The British Society for Sexual Medicine Guidelines on Male Adult Testosterone Deficiency, with Statements for Practice.

Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. A multi-disciplinary panel from BSSM reviewed the available literature on TD and provide evidence-based statements for clinical practice. Evidence was derived from Medline, EMBASE and Cochrane searches on hypogonadism, testosterone therapy (T Therapy) and cardiovascular safety from May 2017 to September 2022. This revealed 1,714 articles, including 52 clinical trials and 32 placebo-controlled randomised controlled trials. A total of twenty-five statements are provided, relating to five key areas: screening, diagnosis, initiating T Therapy, benefits and risks of T Therapy, and follow-up. Seven statements are supported by level 1 evidence, eight by level 2, five by level 3, and five by level 4. Recent studies have demonstrated that low levels of testosterone in men are associated with increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease and COVID 19 infection with increased all-cause mortality, along with significant quality of life implications. These guidelines should help practitioners to effectively diagnose and manage primary and age-related TD.

Routine iso-osmolar contrast media use and acute kidney injury following percutaneous coronary intervention for ST elevation myocardial infarction.

BACKGROUND: Temporal changes in contrast-induced acute kidney injury (CI-AKI) incidence following primary percutaneous coronary intervention (PPCI) are poorly defined. Additionally, the benefits of iso-osmolar contrast media (IOCM) compared to low osmolar CM (LOCM) are uncertain. METHODS: Using data from a regional PPCI service, temporal changes in baseline risk and annual incidence of CI-AKI were studied. A CM protocol change occurred in 2013 allowing a comparison of the incidence of CI-AKI between LOCM (2012-13) and IOCM (2013-15). RESULTS: Between 2012 and 2015, 208 of 1310 patients experienced CI-AKI (15.9%). The Mehran AKI risk score did not change during the study period although there was an increase in the incidence of CI-AKI in later study years (P<0.001 for trend) when IOCM was used. Factors independently associated with CI-AKI were IOCM use (OR=1.96, [95% CI: 1.39-2.75]), age per year (OR=1.02, 95% CI: 1.01-1.04), baseline creatinine per µmol/L (OR=1.006, 95% CI: 1.003-1.01) and contrast volume per milliliter (OR=1.002, 95% CI: 1.001-1.004). The baseline characteristics of patients treated using IOCM (N.=783) vs. LOCM (N.=527) were similar (Mehran Score 6.6 vs. 6.9, P=0.173) but CI-AKI occurred more frequently with IOCM compared to LOCM (19.2% vs. 11.2%, P<0.001). Use of IOCM was independently associated with CI-AKI (OR=1.98, 95% CI: 1.339-2.774, P<0.001) with consistency across all sub-groups of age, gender, baseline creatinine, contrast volume, shock and diabetes. The adjusted in-hospital mortality was increased with IOCM compared to LOCM (OR=3.03, 95% CI: 1.313-6.994, P=0.009). CONCLUSIONS: IOCM use was observed to be associated with an increased occurrence of CI-AKI, and an increase in in-hospital mortality after primary PCI.

British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men-2017.

BACKGROUND: This is an update of the 2008 British Society for Sexual Medicine (BSSM) guidelines. AIM: To provide up-to-date guidance for U.K. (and international) health care professionals managing male sexual dysfunction. METHODS: Source information was obtained from peer-reviewed articles, meetings, and presentations. A search of Embase, MEDLINE, and Cochrane Reviews was performed, covering the search terms "hypogonadism," "eugonadal or hypogonadism or hypogonadal or gonadal," and "low or lower testosterone," starting from 2009 with a cut-off date of September 2017. OUTCOMES: We offer evidence-based statements and recommendations for clinicians. RESULTS: Expert guidance for health care professionals managing male sexual dysfunction is included. CLINICAL TRANSLATION: Current U.K. management has been largely influenced by non-evidence guidance from National Health Service departments, largely based on providing access to care limited by resources. The 2008 BSSM guidelines to date have been widely quoted in U.K. policy decision making. CONCLUSIONS: There is now overwhelming evidence that erectile dysfunction is strongly associated with cardiovascular disease, such that newly presenting patients should be thoroughly evaluated for cardiovascular and endocrine risk factors, which should be managed accordingly. Measurement of fasting serum glucose, lipid profile, and morning total testosterone should be considered mandatory in all newly presenting patients. Patients attending their primary care physician with chronic cardiovascular disease should be asked about erectile problems. There can no longer be an excuse for avoiding discussions about sexual activity due to embarrassment. Hackett G, Kirby M, Wylie K, et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men-2017. J Sex Med 2018;15:430-457.

Dietary Nitrate Supplementation Reduces Circulating Platelet-Derived Extracellular Vesicles in Coronary Artery Disease Patients on Clopidogrel Therapy: A Randomised, Double-Blind, Placebo-Controlled Study.

Extracellular vesicles (EVs) are implicated in the pathogenesis of cardiovascular disease (CVD). Specifically, platelet-derived EVs are highly pro-coagulant, promoting thrombin generation and fibrin clot formation. Nitrate supplementation exerts beneficial effects in CVD, via an increase in nitric oxide (NO) bioavailability. Clopidogrel is capable of producing NO-donating compounds, such as S-nitrosothiols (RSNO) in the presence of nitrite and low pH. The aim of this study was to assess the effect of nitrate supplementation with versus without clopidogrel therapy on circulating EVs in coronary artery disease (CAD) patients. In this randomized, double-blind, placebo-controlled study, CAD patients with (n = 10) or without (n = 10) clopidogrel therapy received a dietary nitrate supplement (SiS nitrate gel) or identical placebo. NO metabolites and platelet activation were measured using ozone-based chemiluminescence and multiple electrode aggregometry. EV concentration and origin were determined using nanoparticle tracking analysis and time-resolved fluorescence. Following nitrate supplementation, plasma RSNO was elevated (4.7 ± 0.8 vs 0.2 ± 0.5 nM) and thrombin-receptor mediated platelet aggregation was reduced (-19.9 ± 6.0 vs 4.0 ± 6.4 U) only in the clopidogrel group compared with placebo. Circulating EVs were significantly reduced in this group (-1.183e11 ± 3.15e10 vs -9.93e9 ± 1.84e10 EVs/mL), specifically the proportion of CD41+ EVs (-2,120 ± 728 vs 235 ± 436 RFU [relative fluorescence unit]) compared with placebo. In vitro experiments demonstrated clopidogrel-SNO can reduce platelet-EV directly (6.209e10 ± 4.074e9 vs 3.94e11 ± 1.91e10 EVs/mL). In conclusion, nitrate supplementation reduces platelet-derived EVs in CAD patients on clopidogrel therapy, increasing patient responsiveness to clopidogrel. Nitrate supplementation may represent a novel approach to moderating the risk of thrombus formation in CAD patients.

British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice.

BACKGROUND: Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. AIM: To review the available literature on TD and provide evidence-based statements for UK clinical practice. METHODS: Evidence was derived from Medline, EMBASE, and Cochrane searches on hypogonadism, testosterone (T) therapy, and cardiovascular safety from May 2005 to May 2015. Further searches continued until May 2017. OUTCOMES: To provide a guideline on diagnosing and managing TD, with levels of evidence and grades of recommendation, based on a critical review of the literature and consensus of the British Society of Sexual Medicine panel. RESULTS: 25 statements are provided, relating to 5 key areas: screening, diagnosis, initiating T therapy, benefits and risks of T therapy, and follow-up. 7 statements are supported by level 1, 8 by level 2, 5 by level 3, and 5 by level 4 evidence. CLINICAL IMPLICATIONS: To help guide UK practitioners on effectively diagnosing and managing primary and age-related TD. STRENGTHS AND LIMITATIONS: A large amount of literature was carefully sourced and reviewed, presenting the best evidence available at the time. However, some statements provided are based on poor-quality evidence. This is a rapidly evolving area of research and recommendations are subject to change. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions and take personal values and preferences and individual circumstances into account. Many issues remain controversial, but in the meantime, clinicians need to manage patient needs and clinical expectations armed with the best clinical evidence and the multidisciplinary expert opinion available. CONCLUSION: Improving the diagnosis and management of TD in adult men should provide somatic, sexual, and psychological benefits and subsequent improvements in quality of life. Hackett G, Kirby M, Edwards D, et al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. J Sex Med 2017;14:1504-1523.

Coronary Perforation Complicating Percutaneous Coronary Intervention in Patients With a History of Coronary Artery Bypass Surgery: An Analysis of 309 Perforation Cases From the British Cardiovascular Intervention Society Database.

BACKGROUND: The evidence base for coronary perforation (CP) occurring during percutaneous coronary intervention in patients with a history of coronary artery bypass surgery (PCI-CABG) is limited and the long-term effects unclear. Using a national PCI database, the incidence, predictors, and outcomes of CP during PCI-CABG were defined. METHODS AND RESULTS: Data were analyzed on all PCI-CABG procedures performed in England and Wales between 2005 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. During the study period, 309 CPs were recorded during 59 644 PCI-CABG procedures with the incidence rising from 0.32% in 2005 to 0.68% in 2013 (P<0.001 for trend). Independent associates of perforation in native vessels included age, chronic occlusive disease intervention, rotational atherectomy use, number of stents, hypertension, and female sex. In graft PCI, predictors of perforation were history of stroke, New York Heart Association class, and number of stents used. In-hospital clinical complications including Q-wave myocardial infarction (2.9% versus 0.2%; P<0.001), major bleeding (14.0% versus 0.9%; P<0.001), blood transfusion (3.7% versus 0.2%; P<0.001), and death (10.0% versus 1.1%; P<0.001) were more frequent in patients with CP. A continued excess mortality occurred after perforation, with an odds ratio for 12-month mortality of 1.35 for perforation survivors compared with matched nonperforation survivors without a CP (P<0.0001). CONCLUSIONS: CP is an infrequent event during PCI-CABG but is closely associated with adverse clinical outcomes. A legacy effect of perforation on 12-month mortality was observed.

Baseline anemia in patients undergoing percutaneous coronary intervention after an acute coronary syndrome-A paradox of high bleeding risk, high ischemic risk, and complex coronary disease.

OBJECTIVES: To define more clearly the associations between baseline anemia, bleeding/ischemia risk, coronary disease severity, and outcomes by revascularization completeness. BACKGROUND: Anemia is associated with adverse outcomes in patients presenting with an acute coronary syndrome (ACS). METHODS AND RESULTS: Data was sourced from hospital databases for patients admitted with an ACS to a single center between 2011 and 2014. Using WHO anemia criteria, 468 (26.9%) of 1731 patients were anemic. In anemic patients, the mean CRUSADE score (34.6 ± 16.9 vs 24.6 ± 13.4, P < 0.0001), mean GRACE scores (165.8 ± 44.9 vs 141.6 ± 40.1, P < 0.0001), and percentage of patients with a high/very high CRUSADE score combined with a high GRACE score (69.3 vs 48.3%, P < 0.0001) was much greater than non-anemic patients. Patients with baseline anemia were more likely to have left main or chronic occlusive disease, and more diseased vessels. The percentage of patients with residual disease (41.2 vs 30.7%, P < 0.0001), the number of residual diseased vessels (0.59 ± 0.83 vs 0.42 ± 0.72, P < 0.0001), and the percentage with a residual CTO (62.4 vs 56.4%, P = 0.036) were all higher than in non-anemic patients. The duration of anti-platelet therapy was significantly shorter in anemic patients (7.8 ± 4.3 vs 11.2 ± 2.4 months, P < 0.001). At 12-months, mortality and stent thrombosis were more likely to occur in anemic patients, with the number of residual vessels associated with adverse survival regardless of anemia status. CONCLUSIONS: Patients with anemia present with high ischemia and bleed risk scores, complex coronary disease, and have adverse outcomes. Incomplete revascularization was associated with worse survival regardless of anemia status.

Vascular Access Site and Outcomes Among 26,807 Chronic Total Coronary Occlusion Angioplasty Cases From the British Cardiovascular Interventions Society National Database.

OBJECTIVES: The aim of this study was to assess, using a national percutaneous coronary intervention (PCI) database, access-site choice and outcomes after chronic total occlusion (CTO) PCI. BACKGROUND: Given the influence of access site on outcomes, the use of radial access in CTO PCI warrants further investigation. METHODS: Data were analyzed from the British Cardiovascular Intervention Society dataset of 26,807 elective CTO PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regression was used to identify predictors of access-site choice and its association with outcomes. RESULTS: There was a significant decrease in femoral artery (FA) access from 84.6% in 2006 to 57.9% in 2013. Procedural factors associated with FA access included dual access (odds ratio [OR]: 3.89; 95% confidence interval [CI]: 3.45 to 4.32), CrossBoss/Stingray (OR: 1.87; 95% CI: 1.43 to 2.12), intravascular ultrasound (OR: 1.32; 95% CI: 1.21 to 1.53), and microcatheter use (OR: 1.18; 95% CI: 1.03 to 1.39). There was an association between FA access and the number of CTO devices used (p = 0.001 for trend). Access-site complications (1.5% vs. 0.5%; p < 0.001), periprocedural myocardial infarction (0.5% vs. 0.2%; p = 0.037), major bleeding (0.8% vs. 0.2%, p < 0.001), transfusion (0.4% vs. 0%; p < 0.001), and 30-day death (0.6% vs. 0.1%; p = 0.002) were more frequent in patients undergoing CTO PCI using FA access. An access-site complication during CTO PCI was associated with significant increases in transfusion (8.0% vs. 0.1%; p < 0.001), procedural coronary complication (17.3% vs. 5.8%; p < 0.0001), major bleeding (8.4% vs. 0.3%; p < 0.001), and mortality at all time points. CONCLUSIONS: FA access remains predominant during CTO PCI, with case complexity and device size associated with its use. Access-site complications were more frequent with FA use and strongly correlated with adverse outcomes.

Comparison of the Effects of Incomplete Revascularization on 12-Month Mortality in Patients <80 Compared With ≥80 Years Who Underwent Percutaneous Coronary Intervention.

Although randomized trial data suggest that complete revascularization improves outcomes after percutaneous coronary intervention (PCI), the impact of differing revascularization strategies in octogenarians is not well defined. We performed a retrospective analysis, which was conducted of 9,628 consecutive patients who underwent PCI at a large UK center. Octogenarians were more likely to have significant co-morbidity, a higher Mehran bleed risk score (24.5 ± 6.8 vs 13.3 ± 7.4, p <0.0001), and more complex disease (baseline SYNTAX score 18.7 ± 11.0 vs 13.1 ± 8.9, p = 0.002) than younger patients. During PCI, octogenarians were more likely to undergo left main or proximal LAD intervention, but despite this, significantly less likely to receive drug-eluting stents (66.5% vs 80.1%, p <0.001). Postprocedurally, octogenarians had greater residual disease burden (residual SYNTAX score 10.1 ± 8.7 vs 1.6 ± 3.3, p <0.0001). At 12 months, adverse outcomes (definite stent thrombosis 3.3% vs 1.1%, p <0.001, clinically driven in-stent restenosis PCI 3.7% vs 2.6%, p = 0.005, and 12-month mortality 12.8% vs 4.2%, p <0.0001) were all more frequent in octogenarians. Although age, shock, diabetes, and BMS use were independently predictive of increased 12-month mortality, incomplete revascularization was not. In conclusion, octogenarians are a complex group to treat balancing high-risk bleeding profile and complex coronary disease. However, in multivariate analysis, incomplete revascularization was not independently predictive of adverse outcomes. These data support a conservative target lesion-only DES-driven revascularization strategy.

Rotational Atherectomy in a Dissected Coronary Artery That Propagated Into the Sinus of Valsalva: Is This the Last Hope?

Percutaneous coronary intervention (PCI) of a resistant, undilatable lesion can result in coronary dissection. Retrograde propagation of a dissection flap into the sinus of Valsalva is a rare phenomenon. It is commonly seen at the time of PCI to a right coronary artery (RCA) and is associated with potentially fatal consequences. Use of rotational atherectomy (RA) is contraindicated in the presence of a coronary dissection. Coronary dissection with preserved flow in asymptomatic patients should be managed conservatively until the dissection heals, but in the case presented here, as coronary flow was compromised, the patient complained of chest pain and ST elevation was observed on electrocardiogram.

Complex Disease, Partial Revascularization, and Adverse Outcomes in Patients Treated With Long-Term Warfarin Therapy Who Underwent Percutaneous Coronary Intervention.

Patients treated with warfarin who undergo percutaneous coronary intervention (PCI) present a difficult therapeutic problem. Their baseline demographics, procedural characteristics, and 12-month outcomes are poorly defined. We conducted a retrospective analysis of all patients who underwent PCI at a major UK Cardiac Center from 2012 to 2013. Of the 2,675 patients who underwent PCI, 155 were on long-term warfarin treatment (5.8%). Patients on warfarin were older and more likely to have significant co-morbidity than those not on warfarin. The modified Mehran bleed score was higher in patients treated with warfarin versus those not treated (19.0 ± 5.8 vs 15.4 ± 8.0, p = 0.004). Baseline SYNTAX scores were higher in the patients treated with warfarin (18.5 ± 9.1 vs 12.4 ± 3.8, p = 0.0006) as were residual SYNTAX scores (8.3 ± 1.1 vs 3.8 ± 5.9, p = 0.001). Bare metal stents were more frequently used in warfarin-treated patients than those not treated (44.8% vs 26.3%, p <0.0001). Antiplatelet monotherapy was prescribed after PCI in 14.4% of patients treated with warfarin and 0.7% of non-warfarin (p <0.0001), whereas average dual anti-platelet therapy duration was also significantly shorter (4.3 vs 10.7 months, p <0.0001). At 1-year follow-up, target-vessel revascularization (6.5% vs 3.3%, p <0.05), stent thrombosis (5.0% vs 2.6%, p = 0.14), death (10.1% vs 4.6%, p <0.01), and target-vessel revascularization/stent thrombosis/death (21.6% vs 10.5%, p = 0.004) were all more common in the warfarin cohort. In conclusion, patients treated with warfarin who need PCI are a complex cohort, more likely to receive incomplete revascularization, less intense, and shorter durations of antiplatelet therapy, and have adverse 1-year outcomes. More trials of both current DES and newer DES technologies in warfarin-treated patients are needed.

Erectile dysfunction: a window to the heart.

Erectile dysfunction (ED) is an early marker of coronary artery disease (CAD) and often manifests before the development of symptomatic CAD. In this case report, we present a 60-year-old man with ED, who demonstrated limited response to the standard management strategies and was subsequently treated with percutaneous pelvic intervention (PPI) of the internal pudendal artery. While on the table for PPI, the patient described a classical history of angina, on which basis he underwent coronary angiography and was found to have narrow proximal left anterior descending stenosis. Coronary artery stent placement was then performed using standard techniques. PPI of pudendal artery stenoses with stents is feasible and can improve cavernosal blood flow and venous leakage as well as erectile function.

Intractable ventricular fibrillation: post ascending aortic dissection repair.

Ascending aortic dissection is a life threatening surgical emergency and carries high peri-operative mortality. Various biological adhesive materials are commonly used in such a surgery to enhance strengthening of separated layers of aortic wall. Despite of extensive use, embolization of the glue material remains a feared complication. Here we are describing a case where BioGlue embolized down the left main stem and resulted in refractory ventricular arrhythmia and hemodynamic instability.

Rivaroxaban in patients with a recent acute coronary syndrome event: integration of trial findings into clinical practice.

Despite significant advances in the management of acute coronary syndrome (ACS) and long-term antiplatelet therapy after an ACS event, patients continue to be at risk of further cardiovascular events. There is evidence that recurrent events are at least partly attributed to the persistent activation of the coagulation system after ACS. Various anticoagulants, including vitamin K antagonists (VKAs) and non-VKA oral anticoagulants, have been evaluated in patients post-ACS, in combination with antiplatelet therapy. The desired outcome would be a further reduction of recurrent cardiovascular events with low or acceptable levels of bleeding complications. Here, we provide an overview of the current clinical trial data of non-VKA oral anticoagulants, focusing on rivaroxaban in particular, for secondary prevention in patients with a recent ACS event.

Extended duration of brachially inserted intra-aortic balloon pump for myocardial protection in two patients undergoing urgent coronary artery bypass grafting.

Intra-aortic balloon pump (IABP) provides myocardial protection for patients who are at risk of myocardial injury during cardiac surgery. The haemodynamic support is crucial in patients with significant and critical coronary artery disease undergoing revascularisation procedures. Traditionally, the femoral arterial access is the preferred route for IABP insertion. This is, however, not always feasible especially in patients with concomitant occlusive peripheral vascular disease. The trans-brachial route can be used as an alternative for percutaneous insertion of the IABP. We report the technique for left trans-brachial insertion of an IABP, and illustrate our experience with two patients requiring urgent coronary artery bypass grafting (CABG) and for whom the IABP duration was over 50 h.