Pregnancy-Associated Spontaneous Coronary Artery Dissection: A Case Report and the Lessons from Practice

@#Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is one of the fatal conditions that most commonly causes pregnancy-associated myocardial infarction. We herein report a case of P-SCAD in a 26-year-old multigravida woman, who complained of angina postpartum with raised cardiac biomarkers and transient ST-segment elevation on electrocardiograms. We emphasize the importance of a high degree of suspicion in the diagnosis of P-SCAD, together with the common presentation, the management approach, and its psychological impacts on the patients.

One-Year Outcomes of Two-Week Double-Dose Clopidogrel Treatment following Percutaneous Coronary Intervention in a State General Hospital in Malaysia

@#Introduction: Previous studies reported that a two-week double-dose clopidogrel treatment following percutaneous coronary intervention has no difference in safety compared to standard therapy. This study aimed to determine the all-cause readmission rate and survival after a year of percutaneous coronary intervention (PCI) in patients who were treated with two-week double-dose clopidogrel regimen. Methods: This was a retrospective study on patients who underwent PCI in a state general hospital in Malaysia in 2014. Patients’ one month and one-year survival status were retrieved using the hospital electronic patient management system. Patients who received a two-week course of 150mg clopidogrel and subsequently a one-year course of standard double antiplatelet therapy were included. Results: A total of 381 out of 563 patients who underwent PCI were included in the analysis, while those who were switched to ticagrelor and transferred to other hospitals post-PCI excluded. Patients had a mean age of 56.9 (SD 10.7), with majority male (331, 86.9%) and Malay (144, 37.8%). The PCI was mainly indicated for ST-elevated myocardial infarction (188, 49.3%), non-STEMI (114, 29.9%) and unstable angina (36, 9.4%). A total of 107 (28.1%) patients were readmitted within the one year post-PCI period. Readmissions were mainly due to ACS (55.5%) and bleeding events (2.4%). The 30-day and 1-year all-cause mortality was 33 cases and 43 cases, respectively. Conclusion: The low readmission and bleeding related readmission suggested that the two-week double-dose clopidogrel regimen was safe for the post PCI patients. Future randomised trial to establish the efficacy of this dosing regimen is therefore warranted.

Development and validation of algorithms for heart failure patient care: a Delphi study

<p><b>INTRODUCTION</b>Although heart failure (HF) management is available at primary and secondary care facilities in Malaysia, the optimisation of drug therapy is still suboptimal. Although pharmacists can help bridge the gap in optimising HF therapy, pharmacists in Malaysia currently do not manage and titrate HF pharmacotherapy. The aim of this study was to develop treatment algorithms and monitoring protocols for angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and spironolactone based on extensive literature review for validation and utilization by pharmacists involved in HF management.</p><p><b>METHODS</b>A Delphi survey involving 32 panellists, from private and government hospitals that provide cardiac services in Malaysia, was conducted to obtain a consensus opinion on the treatment protocols. The panellists completed two rounds of self-administered questionnaires to determine their level of agreement with all the components in the protocols.</p><p><b>RESULTS</b>Consensus agreement was achieved for most of the sections of the protocols for the four classes of drugs. Panellists' opinions were taken into consideration when amending the components of the protocols that did not achieve consensus opinion. Full consensus agreement was achieved with the second survey conducted, enabling the finalisation of the drug titration protocols.</p><p><b>CONCLUSION</b>The resulting validated HF titration protocols can be used as a guide for pharmacists when recommending the initiation and titration of HF drug therapy in daily clinical practice. Recommendations should be made in collaboration with the patient's treating physician, with concomitant monitoring of patient's response to the drugs.</p>

Intrauterine management of fetal supraventricular tachycardia (SVT) with cardiac failure

Fetal arrhythmias are not uncommon in pregnancy. The diagnosis can be established on routine ultrasound scan. Fetal supraventricular tachycardia (SVT) is the most common cause of fetal tachycardia. If left undiagnosed and untreated, these fetuses may develop cardiac failure, hydrops fetalis and eventually death. We report two fetuses diagnosed antenatally to have fetal SVT. Both fetuses were in cardiac failure and were successfully treated with maternal administration of antiarrhythmic medications. Digoxin, and in severe instances, a combination with flecanaide significantly improved fetal outcomes and prevented fetal mortality. The long term prognosis of such patients are good.