Thrombolytic-plus-anticoagulant therapy versus anticoagulant-alone therapy in submassive pulmonary thromboembolism [TVASPE study]: a randomized clinical trial

The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism [PTE] remains controversial We, therefore, conducted this study to compare the effect of thrombolytic plus anticoagulation versus anticoagulation alone on early death and adverse outcome following submassive PTE. We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dilatation/dysfunction but without arterial hypotension or shock. The patients were randomly assigned in a single-blind fashion to receive an anticoagulant [Enoxaparin [1 mg/kg twice a day]] plus a thrombolytic [Alteplase [100 mg] or Streptokinase [1500000 u/2 hours]] or an anticoagulant [Enoxaparin [1 mg/kg twice a day]] alone. The primary endpoint was in-hospital death or clinical deterioration requiring an escalation of treatment. The secondary endpoints of the study were major bleeding, pulmonary hypertension, right ventricular dilatation at the end of the first week, and exertional dyspnea at the end of the first month. Of 50 patients enrolled, 25 patients were randomly assigned to receive an anticoagulant plus a thrombolytic and the other 25 patients were given an anticoagulant alone. The incidence of the primary endpoints was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group [p value = 0.022]. At the time of discharge, pulmonary artery pressure was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group [p value = 0.018]; however, reduction in the right ventricular size or normalization of the right ventricle showed non-significant differences between the two groups. There was no significant difference regarding the New York Heat Association [NYHA] functional class between the two groups at the end of the first month [p value = 0.213]. No fatal bleeding or cerebral bleeding occurred in the patients receiving an anticoagulant plus a thrombolytic. When given in conjunction with anticoagulants, thrombolytics may improve the clinical course of stable patients who have acute submassive pulmonary embolism and prevent clinical deterioration

Isolated dissection of superior mesenteric artery

Isolated dissection of the superior mesenteric artery is a rare occurrence with a hitherto unknown exact etiology. Patients may present with abdominal symptoms or hemodynamic instability. We herein present a case of spontaneous isolated superior mesenteric artery dissection in a 48-year-old man, who was admitted with epigastric pain. Due to an undiagnosed paced rhythm on the electrocardiogram, he was given fibrinolysis treatment for acute myocardial infarction. On further evaluation, angiography revealed that the cause of pain was the dissection of the superior mesenteric artery. The patient's symptoms were diminished with conservative management, obviating the need for the angioplasty of the superior mesenteric artery.

[Prevalence of Clopidogrel resistance in patients candidate for percutaneous coronary intervention]

In patients who undergo coronary angioplasty, Clopidogrel resistance is accompanied with increased risk of cardiovascular events [unstable angina, recurrent MI, death, etc]. In different studies resistance to Clopidogrel has been reported to be up to 30%. Identification of these patients and determining the contributing factors can help us to reduce cardiovascular events. This cross-sectional study was carried out on candidates of elective percutaneous coronary intervention [PCI] in Shahid Modarres Hospital. Resistance to Clopidogrel was evaluated by platelet aggregometry in platelet-rich-plasma [PRP] using a routine aggregometer [Helena Biosciences Europe]. The platelet aggregation was measured before and after exposure to 20 micro mol ADP as a reagent. Contributing factors such as age, gender, metabolic factors and medications were examined by Chi-square test. This study was run on 90 candidates for elective PCI. Their mean age was 62.6 +/- 10.2 years and 52.2% were male. 20% were semi-responder and 7.8% was non-responder. Gender, hypertension, obesity, using angiotensin-converting enzyme inhibitors and calcium channel blockers did not have any role in Clopidogrel resistance, but diabetes, hyperlipidemia, using beta blockers and statins were more common in Clopidogrel resistant patients [p<0.005]. Considering both non-responders and semi-responders, prevalence of resistance to Clopidogrel was 27.8%, so we must be worried about it. Further larger studies should be designed to determine and manage the contributing factors

Evaluation of underlying coronary stenosis severity in patients with acute MI after thrombus aspiration using export catheter

Early clinical and retrospective angiographic evaluations indicated that in patients with acute myocardial infarction [MI], vulnerable plaques most often represented a mild luminal stenosis. More recent studies drawing upon prospective angiograms, however, have demonstrated that in majority of patients with acute MI, the underlying stenosis is significant. Twenty-eight patients with acute MI candidated for thrombectomy were enrolled in this study. Thrombectomy was performed using export thrombectomy catheters. After the injection of nitroglycerin, the severity of the lesions was determined by two independent operators. Between April 2007 and February 2008, 28 patients, comprised of 26 men and 2 women with acute MI, were evaluated, The underlying stenosis was >/= 50% in 22 [78.6%] patients and <50% in the remaining 6 [20.4%] patients [P value < 0.01]. The right coronary artery was the most common vessel involved in the lesions < 50%. Contrary to the general belief of many cardiologists, the majority cases of myocardial infarction occur in consequence of significant stenosis