Spontaneous Left Main Coronary Artery Dissection in a Male.

Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) that is increasingly recognized in young to middle-aged women without typical coronary risk factors. This case report describes a 46-year-old male with a rare presentation of SCAD involving the left main (LM) coronary artery. The patient underwent an emergency coronary angiogram for high-risk ACS and had percutaneous coronary intervention (PCI) of LM due to active ischemia and hemodynamic instability. The extension of intramural hematoma after the LM coronary artery stent confirmed the initial suspicion of SCAD. The diagnosis of SCAD is crucial, as its management differs from other causes of ACS. Coronary angiography is the gold standard for diagnosing SCAD, with adjunctive imaging using optical coherence tomography (OCT) and intravascular ultrasound (IVUS). In this patient, his physical examination findings and further imaging raised a suspicion for systemic connective tissue disease. Genetic analysis was executed, but no reportable variants in any of the 29 genes studied were identified. This case highlights the importance of recognizing SCAD as a potential cause of ACS even in men and emphasizes the findings during coronary angiography that can aid in an accurate diagnosis and appropriate management.

Effect of Sex Difference on Discordance Between Instantaneous Wave-Free Ratio and Fractional Flow Reserve.

BACKGROUND: Physiology-guided percutaneous coronary intervention (PCI) has demonstrated to improve clinical outcomes. Previous trials showed the agreement between iFR and FFR is approximately 80%, however the details of discordance pattern remain to be elucidated. METHODS: We retrospectively reviewed 1024 consecutive intermediate stenotic lesions for which functional evaluation using both iFR and FFR were performed between January 2015 and June 2016. The lesions were classified into 4 groups according to iFR and FFR concordance [(iFR+/FFR+) and (iFR-/FFR-)] or discordance [(iFR+/FFR-) and (iFR-/FFR+)]. RESULTS: Our study evaluated 451 lesions, 264 lesions (58.5%) from men and 187 lesions (41.5%) from women. iFR was similar between women and men, however FFR was significantly higher in women than men. The rate of discordance between iFR and FFR was 21.3% (iFR+/FFR- 12.4% and iFR-/FFR+ 8.9%) in overall cohort. The prevalence of overall concordance and discordance were similar between men and women, however iFR+/FFR- discordance was significantly higher in women (17.1% vs. 9.1%) whereas iFR-/FFR+ discordance was significantly higher in men (11.3% vs. 4.8%). In multivariable analysis, female sex and older age were significantly associated with iFR+/FFR- discordance (odds ratio 1.88 and 1.48, respectively). Conversely, younger age, higher stenosis, and concomitant chronic total occlusion were independent predictors for iFR-/FFR+ discordance (odds ratio 0.67, 1.82, and 4.32, respectively). CONCLUSIONS: Despite similar prevalence of overall concordance and discordance between men and women, iFR+/FFR- discordance was higher in women and iFR-/FFR+ discordance was higher in men. Multivariable analysis showed female sex to be independent predictor of iFR+/FFR- discordance.

Guide Extension-Assisted Stent Implantation at Ostial Right Coronary Artery Creating Stent Tunnel During Transcatheter Aortic Valve Replacement.

Coronary artery occlusion is an uncommon but life-threatening complication of transcatheter aortic valve replacement (TAVR). Both low coronary artery height and externally mounted stented bioprosthesis present an increased risk for coronary artery occlusion, and various prevention strategies have been recommended. We present an 86-year-old woman with failed surgical bioprosthesis, concomitant obstructive ostial right coronary artery (RCA) lesion, and low coronary ostial heights who underwent simultaneous TAVR and percutaneous coronary intervention of ostial RCA. Due to suprannular valve expansion after post-dilation, the RCA ostium was compromised, and a novel stent tunnel was created under the native leaflets towards the left coronary sinus to maintain RCA perfusion.

Risk of amputation associated with sodium-glucose co-transporter 2 inhibitors: A meta-analysis of five randomized controlled trials.

Amputation has been known to be a rare adverse event of sodium glucose co-transporter-2 (SGLT2) inhibitors. It remains unclear whether the SGLT2 inhibitor as a class or specific categories of the SGLT2 inhibitors are linked with an increased risk of amputation. The objective of this meta-analysis was to investigate the association between the amputation risk and the use of SGLT2 inhibitors. The main outcome measure was the risk of amputation. Multiple databases were searched up to February 2020 and data extraction was performed. Inclusion criteria were randomized controlled trials (RCTs) which reported risk of amputation with SGLT2 inhibitors over non-SGLT2 inhibitors or placebo. The risk of bias was assessed by Cochrane bias tool. The initial search yielded 1,873 citations and a total of five RCTs were included in the meta-analysis. The five included studies evaluated a total of 39,067 patients with diabetes mellitus, including 21,395 patients on SGLT2 inhibitors. The incidence rate of amputation ranged from 0.36 to 3.18% in the SGLT2 inhibitor group and from 0% to 2.87% in the control group. Follow up duration ranged from 24 weeks to 4.2 years. Use of SGLT2 inhibitors was not associated with significant increase in the risk of amputation as compared with controls (OR: 1.31, 95% CI: 0.92-1.87, I2 = 75%). Subgroup analysis showed that neither canagliflozin, empagliflozin, nor dapagliflozin was associated with increased risk of amputation. In conclusion, our meta-analysis showed that neither canagliflozin nor other SGLT2 inhibitors increase the risk of amputation.

Antithrombotic strategies after transcatheter aortic valve implantation: Insights from a network meta-analysis.

OBJECTIVES: We aimed to investigate the efficacy and safety of different antithrombotic strategies in patients undergoing transcatheter aortic valve implantation (TAVI) using network meta-analyses. BACKGROUND: Meta-analyses comparing single antiplatelet therapy (SAPT) vs. dual antiplatelet therapy (DAPT), ± oral anticoagulant (OAC) was conducted to determine the appropriate post TAVI antithrombotic regimen. However, there was limited direct comparisons across the different therapeutic strategies. METHODS: MEDLINE and EMBASE were searched through December 2018 to investigate the efficacy and safety of different antithrombotic strategies (SAPT, DAPT, OAC, OAC + SAPT, and OAC + DAPT) in patients undergoing TAVI. The main outcome were all-cause mortality, major or life-threatening bleeding events, and stroke. RESULTS: Our search identified 3 randomized controlled trials and 10 nonrandomized studies, a total of 20,548 patients who underwent TAVI. All OACs were vitamin K antagonists. There was no significant difference on mortality except that OAC + DAPT had significantly higher rates of mortality compared with others (p < .05, I2 = 0%). SAPT had significantly lower rates of bleeding compared with DAPT, OAC+SAPT, and OAC+DAPT (hazard ratio [HR]: 0.59 [0.46-0.77], p < .001, HR: 0.58 [0.34-0.99], p = .045, HR: 0.41 [0.18-0.93], p = .033, respectively, I2 = 0%). There was no significant difference on stroke among all antithrombotic strategies. CONCLUSION: Patients who underwent TAVI had similar all-cause mortality rates among different antithrombotic strategies except OAC+DAPT. Patients on SAPT had significantly lower bleeding risk than those on DAPT, OAC + SAPT, and OAC + DAPT. Our results suggest SAPT is the preferred regimen when there is no indication for DAPT or OAC. When DAPT or OAC is indicated, DAPT + OAC should be avoided.

Prevalence and Clinical Implication of Wellens' Sign in Patients With Non-ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Symmetrically inverted or biphasic T waves in anterior precordial leads, Wellens' sign, have been shown to represent impending infarction of left anterior descending (LAD) territory among unstable angina patients in the studies published more than 3 decades ago, when non-ST-segment elevation myocardial infarction (NSTEMI) was not a recognized entity. The clinical implication of Wellens' sign in the contemporary NSTEMI cohort has not been clarified. METHODS: We performed a retrospective analysis of all NSTEMI patients who underwent coronary angiography between January 2013 and June 2014. Wellens' sign was defined as either symmetrically inverted T waves (≥ 0.10 mV) or biphasic T waves in both leads V2 and V3. Coronary angiograms were reviewed and culprit lesions were determined for each patient. RESULTS: A total of 274 patients were included in the final analysis, of whom 24 (8.8%) had Wellens' sign. Among these 24 patients, 16 had a LAD culprit (eight proximal), two had a non-LAD culprit, and six had non-obstructive coronary artery disease. Patients with Wellens' sign were more likely to have LAD culprit (66.7% vs. 19.6%, P < 0.001) and proximal LAD culprit (33.3% vs. 14.4%, P = 0.035) than those without it. Wellens' sign had a sensitivity of 24.6% and a specificity of 96.2% to predict LAD culprit. CONCLUSIONS: Our study revealed that: 1) Wellens' sign was seen in 8.8% of the patients with NSTEMI; 2) Two-thirds of patients with Wellens' sign had LAD culprit and one-third had proximal LAD culprit; and 3) Sensitivity and specificity of Wellens' sign to predict LAD culprit were 24.6% and 96.2%, respectively.

Clinical Effect of Rebound Hyperthermia After Cooling Postcardiac Arrest: A Meta-Analysis.

Rebound hyperthermia (RH) is frequently seen after completion of targeted temperature management (TTM) in comatose survivors of cardiac arrest. However, its clinical significance is not well understood. Previous studies analyzing the association of RH with clinical outcome have reported conflicting results. The purpose of this meta-analysis is to examine the impact of RH after completion of TTM in patients postcardiac arrest. We reviewed six studies that evaluated the incidence of RH (T > 38°C) with documentation of outcome based on the presence of hyperthermia. We reviewed all six articles and extracted the data for mortality and neurological outcome. A total of 729 patients were analyzed for neurological outcome and 950 patients were analyzed for mortality. RH was found to be associated with a significantly worse neurological outcome (odds ratio [OR] 1.55; 95% confidence interval [CI] 1.13-2.14). RH was not significantly associated with a higher mortality (OR 1.31; 95% CI 1.00-1.72). We also analyzed three studies totaling 206 patients for neurological outcomes and mortality that included patients with severe RH (T > 38.5°C). Severe RH was found to be associated with significantly worse neurological outcome (OR 1.92, 95% CI 1.28-1.90) and significantly worse mortality (OR 2.22, 95% CI 1.50-3.29). RH is common after completion of TTM in comatose patients because of cardiac arrest and is associated with poor neurological outcomes. The clinical impact of RH is likely proportional to the magnitude of RH.

Low QRS Voltage on Presenting Electrocardiogram Predicts Multi-vessel Disease in Anterior ST-segment Elevation Myocardial Infarction.

BACKGROUND: Low QRS voltage was reported to predict adverse outcomes in acute myocardial infarction in the pre-thrombolytic era. However, the association between low voltage and angiographic findings has not been fully addressed. METHODS: We performed a retrospective analysis of patients with anterior ST-segment elevation myocardial infarction (STEMI). Low QRS voltage was defined as either peak to peak QRS complex voltage <1.0mV in all precordial leads or <0.5mV in all limb leads. RESULTS: Among 190 patients, 37 patients (19%) had low voltage. Patients with low voltage had a higher rate of multi-vessel disease (MVD) (76% vs. 52%, p=0.01). Patients with low voltage were more likely to undergo coronary artery bypass grafting (CABG) during admission (11% vs. 2%, p=0.028). Low voltage was an independent predictor for MVD (OR 2.50; 95% CI 1.12 to 6.03; p=0.032). CONCLUSION: Low QRS voltage was associated with MVD and in-hospital CABG in anterior STEMI.

ST-segment Elevation Myocardial Infarction Resulting from Stent Thrombosis in Contemporary Real-World Practice.

Stent thrombosis (ST) is a rare but devastating complication after percutaneous coronary intervention. Newer generation drug-eluting stents (DES) and newer antiplatelet therapies have been shown to decrease the incidence of ST, but we continue to observe ST-segment elevation myocardial infarction (STEMI) due to ST in contemporary practice. A retrospective analysis of 527 patients who presented with STEMI was performed; 57 patients (11%) with angiographically confirmed ST were compared with the patients with STEMI due to de novo lesion. The type of previous stent, the timing of ST, and the use of antiplatelet therapy were reviewed in patients with ST. Patients with ST had higher prevalence of comorbid conditions, such as hypertension, diabetes mellitus, and coronary artery disease, and had lower left ventricular ejection fraction (37 ± 5 vs. 44 ± 16%, p = 0.0011). There was no difference in in-hospital mortality (2 vs. 4%, p = 0.7082). ST was seen most commonly as "very late" (56%), and with previous second-generation DES (40%). Eighty-two percent of patients among early ST, compared with 22% of patients with very late ST were on dual antiplatelet therapy (DAPT). In 12% of patients, ST happened after DAPT was stopped by physician for procedures. ST is seen in a variety of clinical settings with the most common presentation being very late ST and in second-generation DES, which most likely represent the growing population with previous second-generation stents.

First and second generation DESs reduce diabetes adverse effect on mortality and re-intervention in multivessel coronary disease: 9-Year analysis.

BACKGROUND/PURPOSE: Diabetes portends an increased risk of adverse early and late outcomes in patients undergoing PCI. In this study, we aimed to investigate if the adverse effect of diabetes mellitus (DM) on early and late PCI outcomes is reduced with drug-eluting (DES) compared to bare-metal (BMS) stents. METHODS/MATERIALS: We reviewed the Mount Sinai Beth Israel Hospital first PCI experience for multivessel coronary artery disease (CAD, 1998-2009). Patients were excluded if they had single-vessel CAD, emergency, no stent, prior bypass graft or myocardial infarction <24h. Diabetes-effect was derived from 9-year all-cause mortality and re-intervention risk-adjusted hazard ratios [AHR (95% confidence intervals)] for DES (N=2679; 48% three-vessel; 39% DM) and BMS (N=2651; 40% three-vessel; 33% DM) and then stratified based on stent (DES/BMS) and vessel disease (two/three). RESULTS: Diabetes-effect on mortality was lower for DES (AHRDM/NoDM=1.41 [1.14-1.74]) versus BMS (AHRDM/NoDM=1.71 [1.50-2.01]), but this was predominantly driven by two-vessel patients. This diabetes effect was similar for first (DES1: AHRDM/NoDM=1.43 [1.14-1.79]) and second (DES2: AHRDM/NoDM=1.53 [0.77-3.07]) generation DES. Re-intervention comparisons were similarly increased by diabetes in all sub-cohorts. CONCLUSIONS: Our analysis of a large real-world PCI series indicates that diabetes is associated with worse 9-year mortality irrespective of stent type, albeit this is mitigated to varying degrees with DES, particularly in DES2 and in case of 2-vessel disease. A complementary stent-effect analysis confirmed DES-to-BMS and DES2-to-DES1 superiority in both diabetics and non-diabetics.

Positive T wave in lead aVR as an independent predictor for 1-year major adverse cardiac events in patients with first anterior wall ST-segment elevation myocardial infarction.

BACKGROUND: Positive T wave in lead aVR has been shown to predict an adverse in-hospital outcome in patients with anterior wall ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of positive T wave in lead aVR on a long-term outcome has not been fully explored. METHODS: We performed a retrospective analysis of 190 consecutive patients with first anterior wall STEMI who underwent an emergent coronary angiogram. Patients were divided into those with positive T wave > 0 mV and those with negative T wave â‰¦ 0 mV in lead aVR. Baseline and angiographic characteristics, and in-hospital revascularization procedures were recorded. In addition, in-hospital and 1-year major adverse cardiac events (MACE) including death, recurrent myocardial infarction, and target vessel revascularization were recorded. RESULTS: Among 190 patients, 37 patients (19%) had positive T wave and 153 patients (81%) had negative T wave in lead aVR. Patients with positive T wave had higher rate of left main disease defined as stenosis ≥50% (11% vs. 2%, p = .028) than those with negative T wave. Patients with positive T wave had higher rate of 1-year MACE (38% vs. 13%, p < .001) driven by higher all-cause mortality (27% vs. 5%, p < .001). Positive T wave was an independent predictor for 1-year MACE (OR 2.74; 95% CI 1.04-7.15; p = .04). CONCLUSION: Positive T wave in lead aVR was an independent predictor for 1-year MACE in patients with first anterior wall STEMI.

Clinical Effect of Rebound Hyperthermia After Cooling Postcardiac Arrest: A Retrospective Cohort Study.

Therapeutic hypothermia is used in select patients after out-of-hospital cardiac arrest (OHCA) to improve neurologic outcome. Rebound hyperthermia (RH) is commonly observed post-treatment. Previous studies analyzing the association of RH with clinical outcome have reported conflicting results. The purpose of this study is to examine the impact of RH after completion of therapeutic hypothermia in patients postcardiac arrest. We analyzed a retrospective cohort from our institution. All adults who underwent therapeutic hypothermia post-OHCA were divided into two cohorts depending on the presence/absence of fever (T > 38°C) within 24 hours of completing hypothermia protocol. Clinical outcomes were analyzed at hospital discharge or death. Among 306 patients admitted with OHCA, 117 underwent hypothermia, 97 survived 24 hours postrewarming. Twenty-seven patients (50%) with RH died compared with 20 (47%) without RH (OR, 1.15; 95% CI, 0.52-2.57). Twenty-six patients (67%) with RH had a poor neurologic outcome compared with 27 (63%) without RH (OR 1.19, 95% CI, 0.51-2.74). RH is common after completion of therapeutic hypothermia in comatose patients due to cardiac arrest and is associated with poor neurologic outcomes. We found no significant clinical impact of rebound hypothermia on neurologic outcome or mortality, but our study was underpowered to reveal such impact if it exists.

The role of angiographic follow-up after percutaneous coronary intervention.

In the early days of coronary angioplasty, follow-up coronary angiography was often performed to assess restenosis. Angiographic restenosis has been shown to be associated with worse clinical outcomes, though the exact causality has yet to be determined. Numerous studies have repeatedly demonstrated that routine follow-up coronary angiography increases the incidence of target lesion revascularization without a clear reduction in mortality or myocardial infarction. Despite the lack of proven benefit of angiographic follow-up, routine follow-up coronary angiography is still being performed in certain countries and facilities. There are several factors that might explain the lack of benefit of angiographic follow-up: 1) lower incidence of stent failure in the current drug-eluting stent era has attenuated the net clinical benefit of follow-up angiography. 2) Angiographic restenosis might not lead to myocardial ischemia. 3) Patients that do have functionally significant restenosis are often referred for coronary angiography due to clinical indications such as intractable angina. 4) Absence of restenosis at the time of follow-up angiography does not exclude future restenosis. The absence of proven benefit in unselected populations does not necessarily preclude the presence of benefit in selected population, and there may be a subgroup of patients who can benefit from angiographic follow-up such as those with a large myocardial ischemic territory or those at very high risk of restenosis. Until there is more clinical evidence with respect to follow-up angiography, the decision of whether or not to perform it routinely in selected high-risk population should entail an in-depth discussion with the patient.

STEMI notification by EMS predicts shorter door-to-balloon time and smaller infarct size.

BACKGROUND: Emergency medical services (EMS) transportation is associated with shorter door-to-balloon (DTB) time in patients with ST-segment elevation myocardial infarction (STEMI). In addition to EMS transportation, prehospital notification of STEMI by EMS to receiving hospital might be able to further shorten DTB time. We evaluated the impact of STEMI notification on DTB time as well as infarct size. METHODS: We performed a retrospective analysis of consecutive patients with anterior wall STEMI who underwent emergent coronary angiography. We excluded patients who presented with cardiac arrest and those who were transferred from non-percutaneous coronary intervention-capable hospitals. Mode of transportation were categorized into the 3 groups: (1) EMS transport with STEMI notification, (2) EMS transport without STEMI notification, and (3) self-transport. Baseline characteristics, laboratory data, left ventricular ejection fraction (LVEF), and DTB time were compared among the 3 groups. RESULTS: A total of 148 patients were included in the final analysis. Of the 148 patients, 56 patients arrived by EMS transport with STEMI notification, 56 patients arrived by EMS transport without STEMI notification, and 36 patients arrived by self-transport. Patients who arrived by EMS transport with STEMI notification had the shortest DTB time among the 3 groups. Patients who arrived by EMS transport with STEMI notification had smaller infarct size, as indicated by lower peak creatine kinase value and higher LVEF, compared with those who arrived by EMS transport without STEMI notification. CONCLUSION: Emergency medical services transport with STEMI notification was associated with shorter DTB time and smaller infarct size in patients with anterior wall STEMI.

Shock Index as a predictor for In-hospital mortality in patients with non-ST-segment elevation myocardial infarction.

BACKGROUND/PURPOSE: Shock index (SI), a ratio of heart rate/systolic blood pressure, has been reported to predict increased mortality in patients with ST-segment elevation myocardial infarction. However, the prognostic value of SI has not been fully elucidated in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS/MATERIALS: We performed a retrospective analysis of 481 consecutive NSTEMI patients who underwent coronary angiography from January 2013 to June 2014. Systolic blood pressure and heart rate on presentation were recorded, and SI was calculated as heart rate/systolic blood pressure. Patients were divided into those with SI≧0.7 and those with SI<0.7. Baseline and angiographic characteristics were recorded. In addition, cardiogenic shock and in-hospital mortality were recorded and compared between the two groups. RESULTS: Among 481 patients, 103 patients (21.4%) had SI≧0.7. No statistically significant difference was observed in baseline characteristics between the two groups. Patients with SI≧0.7 had a lower left ventricular ejection fraction than those with SI<0.7 (56 [35-60] % vs. 60 [45-64] %, p=0.035). Patients with SI≧0.7 had a higher rate of cardiogenic shock on admission (2.9% vs. 0.3%, p=0.032). Patients with SI≧0.7 had a higher, albeit statistically insignificant, incidence of cardiogenic shock after admission (5.0% vs. 1.9%, p=0.074). The total incidence of cardiogenic shock was higher in patients with SI≧0.7 (7.8% vs. 2.1%, p=0.001). Patients with SI≧0.7 had higher in-hospital mortality (4.9% vs. 0.5%, p=0.006) than those with SI<0.7. CONCLUSION: Elevated SI was associated with higher in-hospital mortality in patients with NSTEMI.

Does Oral Beta-Blocker Therapy Improve Long-Term Survival in ST-Segment Elevation Myocardial Infarction With Preserved Systolic Function? A Meta-Analysis.

BACKGROUND: The effect of oral beta-blocker therapy on long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) who are treated with primary percutaneous coronary intervention (PCI) and who have preserved left ventricular ejection fraction (LVEF) remains unclear. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies evaluating the effect of oral beta-blocker therapy in patients with STEMI who underwent primary PCI and who had preserved LVEF. The primary outcome was all-cause mortality. Randomized controlled trials and the observational studies that reported an adjusted hazard ratio (or hazard ratio in the propensity score-matched patients) with follow-up duration equal to or more than 6 months were included. Pooled hazard ratio with 95% confidence interval (CI) was calculated using a random effect model. RESULTS: No randomized controlled trials met the inclusion criteria. Seven observational studies totaling 10 857 patients met the inclusion criteria. Follow-up duration ranged from 6 months to 5.2 years. Preserved LVEF was defined as 40% in 4 studies and 50% in 3 studies. Based on the pooled estimate, oral beta-blocker therapy was associated with a reduction in all-cause mortality (combined hazard ratio 0.79, 95% CI 0.65-0.97). CONCLUSION: This meta-analysis demonstrates that oral beta-blocker therapy is associated with decreased all-cause mortality in patients with STEMI who are treated with primary PCI and who have preserved LVEF. This supports the current American College of Cardiology Foundation/American Heart Association 2013 Guideline for the Management of STEMI.