48 research outputs found
Coronary artery disease and schizophrenia: the interplay of heart and mind
This editorial refers to āThe effect of schizophrenia on major adverse cardiac events, length of hospital stay, and prevalence of somatic comorbidities following acute coronary syndromeā, by R. Attar et al., doi:10.1093/ehjqcco/qcy055
Relationship between lipoproteins, thrombosis and atrial fibrillation
The prothrombotic state in atrial fibrillation (AF) occurs as a result of multifaceted interactions, known as Virchowās triad of hypercoagulability, structural abnormalities, and blood stasis. More recently, there is emerging evidence that lipoproteins are implicated in this process, beyond their traditional role in atherosclerosis. In this review, we provide an overview of the various lipoproteins and explore the association between lipoproteins and AF, the effects of lipoproteins on haemostasis, and the potential contribution of lipoproteins to thrombogenesis in AF. There are several types of lipoproteins based on size, lipid composition, and apolipoprotein category, namely: chylomicrons, very low-density lipoprotein, low-density lipoprotein (LDL), intermediate-density lipoprotein, and high-density lipoprotein. Each of these lipoproteins may contain numerous lipid species and proteins with a variety of different functions. Furthermore, the lipoprotein particles may be oxidized causing an alteration in their structure and content. Of note, there is a paradoxical inverse relationship between total cholesterol and LDL cholesterol (LDL-C) levels, and incident AF. The mechanism by which this occurs may be related to the stabilizing effect of cholesterol on myocardial membranes, along with its role in inflammation. Overall, specific lipoproteins may interact with haemostatic pathways to promote excess platelet activation and thrombin generation, as well as inhibiting fibrinolysis. In this regard, LDL-C has been shown to be an independent risk factor for thromboembolic events in AF. The complex relationship between lipoproteins, thrombosis and AF warrants further research with an aim to improve our knowledge base and contribute to our overall understanding of lipoprotein-mediated thrombosis
Case series of iatrogenic coronary stent avulsion: a rare complication with varied management strategies
Background
Coronary stent avulsion is a rare, infrequently reported complication of percutaneous coronary intervention (PCI) with no consensus on management options.
Case summary
This case series presents three descriptions of iatrogenic coronary stent avulsions, and three different bailout management strategies. All patients presented with acute coronary syndrome and required PCI. In the first case, a freshly implanted stent was entrapped in a coronary guidewire and avulsed upon withdrawal of the wire into the aortic sinus. In the second case, a staged procedure to implant a new stent was complicated by stent dislodgement and entanglement with a recently implanted stent leading to avulsion of both stents into the aortic sinus and resultant dissection to the coronary arteries. In the third case, following a successful stent implantation, the tip of the coronary guidewire was bound to the proximal edge of the stent resulting in avulsion of the newly implanted stent into the ascending aorta upon retraction of the wire at the end of the procedure. The first two patients were managed percutaneously, and the third surgically. All patients have had acceptable technical and clinical outcomes.
Discussion
In the absence of a consensus on best bailout management strategy, we discuss the mechanisms of and the potential management options for this rare, but serious, complication
The role of procoagulant phospholipids on the surface of circulating blood cells in thrombosis and haemostasis
Phospholipids (PLs) are found in all cell types and are required for structural support and cell activation signalling pathways. In resting cells, PLs are asymmetrically distributed throughout the plasma membrane with native procoagulant aminophospholipids (aPLs) being actively maintained in the inner leaflet of the membrane. Upon platelet activation, aPLs rapidly externalize to the outer leaflet and are essential for supporting the coagulation cascade by providing binding sites for factors in the cell-based model. More recent work has uncovered a role for enzymatically oxidized PLs (eoxPLs) in facilitating coagulation, working in concert with native aPLs. Despite this, the role of aPLs and eoxPLs in thrombo-inflammatory conditions, such as arterial and venous thrombosis, has not been fully elucidated. In this review, we describe the biochemical structures, distribution and regulation of aPL externalization and summarize the literature on eoxPL generation in circulating blood cells. We focus on the currently understood role of these lipids in mediating coagulation reactions in vitro, in vivo and in human thrombotic disease. Finally, we highlight gaps in our understanding in how these lipids vary in health and disease, which may place them as future therapeutic targets for the management of thrombo-inflammatory conditions
Case series of iatrogenic coronary stent avulsion: a rare complication with varied management strategies
Background
Coronary stent avulsion is a rare, infrequently reported complication of percutaneous coronary intervention (PCI) with no consensus on management options.
Case summary
This case series presents three descriptions of iatrogenic coronary stent avulsions, and three different bailout management strategies. All patients presented with acute coronary syndrome and required PCI. In the first case, a freshly implanted stent was entrapped in a coronary guidewire and avulsed upon withdrawal of the wire into the aortic sinus. In the second case, a staged procedure to implant a new stent was complicated by stent dislodgement and entanglement with a recently implanted stent leading to avulsion of both stents into the aortic sinus and resultant dissection to the coronary arteries. In the third case, following a successful stent implantation, the tip of the coronary guidewire was bound to the proximal edge of the stent resulting in avulsion of the newly implanted stent into the ascending aorta upon retraction of the wire at the end of the procedure. The first two patients were managed percutaneously, and the third surgically. All patients have had acceptable technical and clinical outcomes.
Discussion
In the absence of a consensus on best bailout management strategy, we discuss the mechanisms of and the potential management options for this rare, but serious, complication
Severe symptomatic aortic stenosis: medical therapy and transcatheter aortic valve implantation (TAVI)āa real-world retrospective cohort analysis of outcomes and cost-effectiveness using national data
Objectives: Determine the real-world difference
between 2 groups of patients with severe aortic
stenosis and similar baseline comorbidities: surgical
turn down (STD) patients, who were managed
medically prior to the availability of transcatheter aortic
valve implantation (TAVI) following formal surgical
outpatient assessment, and patients managed with a
TAVI implant.
Design: Retrospective cohort study from real-world
data.
Setting: Electronic patient letters were searched for
patients with a diagnosis of severe aortic stenosis and
a formal outpatient STD prior to the availability of TAVI
(1999ā2009). The second group comprised the first 90
cases of TAVI in South Wales (2009 onwards). 2 years
prior to and 5 years following TAVI/STD were assessed.
Patient data were pseudoanonymised, using the Secure
Anonymized Information Linkage (SAIL) databank, and
extracted from Office National Statistics (ONS), PatientEpisode
Database for Wales (PEDW) and general
practitioner databases.
Population: 90 patients who had undergone TAVI in
South Wales, and 65 STD patients who were medically
managed.
Main outcome measures: Survival, hospital
admission frequency and length of stay, primary care
visits, and cost-effectiveness.
Results: TAVI patients were significantly older (81.8 vs
79.2), more likely to be male (59.1% vs 49.3%),
baseline comorbidities were balanced. Mortality in TAVI
versus STD was 28% vs 70% at 1000 days follow-up.
There were significantly more hospital admissions per
year in the TAVI group prior to TAVI/STD (1.5 (IQR 1.0ā
2.4) vs 1.0 IQR (0.5ā1.5)). Post TAVI/STD, the TAVI
group had significantly lower hospital admissions (0.3
(IQR 0.0ā1.0) vs 1.2 (IQR 0.7ā3.0)) and lengths of stay
(0.4 (IQR 0.0ā13.8) vs 11.0 (IQR 2.5ā28.5), p<0.05).
The incremental cost-effectiveness ratio (ICER) for TAVI
was Ā£10 533 per quality-adjusted life year (QALY).
Conclusions: TAVI patients were more likely to survive
and avoid hospital admissions compared with the
medically managed STD group. The ICER for TAVI was
Ā£10 533 per QALY, making it a cost-effective procedure
The impact of coronary perforation in percutaneous interventions involving the left main stem coronary artery in the United Kingdom 2007-2014: Insights from the British Cardiovascular Intervention Society database
Background
Percutaneous coronary intervention (PCI) is increasingly utilized for treatment of coronary disease involving the unprotected left main stem (ULMS). However, no studies to date have examined the outcomes of such interventions when complicated by coronary perforation (CP).
Methods
Using the British Cardiovascular Intervention society (BCIS) database, data were analyzed on all ULMSāPCI procedures complicated by CP in England and Wales between 2007 and 2014. Multivariate logistic regressions were used to identify predictors of ULMS CP and to evaluate the association between this complication and outcomes.
Results
During 10,373 ULMSāPCI procedures, CP occurred more frequently than in nonāULMSāPCI (0.9 vs. 0.4%, pā<ā.001) with a stable annual incidence. Covariates associated with CP included number of stents used, female gender, use of rotational atherectomy and chronic total occlusion (CTO) intervention. Adjusted odds of adverse outcomes for ULMSāPCI complicated by CP were higher for periāprocedural complications including cardiogenic shock, tamponade, sideābranch loss, DC cardioversion, ināhospital major bleeding, transfusion requirement, and periāprocedural myocardial infarction. There were also significantly increased odds for ināhospital major adverse cardiac events (MACCE, OR 8.961, 95% CI [4.902ā16.383]) and 30āday mortality (OR 5.301, 95% CI [2.741ā10.251]).
Conclusions
CP is an infrequent event during ULMSāPCI and is predicted by female gender, rotational atherectomy, CTO interventions or number of stents used. CP was associated with significantly higher odds of mortality and morbidity, but at rates similar to previously published allācomer PCI complicated by CP
The impact of intracoronary imaging on PCI outcomes in cases utilising rotational atherectomy: an analysis of 8,417 rotational atherectomy cases from the British Cardiovascular Intervention Society Database
Introduction. There is increasing evidence supporting the use of intracoronary imaging to optimize the outcomes of percutaneous coronary intervention (PCI). However, there are no studies examining the impact of imaging on PCI outcomes in cases utilising rotational atherectomy (RA-PCI). Our study examines the determinants and outcomes of using intracoronary imaging in RA-PCI cases including 12-month mortality. Methods. Using the British Cardiac Intervention Society database, data were analysed on all RA-PCI procedures in the UK between 2007 and 2014. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural, and outcome associations with intravascular imaging. Results. Intracoronary imaging was used in 1,279 out of 8,417 RA-PCI cases (15.2%). Baseline covariates associated with significantly more imaging use were number of stents used, smoking history, previous CABG, pressure wire use, proximal LAD disease, laser use, glycoprotein inhibitor use, cutting balloons, number of restenosis attempted, off-site surgery, and unprotected left main stem (uLMS) PCI. Adjusted rates of in-hospital major adverse cardiac/cerebrovascular events (IH-MACCE), its individual components (death, peri-procedural MI, stroke, and major bleed), or 12-month mortality were not significantly altered by the use of imaging in RA-PCI. However, subgroup analysis demonstrated a signal towards reduction in 12-month mortality in uLMS RA-PCI cases utilising intracoronary imaging (OR 0.67, 95% CI 0.44ā1.03). Conclusions. Intracoronary imaging use during RA-PCI is associated with higher risk of baseline and procedural characteristics. There were no differences observed in IH-MACCE or 12-month mortality with intracoronary imaging in RA-PCI
Predictors of 1- and 12-month mortality in bifurcation coronary intervention: a contemporary perspective
Aim: Bifurcation-PCI is performed frequently, although without extensive evidence to back up a definitive solution for its complexity. We set out to identify factors associated with 1- and 12-month mortality after bifurcation-PCI between 2017 and 2021 in our tertiary centre in Wales, UK. Results: Of 732 bifurcation PCI cases (mean age 69; 25% female), 67% were in ACS, 42% were left main PCI and 25.3% involved two-stent strategy. 30-day and 12-month mortality were 1.9% and 8.2%, respectively. Age, diabetes, smoking and renal failure are associated with mortality after bifurcation-PCI, while the choice between provisional and 2-stent strategies did not impact mortality/TLR. Conclusion: Awareness of āreal-worldā outcomes of bifurcation-PCI should be used for appropriate patient selection, technique planning and procedural consent
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Differential Roles of the PKC Novel Isoforms, PKCĪ“ and PKCĪµ, in Mouse and Human Platelets
Background
Increasing evidence suggests that individual isoforms of protein kinase C (PKC) play distinct roles in regulating platelet activation.
Methodology/Principal Findings
In this study, we focus on the role of two novel PKC isoforms, PKCĪ“ and PKCĪµ, in both mouse and human platelets. PKCĪ“ is robustly expressed in human platelets and undergoes transient tyrosine phosphorylation upon stimulation by thrombin or the collagen receptor, GPVI, which becomes sustained in the presence of the pan-PKC inhibitor, Ro 31-8220. In mouse platelets, however, PKCĪ“ undergoes sustained tyrosine phosphorylation upon activation. In contrast the related isoform, PKCĪµ, is expressed at high levels in mouse but not human platelets. There is a marked inhibition in aggregation and dense granule secretion to low concentrations of GPVI agonists in mouse platelets lacking PKCĪµ in contrast to a minor inhibition in response to G protein-coupled receptor agonists. This reduction is mediated by inhibition of tyrosine phosphorylation of the FcRĪ³-chain and downstream proteins, an effect also observed in wild-type mouse platelets in the presence of a PKC inhibitor.
Conclusions
These results demonstrate a reciprocal relationship in levels of the novel PKC isoforms Ī“ and Īµ in human and mouse platelets and a selective role for PKCĪµ in signalling through GPVI