Post-percutaneous coronary intervention CYP2C19 genotyping in an Irish population: The potential role in identifying clopidogrel therapy-related bleeding risks.

AIMS: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains the standard of care. CYP2C19 genetic polymorphisms cause variable clopidogrel bioactivation. Increased function (CYP2C19*17) allele carriers (rapid metabolizers [RM] or ultrarapid metabolizers [UM]) are clopidogrel hyper-responders, hence are more susceptible to clopidogrel-related bleeding. Since current guidelines recommend against routine genotyping following PCI, data on the clinical utility of CYP2C19*17 genotype guided strategy are sparce. Our study provides real-world data on the 12-month follow-up of CYP2C19 genotyping in patients post-PCI. METHODS: This is a cohort study within an Irish population receiving 12-month DAPT following PCI. It identifies the prevalence of CYP2C19 polymorphisms within an Irish population and describes the ischaemic and bleeding outcomes after 12 months of DAPT. RESULTS: A total of 129 patients were included with the following CYP2C19 polymorphism prevalence: 30.2% hyper-responders (26.4% RM [1*/17*], 3.9% UM [17*/17*]) and 28.7% poor-responders (22.5% IM [1*/2*], 3.9% IM [2*/17*], 2.3% PM [2*/2*]). A total of 53 and 76 patients received clopidogrel and ticagrelor, respectively. At 12 months, total bleeding incidence within the clopidogrel group was positively correlated with CYP2C19 activity: IM/PM (0.0%), NM (15.0%) and RM/UM (25.0%). The positive relationship showed a moderate association that was statistically significant: rτ = 0.28, P = 0.035. CONCLUSIONS: The prevalence of CYP2C19 polymorphisms in Ireland is 58.9% (30.2% CYP2C19*17, 28.7% CYP2C19*2) with an approximately one in three chance of being a clopidogrel hyper-responder. Positive correlation between bleeding and increasing CYP2C19 activity within the clopidogrel group (n = 53) suggests possible clinical utility of a genotype-guided strategy identifying high bleeding risk with clopidogrel in CYP2C19*17 carriers, but further studies are required.

Lifelong Aspirin for All in the Secondary Prevention of Chronic Coronary Syndrome: Still Sacrosanct or Is Reappraisal Warranted?

Four decades have passed since the first trial suggesting the efficacy of aspirin in the secondary prevention of myocardial infarction. Further trials, collectively summarized by the Antithrombotic Trialists' Collaboration, solidified the historical role of aspirin in secondary prevention. Although the benefit of aspirin in the immediate phase after a myocardial infarction remains incontrovertible, a number of emerging lines of evidence, discussed in this narrative review, raise some uncertainty as to the primacy of aspirin for the lifelong management of all patients with chronic coronary syndrome (CCS). For example, data challenging the previously unquestioned role of aspirin in CCS have come from recent trials where aspirin was discontinued in specific clinical scenarios, including early discontinuation of the aspirin component of dual antiplatelet therapy after percutaneous coronary intervention and the withholding of aspirin among patients with both CCS and atrial fibrillation who require anticoagulation. Recent primary prevention trials have also failed to consistently demonstrate net benefit for aspirin in patients treated to optimal contemporary cardiovascular risk factor targets, indicating that the efficacy of aspirin for secondary prevention of CCS may similarly have changed with the addition of more modern secondary prevention therapies. The totality of recent evidence supports further study of the universal need for lifelong aspirin in secondary prevention for all adults with CCS, particularly in stable older patients who are at highest risk for aspirin-induced bleeding.

Late Erosion of Percutaneous ASD Occlusion Device.

Percutaneous closure of atrial septal defects (ASDs) is an ever more common treatment modality in selected patients. Device erosion is a rare but often fatal complication of this therapy, which usually presents early in the post-procedure course. We describe the case of a patient presenting with chest pain and shock in whom early recognition and intervention prevented a negative outcome. Awareness of this potentially lethal complication is important as the population of patients undergoing percutaneous procedures for structural heart disease continues to grow. LEARNING POINTS: As the number of patients undergoing percutaneous atrial septal defect closure increases, so too will the volume presenting with late complications.Early recognition and intervention in cases of device erosion is critical to prevent death.

Interns as medical educators: student and intern experiences from the intern-delivered teaching program at University Hospital Limerick.

BACKGROUND: The acquisition and assimilation of knowledge through history-taking and clinical skills practice are core aspects of training for medical students. Interns, who have recently graduated and have entered into clinical practice, are uniquely positioned to assume a pivotal role in student education. AIMS: The goal of this study was to evaluate feedback from both students as well as intern tutors on the intern-delivered teaching program at University Hospital Limerick (UHL) from 2015 to 2016. METHODS: Eighty-five interns participated in the program at UHL in 2015 and 2016, aiming to deliver four 1-h tutorials to 285 Year 3 or Year 4 students from UL Graduate Entry Medical (GEMS) Program. A flexible schedule focused on practical skills and knowledge translation was created with oversight from Lead Interns and Professor of Medicine, with administrative support. Feedback was assessed using anonymous survey questionnaires. RESULTS: The survey response rate was 74% in 2015 and 75% in 2016. Student feedback on the performance of intern tutors was positive. More than 50% of students deemed tutorials on history-taking and clinical examination as the most valuable. Over 76% of students indicated a desire to participate as tutors after graduation. Logistical issues in agreeing mutually suitable timeslots were identified as the major barrier for delivery of teaching. From the intern perspective, over 85% reported benefits in areas of professional development and knowledge consolidation. CONCLUSIONS: Participation in intern-delivered teaching leads to clinical and educational benefits for both students and interns. However, several logistical barriers were identified and require refinement.

Streptococcus bovis Endocarditis after Colonic Polypectomy.

We describe a case of Streptococcus lutetiensis infective endocarditis occurring in a patient following colonic polypectomy. The patient had multiple risk factors for infective endocarditis including pre-existing mitral valve prolapse and regurgitation. Transoesophageal echocardiography revealed a friable mass on the posterior mitral valve leaflet, confirming the diagnosis. The patient was treated with intravenous antibiotics, successfully underwent mitral valve surgery and was discharged home for outpatient follow-up. This report details an uncommon case presentation, highlights areas for improvement in clinical practice, and summarises the current knowledge available in the literature regarding Streptococcus bovis infective endocarditis. LEARNING POINTS: Infective endocarditis occurring in association with gastrointestinal endoscopy is rare.Clinical suspicion of infective endocarditis after colonic polypectomy or biopsy should be maintained, especially in those with risk factors for infective endocarditis.Antibiotic prophylaxis against infective endocarditis is not recommended for routine gastrointestinal endoscopic procedures.