and clinical data were obtained through electronic patient records. Standard Bayesian statistics were employed for analysis. Results During the study period, 568 patients presented with STEMI. The mean age was 63.6±12 years and 76.4% were men. Of these, 535 (94.2%) underwent primary percutaneous coronary intervention, 12 (2.1%) underwent urgent coronary artery bypass and 21 (3.7%) were treated medically. Mean peak hs-cTnT levels were significantly higher in those who died within 30 days compared with those who survived (12238ng/L vs 4657ng/L, respectively; p=0.004). Peak hs-cTnT levels were also significantly higher in those who died within 1year compared with those who survived (10319ng/L vs 4622ng/L, respectively; p=0.003). The left anterior descending artery was associated with the highest hs-cTnT and was the most common culprit in those who died at 1year. An inverse relationship was demonstrated between peak hs-cTnT and LVEF (Pearson’s R=0.379; p Conclusions In STEMI, those who died at 30 days and 1year had significantly higher peak troponin levels than those who survived. Peak troponin is also inversely proportional to LVEF with higher troponins associated with lower LVEF.</p