Bleeding following percutaneous coronary intervention has important prognostic implications. The Academic Research Consortium (ARC) recently proposed a list of clinical criteria to define patients at ...high bleeding risk (HBR).
This study sought to validate the ARC definition for HBR patients in a contemporary real-world cohort.
Patients undergoing coronary stenting between 2014 and 2017 at a tertiary-care center were defined as HBR if they met at least 1 major or 2 minor ARC-HBR criteria. To account for the presence of multiple criteria, patients were further stratified by the number of times they fulfilled the ARC-HBR definition. The primary endpoint was a composite of peri-procedural in-hospital or post-discharge bleeding at 1 year. Secondary endpoints included individual components of the primary bleeding endpoint, myocardial infarction, and all-cause mortality.
Among 9,623 patients, 4,278 (44.4%) qualified as HBR. Moderate or severe anemia was the most common major criterion (33.2%); age ≥75 years was the most frequent minor criterion and the most common overall (46.8%). The rate of the primary bleeding endpoint at 1 year was 9.1% in HBR patients compared with 3.2% in non-HBR patients (p < 0.001), with a stepwise increase in bleeding risk corresponding to the number of times the ARC-HBR definition was fulfilled. HBR patients also experienced significantly higher rates of all secondary endpoints.
This study validates the ARC-HBR definition in a contemporary group of patients who underwent percutaneous coronary intervention. The ARC-HBR definition identified patients at increased risk not only for bleeding but also for thrombotic events, including all-cause mortality. Coexistence of multiple ARC-HBR criteria showed additive prognostic value.
Transient left bundle branch block occurring during a nuclear stress test in the setting of myocardial bridging is a relatively rare finding. We report a case of a 75-year-old male who presented with ...typical stable angina. Serial troponins were negative, and the electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy and T-wave inversions in the lateral leads. The nuclear stress test was non-ischemic but showed a transient left bundle branch block associated with chest pain and shortness of breath that occurred right after the administration of regadenoson. Coronary angiography revealed non-obstructive coronary artery disease and a mid-LAD myocardial bridge.
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, especially in patients with recent percutaneous coronary intervention ...(PCI). We aimed to illustrate the types and timing of different surgeries occurring after PCI, and to evaluate the risk of thrombotic and bleeding events according to the perioperative antiplatelet management. Patients undergoing urgent or elective non-cardiac surgery within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, or stent thrombosis) at 30 days. Perioperative bleeding was defined as ≥ 2 units of blood transfusion. A total of 1092 surgeries corresponding to 747 patients were classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones, and were associated with an increased risk of both MACE and bleeding. Preoperative interruption of antiplatelet therapy (of any kind) occurred in 44.6% of all NCS and was more likely for procedures occurring later post-PCI and at intermediate risk. There was no significant association between interruption of antiplatelet therapy and adverse cardiac events. Among patients undergoing NCS within 1 year of PCI, perioperative ischemic and bleeding events primarily depend on the estimated surgical risk and urgency of the procedure, which are increased early after PCI. Preoperative antiplatelet interruption was not associated with an increased risk of cardiac events.
Background Women have been associated with higher rates of recurrent events after percutaneous coronary intervention than men, possibly attributable to advanced age at presentation and greater ...comorbidities. These factors also put women at higher risk of bleeding, which may influence therapeutic strategies and clinical outcomes. Methods and Results We performed a patient-level pooled analysis of 4 postapproval registries to evaluate sex-related differences in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. HBR required fulfillment of at least 1 major or 2 minor criteria of the Academic Research Consortium definition. Outcomes of interest were major bleeding and major adverse cardiac events (composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis). Of the total 10 502 patients, 2832 (27.0%) were women. The prevalence of HBR was higher in women compared with men (29.0% versus 20.5%,
<0.0001). Women at HBR were older and had more comorbidities, while men at HBR were more often smokers, with prior myocardial infarction and more complex coronary lesions. At 4 years, women at HBR had significantly higher major bleeding compared with men at HBR (10.8% versus 6.2%,
<0.0001); however, this difference was attenuated after multivariable adjustment (hazard ratio, 0.92; 95% CI, 0.41-2.08). Major adverse cardiac event rates between groups were similar (12.2% versus 12.6%,
=0.82) and remained consistent after adjustment (hazard ratio, 0.64; 95% CI, 0.32-1.28). Conclusions The prevalence of HBR was higher in women compared with men, with considerable differences in the distribution of criteria. Women at HBR experienced higher rates of major bleeding but similar major adverse cardiac event rates compared with men at HBR at 4 years.
Pharmaceutical companies are the manufacturing units of drugs, with established conformity for dispersal into the public. To increase their sales and hence, their shareholder value, these ...corporations need to make their product have earmarks of a better formulation than those already available and stand out from their adversaries. This is achieved with the help of rigorous promotion of the drug to the prescribers. Medical Representatives (MRs) or Pharmaceutical Sales Representatives (PSRs) advertise to the doctors with the help of eye catching visual presentation, citing various benefits and advantages. These presentations are accompanied by leave-behind brochures, pamphlets, drug guides, drug samples etc. for the doctor to read, and are consistently full of points featuring the promoted drug as an advancement with better effectiveness, supported with various research works, colorful pictures, graphs and diagrams that make a physician take notice of the advertised drug. This raises the question of the ability of a GP to critically appraise the information presented to him/her and segregate the fact from fraud. Too often aid is tied to the trade, and any practicing physician should be aware of the tricks being played on him/her and be able to wring the quality of the information presented from the vast quantity of information and assess it for its accuracy.
PURPOSE OF REVIEWThe purpose of this review is to summarize the existing evidence for use of long-term antiplatelet therapies for primary and secondary prevention of adverse cardiovascular events.
...RECENT FINDINGSIn the setting of primary prevention, several contemporary trials have shown a lack of net clinical benefit with use of aspirin across different patient groups, including those with diabetes mellitus, older age or high estimated cardiac risk. For secondary prevention, the addition of either ticagrelor or low-dose rivaroxaban to aspirin monotherapy significantly lowered recurrent vascular events, albeit with excess bleeding. Aspirin withdrawal did not result in excess thrombotic risk or less bleeding among patients undergoing percutaneous coronary intervention (PCI) treated with ticagrelor.
SUMMARYIn the contemporary era, routine use of aspirin is not beneficial in the majority of patients free of cardiac disease. In contrast, for secondary prevention, aspirin monotherapy is not sufficient to lower recurrent vascular risk. Antiplatelet monotherapy with ticagrelor may emerge as an alternative to lower bleeding whereas maintaining ischemic efficacy in selected patients undergoing PCI.
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Case:
26 y/o female immigrant from a developing nation presented with shortness of breath at rest. On physical exam, she desaturated to 75% with minimal movement, had an audible ...pansystolic murmur, and 2+ pitting edema. Initial presentation was indicative of decompensated Heart Failure (HF). 2D Echocardiogram (Echo) showed a right sinus of Valsalva aneurysm (SOV) with a left to right shunt to the pulmonary artery, as well as, severe pulmonary hypertension (PHTN) and moderate pericardial effusion. CT Scan of the chest showed a right Ruptured SOV (RSOV) with a dissection flap extending into the aorta. Transesophageal Echocardiogram confirmed the diagnosis; noted a right RSOV extending into the pulmonary artery causing severe pulmonary HTN leading to HF and pericardial effusion. The patient underwent surgical correction with full recovery and resolution of symptoms.
Conclusions:
SOV is a rare cardiac complication with variable etiology. Congenital causes are often found early in age and resolved surgically. Cases regarding the management of adults, especially in the critical care setting, are not well described. Here we report a 26-year-old female who rapidly developed HF with PHTN and pericardial effusion secondary to an RSOV. This case shows the importance of Echo in managing HF and determining its etiology. Using Echo we saw a dilated Inferior Vena Cava of 2.7 cm characteristic of HF. Next, we were able to visualize a dilated RSOV with a shunt to the right, subsequent turbulent flow through the Aortic valve, and severe tricuspid regurgitation. Lastly, we were able to see elevated pulmonary artery systolic pressure secondary to the shunt, and subsequent pericardial effusion (fig 1). The patient's symptoms were initially managed with IV diuretics and resolved with surgery. This is a rare case of right-sided RSOV extending into the pulmonary artery, its successful treatment, and the important role of Echo in treating HF and PHTN.
During the early peak of the COVID-19 pandemic, several measures were instituted to reduce the risk of exposure among patients to the novel SARS-CoV-2 virus, including the implementation of a virtual ...healthcare encounter system. Unfortunately, this resulted in considerable interruptions in the dispensation of healthcare services to chronically ill patients, particularly among patients with chronic heart failure (CHF).
We aim to study whether the patients who presented to the Kings County Hospital Emergency Department (KCH ED) with symptoms of CHF exacerbation in the months following the COVID-19 pandemic peak in New York City were impacted due to the interruption in their regular cardiology outpatient clinic visits.
The COVID-CHF study is a single-center, retrospective study of patients with CHF that presented to the KCH ED between 05/01/2020 - 12/31/2020 with CHF exacerbation symptoms, selected utilizing ICD-10 codes for admission diagnoses. Continuous variables are reported as mean ± standard deviations or median (interquartile range), while categorical variables are presented as numbers with frequencies. All analyses were performed on Microsoft Excel and R software.
A total of 268 patients were included in our study, with the mean age 65.7±13.8 years and 45% female. The burden of comorbidities was high, with >50% of patients having hypertension, diabetes mellitus, and chronic kidney disease. Of the total patient population, only 61 (22.8%) patients attended a televisit appointment during the preceding pandemic months. At ED presentation, the primary presenting symptom was shortness of breath (86%), and the average hospital stay per visit was 3 (2-6) days. The projected mortality risk, according to the MAGGIC score, was 16 ± 10% at 1 year and 35 ± 17% at 3 years for our patient population. Although the gap between clinic visits and ER visits did not increase the mortality risk, patients presenting with worse New York Heart Association (NYHA) class symptoms had higher mortality risk (Figure). At discharge, 82% of patients were prescribed diuretics and 81% beta-blockers. Two patients died during admission and 3 patients died after discharge.
In our study, we noticed that despite the implementation of a virtual healthcare system during the COVID-19 pandemic, less than one-fourth of CHF patients were able to utilize it, and consequently, there was an increase in ED visits for acute CHF exacerbations in the ensuing months. Additionally, a worse grade of presenting symptoms was associated with higher mortality risk. Key Words: COVID-19, Heart Failure, Virtual Health
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