A secondary prevention lipid clinic reaches low-density lipoprotein cholesterol goals more often than usual cardiology care with coronary heart disease.

OBJECTIVE: The objective of this study was to determine whether enrollment in a multidisciplinary secondary prevention lipid clinic (SPLC) for 3 or more years was associated with improved adherence to lipid guidelines as compared with usual care provided by cardiologists. METHODS: Patients with documented coronary artery disease (CAD), enrolled in a SPLC, and followed for at least 3 years were identified by the use of a computer database. The comparison group included patients with CAD who received usual care from a cardiologist during the same time period. The percentage of patients achieving low-density lipoprotein cholesterol (LDL-C) goals at enrollment and after at least 3 years of follow-up was determined for both groups. The average total cholesterol, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides were determined after at least 3 years of follow-up for both groups. RESULTS: Patients enrolled in the SPLC reached the LDL-C goals more often than usual care cardiology patients (goal <100mg/dL: 81.9% vs. 72.8%, P < .001; optional goal <70 mg/dL: 41.9% vs. 28.6%, P < .001). The patients enrolled in the SPLC had lower average total cholesterol, triglycerides, and LDL-C and greater average HDL-C after 3 years. All the lipid parameters decreased for patients in usual cardiology care, but these changes were not statistically significant. CONCLUSIONS: This multidisciplinary secondary prevention lipid clinic achieved the LDL-C goals (<100mg/dL and optional goal <70 mg/dL) more often than usual cardiology care for patients with CAD after 3 years of lipid management.

Myocardial infarction as a presentation of clinical in-stent restenosis.

BACKGROUND: In-stent restenosis is considered to be a gradual and progressive condition and there is scant data on myocardial infarction (MI) as a clinical presentation. METHODS AND RESULTS: Of 2,462 consecutive patients who underwent percutaneous coronary intervention between June 2001 and December 2002, clinical in-stent restenosis occurred in 212 (8.6%), who were classified into 3 groups: ST elevation MI (STEMI), non-ST elevation MI (NSTEMI) and non-MI. Of the 212 patients presenting with clinical in-stent restenosis, 22 (10.4%) had MI (creatine kinase (CK)>or=2xbaseline with elevated CKMB). The remaining 190 (89.6%) patients had stable angina or evidence of ischemia by stress test without elevation of cardiac enzymes. Median interval between previous intervention and presentation for clinical in-stent restenosis was shorter for patients with MI than for non-MI patients (STEMI, 90 days; NSTEMI, 79 days; non-MI, 125 days; p=0.07). Diffuse in-stent restenosis was more frequent in MI patients than in non-MI patients (72.7% vs 56.3%; p<0.005). Renal failure was more prevalent in patients with MI than in those without MI (31.8% vs 6.3%, p=0.001). Compared with the non-MI group, patients with MI were more likely to have acute coronary syndromes at the time of index procedure (81.8% vs 56.8%, p=0.02). CONCLUSION: Clinical in-stent restenosis can frequently present as MI and such patients are more likely to have an aggressive angiographic pattern of restenosis. Renal failure and acute coronary syndromes at the initial procedure are associated with MI.

Submassive pulmonary embolism and paradoxical embolic stroke treated with percutaneous rheolytic thrombectomy and closure of the patent foramen ovale.

The presence of patent foramen ovale (PFO) in patients with large pulmonary emboli (PE) is associated with an increased risk of stroke and mortality. Many patients are ineligible to receive thrombolytic therapy. We present a patient with bilateral PE and cryptogenic stroke who was treated effectively with rheolytic thrombectomy with AngioJet, PFO closure with CardioSeal device, and placement of an inferior vena cava filter.

Thrombus-in-transit and paradoxical embolism.

Paradoxical embolism is an uncommon but clinically important phenomenon. Elements of diagnosis include the presence of: (1) a venous thrombus, (2) an arterial embolus, (3) a communication between the right and left heart, and (4) a thrombus traversing such a communication. Unfortunately, all of these elements can be rarely demonstrated in each case but the probability should be considered in any patient with 2 or more present. It should be suspected in patients who have evidence of systemic arterial emboli without apparent cause. A transesophageal echocardiogram with contrast should be considered in cases where paradoxical embolism is a possibility. We present a case in which a "thrombus-in-transit" was imaged across the interatrial septum in a patient with a patent foramen ovale, deep venous thrombosis, and an embolic cerebrovascular stroke.

Cardiac manifestations of the antiphospholipid antibody syndrome: a review.

The antiphospholipid antibody syndrome (APLAS), though an uncommon entity involves multiple organs in the body. The antiphospholipid antibodies (APLA) refer to several groups of autoantibodies against negatively charged phospholipids occurring independently or in association with systemic lupus erythematosus (SLE) and related autoimmune disorders. Several studies to date found those patients with APLA, predominantly IgG and to lesser extent IgM isotype and lupus anticoagulant (LAC) are associated with arterial and venous thrombosis, recurrent fetal loss, thrombocytopenia, and livedo reticularis. We have described two cases of APLAS, one primary and the other secondary, their management and cardiac manifestations. Cardiac manifestations of the syndrome include coronary artery thrombosis and valvular heart disease. These can be serious and difficult to treat. Although the exact treatment of the cardiac manifestations of APLAS is not clear, anticoagulation is the currently recommended therapy.