Prognostic impact of coronary collaterals in acute coronary syndrome (PICC-ACS): A meta-analysis of observational studies

INTRODUCTION: The coronary collateral circulation (CCC) is an alternative source of blood supply in coronary artery disease (CAD). The prognostic value of the presence of CCC at the time of acute coronary syndrome (ACS) is undefined with regards to hard outcomes, particularly reduction in mortality. The study's aim is to determine if the presence of CCC demonstrated by coronary angiography during an ACS is associated with a reduction in mortality.  METHODS: We conducted a systematic search of studies using MEDLINE, EMBASE, ScienceDirect, Scopus, and Cochrane Central Register of Controlled Trials databases in all languages and examined reference lists of studies. The inclusion criteria were 1) observational; 2) population included adults >19 years old with an acute coronary syndrome; 3) reported data on mortality in association with the presence or absence of CCC on angiography; and 4) should have controlled for confounders by using logistic regression analysis. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale for observational studies. The outcome of interest was reduction in all-cause mortality, assessed using Mantel-Haenzel analysis of random effects to compute for risk ratios. RESULTS: Pooled analysis from 11 identified trials with 8,370 subjects showed that among patients with ACS who underwent coronary angiography, the presence of CCC showed a trend towards benefit in terms of mortality, but was not statistically different from those without CCC [RR 0.65, (95% CI 0.38 to 1.12), p CONCLUSION: The presence of CCC during ACS showed a trend towards mortality reduction. Further, among patients treated with PCI, those with CCC had an incrementally significant reduction in mortality compared to those without CCC.

Cardiovascular manifestations in Noonan syndrome: Report of three cases

OBJECTIVES: Noonan syndrome is a rare disease presenting with phenotypic features. Over two-thirds of patients with Noonan Syndrome have congenital heart defects with pulmonic stenosis as the most common cardiac abnormality. As a means of focusing on these complications, we report three patients with stigmata of Noonan Syndrome, each of whom had a combination of pulmonic stenosis and other cardiac abnormalities. PATIENTS AND METHODS: The clinical features and cardiac abnormalities of three patients with Noonan Syndrome were studied, and a literature review on cardiovascular manifestations of this syndrome was undertaken. RESULTS: The three patients we report had physical features compatible with Noonan Syndrome. Pulmonic stenosis is common among three cases and other cardiac abnormalities were also noted with the aid of 2D-echocardiogram. CONCLUSION: The existence of several types of cardiac abnormalities within one syndrome is unusual and requires further investigation. Thorough history and physical examination is of utmost importance in diagnosing a rare condition with associated cardiac abnormalities. Recognition of common abnormalities in patients with Noonan Syndrome would aid both clinical course and management of this rare condition.

Clinical profile and outcomes of adult patients with echocardiographic evidence of cardiac tamponade at the Philippine General Hospital: A 5-year study (the captive-heart study)

BACKGROUND: Cardiac tamponade is a life-threatening hemodynamic condition from pericardial effusions that increase intrapericardial pressure suffeciently to externally compress and restrict cardiac chamber filling, constrain cardiac output, and induce backward failure. The number of pericardial effusions arising from cardiothoracic post-surgical and catheter-based procedures accounts for 70% of all the cases in one series. In the Philippines, tuberculous infection remains as one of the most common etiologies of pericarditis, and accounts for 25.1% of the 438 cases of pericardial effusion in a local review. METHODS: This is a retrospective cross-sectional study. The inpatient adult echocardiograhy database of the Philippine General Hospital-Section of Cardiology from June 2007 to June 2012 was reviewed, and all confirmed studies with evidence of cardiac tamponade on echocardiography were included. RESULTS: A total of 58 patients were included in this review. The age ranged from 18-75 years, with mean of 43±15 years. Thirty-eight (66%) patients were diagnosed cases of malignancy, with lung cancer as the most common type. The other concomitant conditions included pulmonary tuberculosis (12%), presence of pulmonary mass of undetermined etiology (7%), systemic lupus erythematosus (3%), endocrine disorder (3%), renal failure (3%), and post cardiac surgery status (2%). The most common clinical findings were tachycardia (84%) and elevated jugular venous pressure (57%). Hemodynamic compromise was seen in 8 patients (14%), and Beck's triad was present in only 5 (9%) of the cases. The pericardial effusions were moderate to large in size in 95% of the cases. All effusions were circumferencial, and 100% had right-sided chamber collapse, 38 (66%) of which had both right atrial and right ventricular diastolic collapse. CONCLUSIONS: Malignancy and TB pericarditis account for most cases of cardiac tamponade in our setting. There should be a high index of suspicion for cardiac tamponade among patients presenting with difficulty of breathing and tachycardia, especially on a background of malignancy of TB infection. Cardiac tamponade carries a high in-hospital mortality rate and prompt recognition and intervention is warranted. There was a higher rate of intervention among those who survived their hospitalization, a finding that is similarly reflected by a previous study.

Prevalence of cardio-embolic event among patients with spontaneous echo contrast on transthoracic echocardiography (SMOCC-Heart Study)

CONTEXT: Spontaneous echo contrast (SEC) is a swirling smoke-like image seen inside the heart chambers or in the great vessels. Left Ventricular (LV) dysfunction is known to predispose patients to SEC. The management of SEC is still not as established. Even in patients with atrial fibrillation, SEC does not improve the prediction of cardio-embolic events beyond that of the clinical scoring.METHODS: Retrospective cross-sectional study.RESULTS: The study results included 89 patients with SEC. The mean age was 53.9 ± 14.3, with 67% males. The underlying cardiac condition were ischemic heart disease in 68%, non-ischemic cardiomyopathy in 19.3%, and rheumatic valvular heart disease in 12.5%. The most common comorbities were hypertension (54%), renal insufficiency (34%), and diabetes mellitus (34%). Nineteen percent of the patients were in atrial fibrillation. The location of the SEC was in the left ventricle in 90%. The mean ejection fraction was 34.8 ± 16.3% and the ejection fraction was CONCLUSION AND RECOMMENDATIONS: SEC is an imaging phenomenon that is associated with LV dysfunction with 64% of the patients with an EF of ? 35%. The presence of SEC increases the occurrence of cardio- embolic events in this population with a prevalence of 10% compared to the reported incidence of 1.8 - 2.4% incidence among patients with LV systolic dysfunction. Albeit in higher percentages, the most common co-morbid conditions are also the same risk factors that are independently associated with increased cardiovascular events. That is why the association of SEC with cardio-embolic events as well as its management, is still not well established, and recommendations on anticoagulation still depend on established clinical scoring. Further study that would associate the different characteristics and co-morbid conditions of patients with SEC to cardio-embolic event is in order.