Clinical significance of high on-treatment platelet reactivity in patients with prolonged clopidogrel therapy

Background/Aims@#Prolonged dual antiplatelet therapy (DAPT) with aspirin and clopidogrel beyond 1 year has been shown to reduce ischemic events at the expense of increased bleeding. However, limited data are available on the clinical significance of platelet reactivity (PR) at 1 year. @*Methods@#We retrospectively identified 331 patients who underwent percutaneous coronary intervention (PCI) and assessed the on-clopidogrel PR using VerifyNow P2Y12 assay at 1 year in a single center. Two hundred eleven patients were on DAPT for > 1 year. The relationship between high on-treatment platelet reactivity (HPR) at 1 year and clinical outcomes beyond 1 year, as well as the longitudinal change in PR was analyzed. @*Results@#At 1 year, 135 (64%) patients showed HPR and 76 (36%) did not. There was a significant increase in ischemic endpoint events, including cardiovascular death, non-fatal myocardial infarction, and stroke/transient ischemic attack in patients with compared to without HPR at 1 year (hazard ratio [HR], 2.68; 95% confidence interval [CI], 1.06 to 6.77; p = 0.036). However, the incidence of any Bleeding Academic Research Consortium bleeding was significantly lower in the HPR group (HR, 0.11; 95% CI, 0.02 to 0.65; p = 0.015). In the longitudinal analysis, PR significantly decreased from post-load to 1 year after index PCI in the non-HPR group. Conversely, the HPR group showed high PR from baseline through 1 year. @*Conclusions@#HPR at 1 year may be a useful surrogate for predicting ischemic and bleeding events in patients on prolonged DAPT. Patients with and without HPR at 1 year showed different patterns of longitudinal change in PR.

Automatic consultation system for patients with cardiac implantable electronic devices undergoing magnetic resonance imaging

Background@#Safety evaluation for patients with cardiac implantable electronic devices (CIEDs) undergoing magnetic resonance imaging (MRI) scanning is often overlooked. We developed an automatic consultation system (ACS) to improve the screening rate in these patients. @*Methods@#ACS was developed by the Hospital Information System Development Department of Seoul National University Bundang Hospital. It was designed to automatically request pre-MRI cardiac evaluation in patients with CIED when MRI orders are issued. The proportion of the patients without pre-MRI cardiologic evaluation was evaluated before and after the ACS application. @*Results@#From January 2016 to June 2018, a total of 157 patients with CIEDs [pacemaker 136 (86.6%), ICD or CRT-D 21 (13.4%), MR-conditional 117 (74.5%)] visited the MRI facility. Before the ACS application, 23 out of 84 patients (27.4%) did not have adequate pre-MRI cardiologic evaluation. Despite urgent request for pre-MRI cardiac evaluation, MRI examination was postponed or cancelled in 14 (60.8%) cases. After the ACS application, all 73 patients underwent proper cardiologic evaluation before their MRI examinations (P < 0.001). The proportion of immediate request for pre-MRI evaluation at the moment of MRI order also improved with the ACS application (before ACS 57.1%, after ACS 100%, P < 0.001). @*Conclusions@#The newly developed ACS helped the patients with CIED receive MRI scan safely on the schedule, improving the quality of care in this population.

Experiences of magnetic resonance imaging scanning in patients with pacemakers or implantable cardioverter-defibrillators

BACKGROUND/AIMS: Despite the U.S. Food and Drug Adminstration approving a magnetic resonance imaging (MRI)-conditional pacemaker system in 2011, many physicians remain reluctant to perform MRI scanning in patients with cardiac implantable electronic devices. Herein, we aimed to evaluate the real-world safety of MRI in these patients. METHODS: This single-center retrospective study examined the interrogation data and outcomes of patients with pacemakers or implantable cardioverter defibrillators who underwent MRI. MRI interrogation data were collected pre- and post-MRI and after 1 month of follow-up; these included the lead impedance, measured P- and R-wave amplitudes, and capture threshold. We compared these results between the magnetic resonance (MR)-conditional and conventional groups. RESULTS: From September 2013 to December 2015, 35 patients with cardiac implantable electronic devices underwent 43 MRI scans, with a mean follow-up of 5 months. Among these 35 patients, 14 (40%) had MR-conditional devices and 21 (60%) had conventional devices. Seven patients had high voltage devices, which were all the conventional type. There were no adverse events associated with MRI during the follow-up period, and there were no significant differences in the interrogation data changes between the conventional and MR-conditional groups. CONCLUSIONS: This single-center retrospective study found that MRI can be performed safely in patients with pacemakers or implantable cardioverter defibrillators, regardless of the MRI support, as long as appropriate precautions are taken.

Two Cases of Complications during Percutaneous Coronary Intervention for Myocardial Infarction in Patients with Concurrent Chronic Total Occlusion in an Emergency Setting

Morbidity and mortality rates associated with acute myocardial infarction accompanying chronic total occlusion are comparatively high. European guidelines recommend primary intervention for the causative lesion in patient with acute myocardial infarction. Therefore, it is important to identify the culprit lesion. We report two cases of myocardial infarction with concurrent chronic total occlusion in an emergency setting.

Clinical Flow and Outcomes in Patients with Malignant Spinal Cord Compression in Korea / 대한내과학회지

BACKGROUND/AIMS: We investigated the process from the development of symptoms to treatment and analyzed the clinical characteristics, treatment outcomes, and prognostic factors related to the treatment response and survival of patients with malignant spinal cord compression (SCC). METHODS: This study retrospectively reviewed the medical records of 56 patients diagnosed with metastatic SCC using magnetic resonance imaging (MRI) from January 2002 to December 2011. RESULTS: The median age of the patients was 59.5 years, and the most common origin of metastatic SCC was lung cancer. The median interval from symptom development to visiting the hospital was 7 days, and the median interval from admission to the date of clinical diagnosis was 0 days. The median interval from clinical diagnosis to the date of MRI or therapy was 1 or 4 days, respectively. Twenty-six patients (46.4%) had ambulation dysfunction at initial presentation, and 33 patients (61.1%) had ambulation dysfunction after radiotherapy or surgery. The rate of patients regaining walking ability was 17.6% with radiotherapy and 25% with surgery. In univariate analysis, good performance status, ambulatory function, and autonomic function before therapy were favorable predictors of ambulatory function after treatment in all patients. No significant factor was found in multivariate analysis. Median overall survival (OS) was 67 days, and the significant factors for survival by multivariate analysis were performance status and the presence of prostate cancer. CONCLUSIONS: The therapeutic response of ambulatory function and OS in malignant SCC is very poor. Multidisciplinary communication is required for the prompt and optimal management of patients with malignant SCC.

Cancer Patient with Major Depressive Disorder Initially Suspected of Opioid Dependence or Abuse / 대한내과학회지

The importance of opiate dependence or abuse is increasing in the context of the increasing number of cancer survivors and patients with chronic cancer pain. Cancer patients are likely to have psychological disorders such as depression, anxiety, and sleep disturbances. It is important to distinguish these psychological disorders from opiate dependence or abuse. We report a case of a cancer patient with major depressive disorder who was initially suspected of opiate dependence or abuse.