Management of a large intraluminal thrombus in an aneurysmal coronary segment with normal coronary flow.

A coronary artery aneurysm (CAA) is an uncommon clinical finding with an incidence of <5% in adults. The presence of a large intracoronary thrombus within an aneurysmal coronary artery and normal coronary flow is usually a very challenging case scenario. Here, we present a case of a patient presenting with typical chest pain symptoms, high-risk findings on a pharmacological nuclear stress test and coronary angiogram showing severe multivessel coronary artery disease, including a large aneurysmal segment within the proximal left anterior descending artery with a large thrombus that did not affect intracoronary flow. Today, there are no published guidelines for the management of CAA with a normal intracoronary flow. The approach used in this case was initial antithrombotic therapy followed by a successful staged percutaneous coronary intervention. Here, we present a case supporting the use of combined intravenous anticoagulant and antiplatelet therapy for 48 hours, followed by successful percutaneous intervention guided by intravascular ultrasound.

Review and Analysis of Publication Trends over Three Decades in Three High Impact Medicine Journals.

CONTEXT: Over the past three decades, industry sponsored research expanded in the United States. Financial incentives can lead to potential conflicts of interest (COI) resulting in underreporting of negative study results. OBJECTIVE: We hypothesized that over the three decades, there would be an increase in: a) reporting of conflict of interest and source of funding; b) percentage of randomized control trials c) number of patients per study and d) industry funding. DATA SOURCES AND STUDY SELECTION: Original articles published in three calendar years (1988, 1998, and 2008) in The Lancet, New England Journal of Medicine and Journal of American Medical Association were collected. DATA EXTRACTION: Studies were reviewed and investigational design categorized as prospective and retrospective clinical trials. Prospective trials were categorized into randomized or non-randomized and single-center or multi-center trials. Retrospective trials were categorized as registries, meta-analyses and other studies, mostly comprising of case reports or series. Study outcomes were categorized as positive or negative depending on whether the pre-specified hypothesis was met. Financial disclosures were researched for financial relationships and profit status, and accordingly categorized as government, non-profit or industry sponsored. Studies were assessed for reporting COI. RESULTS: 1,671 original articles were included in this analysis. Total number of published studies decreased by 17% from 1988 to 2008. Over 20 year period, the proportion of prospective randomized trials increased from 22 to 46% (p < 0.0001); whereas the proportion of prospective non-randomized trials decreased from 59% to 27% (p < 0.001). There was an increase in the percentage of prospective randomized multi-center trials from 11% to 41% (p < 0.001). Conversely, there was a reduction in non-randomized single-center trials from 47% to 10% (p < 0.001). Proportion of government funded studies remained constant, whereas industry funded studies more than doubled (17% to 40%; p < 0.0001). The number of studies with negative results more than doubled (10% to 22%; p<0.0001). While lack of funding disclosure decreased from 35% to 7%, COI reporting increased from 2% to 84% (p < 0.0001). CONCLUSION: Improved reporting of COI, clarity in financial sponsorship, increased publication of negative results in the setting of larger and better designed clinical trials represents a positive step forward in the scientific publications, despite the higher percentage of industry funded studies.