Ischemic and Bleeding Outcomes of Potent P2Y12 Inhibitor Antiplatelet Agents Versus Clopidogrel in Elderly Patients With Acute Coronary Syndrome: A Meta-Analysis of Randomized Trials.

BACKGROUND: The role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population. METHODS AND RESULTS: PubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82-1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75-1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78-1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82-1.86]; p=0.31). However, potent oral P2Y12 inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68-0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09-1.59]; p<0.01). CONCLUSION: In comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.

Sex Differences in the Clinical Outcomes After Left Atrial Appendage Closure: A Systematic Review and Meta-Analysis.

INTRODUCTION: Left atrial appendage occlusion (LAAO) has emerged as a reasonable alternative to oral anticoagulation in a selective group of patients with atrial fibrillation (AF). While women are known to have higher risk of AF-related stroke, the impact of sex differences on the clinical outcomes of LAAO has not been well-studied. OBJECTIVE: We sought to perform a meta-analysis evaluating sex differences on the outcomes of patients undergoing LAAO. METHODS: We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases (from inception to October 2021) for studies evaluating the impact of sex difference on LAAO procedural outcomes. We used a random-effects model to calculate risk ratio (RR) with 95% confidence intervals (CI). In-hospital all-cause mortality and ischemic stroke were the primary endpoints. In-hospital pericardial effusion/cardiac tamponade, major bleeding, technical success, device-related thrombus, and hospital length of stay were secondary outcomes. RESULTS: A total of 5 studies with 54,754 patients were included, of whom 22,461 (41%) were females. Female sex was associated with higher rates of in-hospital all-cause mortality (RR 2.18; 95% CI 1.46-3.26; P = 0.0001) and in-hospital ischemic stroke (RR 1.67; 95% CI 1.06-2.61; P = 0.03) when compared with males. Females had higher rates of in-hospital major bleeding (RR 1.93; 95% CI 1.40-2.67; P < 0.0001) and hospital length of stay >1 day (RR 1.38; 95% CI 1.33-1.45; P < 0.00001). There were no differences between females and males in terms of technical success (RR 1.00; 95% CI 1.00-1.00; P = 1.00) and device-related thrombus and (RR 0.94, 95% CI 0.31-2.82; P = 0.91). CONCLUSION: Women are more likely to experience worse periprocedural outcomes with longer hospital stay after LAA closure. Further efforts are needed to increase the participation of women in clinical studies and to assess these differences to properly address the discrepancy in outcomes between men and women.

Acute myocardial infarction in a young man with large left ventricular thrombus and the antiphospholipid syndrome.

Antiphospholipid syndrome is an autoimmune disorder that presents clinically with venous and/or arterial thrombosis and can affect any organ. Coronary artery involvement and left ventricular thrombus are rare presentations. We report the case of a 23-year-old male smoker with a strong family history of premature coronary artery disease who presented with acute anterolateral ST elevation myocardial infarction and large left ventricular thrombus. He was treated with primary percutaneous coronary intervention with thrombectomy without stenting. He was later diagnosed with antiphospholipid syndrome.

Sinus of Valsalva Aneurysm: A Rare Cause of Dyspnea.

Sinus of Valsalva aneurysm (SOVA) is a rare clinical entity. Clinical manifestations can vary from an incidental finding on an imaging study to a life-threatening emergency. We report a case of a 51-year-old female with a large symptomatic left SOVA. Echocardiogram and computed tomography angiography (CTA) of the chest revealed marked dilatation of the left sinus of Valsalva, measuring 7.5 cm. This resulted in superior displacement of the left main coronary artery. Surgical repair of the aneurysm with reimplantation of the right and left coronary arteries was performed in addition to aortic valve replacement (Bentall procedure). The patient had an uneventful postoperative course and remains asymptomatic at the three-month follow-up visit.