Ticagrelor use in patients after percutaneous coronary intervention: one year follow up in a community hospital.

BACKGROUND: Current guidelines from American College of Cardiology (ACC) recommend ticagrelor over clopidogrel in patients with acute coronary syndrome. We have observed many patients being switched from ticagrelor to clopidogrel after percutaneous coronary intervention (PCI) in our hospital. Our goal is to evaluate the use rate of ticagrelor and categorize the reasons for non-use. METHODS: We performed a retrospective data analysis of all patients who underwent PCI at Unity Hospital of Rochester, New York, from January 2019 to January 2020. A total of 330 patients underwent PCI for ACS over the year. After exclusions, 277 patients were enrolled in the analysis. RESULTS: Of the 277 patients, 179 (65%) completed one year of ticagrelor therapy, and 98 (35%) stopped ticagrelor and transitioned to clopidogrel. The most common reason for switching from ticagrelor was dyspnea (42 patients), followed by cost concerns (41 patients). CONCLUSION: At our community hospital, completion of one-year use of ticagrelor post-PCI occurred in 65% of patients. The most common reasons for discontinuation are dyspnea and medication cost.

Is obstructive sleep apnea associated with ventricular tachycardia? A retrospective study from the National Inpatient Sample and a literature review on the pathogenesis of Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is a known independent risk factor for a multiple cardiovascular morbidities and mortality. The association of OSA and ventricular arrhythmias is less well understood. The aim of this analysis is to study the relationship between OSA and ventricular tachyarrhythmias. HYPOTHESIS: OSA is associated with increased ventricular arrhythmias. METHODS: Data from the national inpatient sample (NIS) 2012 to 2014, were reviewed. Discharges associated with OSA were identified as the target population using the relevant ICD-9-CM codes. The primary outcome was a diagnosis of ventricular tachycardia (VT) in the OSA population. Secondary outcomes include the rate of ventricular fibrillation (VF) and cardiac arrest. Multivariable analyses were performed to examine the association of VT with multiple potential confounding clinical variables. RESULTS: Of 18 013 878 health encounters, 943 978 subjects (5.24%) had a diagnosis of OSA. VT and VF were more prevalent among patients with OSA compared to those without a diagnosis of OSA (2.24% vs 1.16%; P < 0.001 and 0.3% vs 0.2%; P < 0.001, respectively). Odds ratio for cardiac arrest in OSA group was not statistically significant (1, 95% confidence interval 0.97-1.02, P < 0.76). In unadjusted analyses, all examined comorbidities were significantly more common in those with OSA, including diabetes mellitus, hypertension, chronic kidney disease, acute coronary syndrome, and heart failure. CONCLUSION: OSA is associated with increased rates of ventricular tachyarrhythmia.

Recurrent Pseudomonas aortic root abscess complicating mitral valve endocarditis.

We report on a man with Pseudomonas aeruginosa endocarditis causing an aortic root abscess. He underwent surgery with a homograft aortic root replacement and insertion of a tissue aortic valve. The patient then manifested recurrent aortic root infection and respiratory arrest, and eventually succumbed to sepsis. This case highlights the aggressive nature of an uncommon pathogen causing an atypical but lethal form of endocarditis, despite modern medical and surgical treatment.

Interobserver reliability in the assessment of coronary stenoses by multidetector computed tomography.

OBJECTIVE: To determine the interobserver reliability for grading coronary stenosis severity with coronary computed tomographic angiography (CCTA). METHODS: Five readers independently reviewed 40 CCTA studies, first the axial images alone, then in combination with multiplanar reconstructions. The stenosis severity in each segment was scored on a 5-point scale. Intraclass correlation (ICC) analysis was performed to assess interobserver reliability on a segmental basis. RESULTS: The reliability was good to moderate in the right coronary artery, left main artery, left anterior descending artery and branches, and the proximal circumflex (ICC: 0.44-0.75) but fair to poor for the posterior descending artery, the posterolateral branch, the obtuse marginal branches, and the distal circumflex (ICC: 0.15-0.39). The ICC correlated with the reference diameter. Although there was no significant difference in the ICC between the scanner types, there were more unevaluable segments in the 16-row scanner compared with the 64-row scanner (2.4 vs 1.4 segments/patient). Addition of multiplanar reconstruction to axial images led to fewer uninterpretable segments and reclassification of stenosis grade in 23% of the segments. CONCLUSIONS: Interobserver reliability for stenosis severity by CCTA varies between segments and correlates with the reference diameter.

The role of calcium score and CT angiography in the medical management of patients with normal myocardial perfusion imaging.

BACKGROUND: Individuals with normal myocardial perfusion imaging (MPI) may still have substantial coronary artery disease (CAD), which would benefit from aggressive medical therapy. The role of coronary artery calcium-score (CAC) and/or coronary CT Angiography (CTA) to identify additional treatment candidates in this population is unknown. METHODS: Ninety-four patients completed the study protocol and underwent CAC and CTA after MPI. RESULTS: In 81 patients who had a normal MPI, an algorithm using the clinical predictors, CAC, and then CTA was created to identify candidates for aggressive medical management; 24/81 patients had a high Framingham Risk Score (FRS) or diabetes, and need aggressive medical management, while 6/81 patients had a low FRS and low post-MPI probability of CAD. The use of CAC in 51/81 patients with intermediate clinical predictors would identify 23/51 patients with low risk (CAC < 100) and 11/51 patients (CAC > 400) for aggressive medical management. The remaining 17/51 patients with intermediate CAC scores (100-399) would require CTA, of which, would identify 8/17 additional patients with >50% stenosis for aggressive medical therapy. CONCLUSION: A stepwise approach including history, CAC and CTA can identify about 50% of the patients with normal MPI who have a higher risk and may benefit from aggressive medical management.