The utility of radiographic assessment of the internal mammary arteries in chest wall irradiated patients.

PURPOSE: The internal mammary arteries (IMA's) are historically recognized to be protected against atherosclerosis. Whether chest wall-irradiation for breast cancer leads to significant IMA damage remains unclear. The utility of computed tomography (CT) and mammography to detect radiation-induced damage to the IMA's and its branches is not known. The objective of this study is to assess the susceptibility of IMA's to radiation-induced atherosclerosis, and the utility of CT scan and mammography in the assessment of IMA and its branches. METHODS: A retrospective analysis of breast cancer patients who received chest wall-radiotherapy was performed. Patients with CT scans and/or mammograms ≥5 years post-radiotherapy were included. Baseline characteristics, coronary artery calcification (CAC), the presence of IMA damage assessed by CT scan, and IMA branch calcifications by mammography were recorded. RESULTS: None of the 66 patients with CT scans post-radiotherapy revealed IMA atherosclerosis. There were 28 (42.4%) patients with CAC, of which four (14.3% of CAC subgroup or 6.1% of the total cohort) had calcifications on either side on mammogram (Chi-square test, p = 0.74). Out of the 222 patients with mammograms, 36 (16.2%) had IMA branch calcifications. Two hundred and ten patients received unilateral radiotherapy, and 27 (12.9%) of these patients had calcifications on the irradiated side, and 26 patients (12.4%) had calcifications on the contralateral side (OR = 1.0). CONCLUSION: IMA's do not exhibit signs of radiation-induced atherosclerosis when evaluated by CT scan. In addition, there is no association between radiotherapy for breast cancer and the presence of IMA branch calcification on mammograms.

NOAC-Based Sual Therapy Versus Warfarin-Based Triple Therapy After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: Several randomized clinical trials (RCTs) have compared the use of dual therapy (DT), or one of the non-vitamin K antagonist oral anticoagulants (NOAC) with a P2Y12 agent, versus triple therapy (TT), consisting of a vitamin-K antagonist (VKA) along with dual antiplatelet therapy, in patients with concomitant atrial fibrillation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). We performed a meta-analysis and systematic review of RCTs to evaluate the safety and efficacy of NOAC-based DT in such patients. METHODS: The major efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of mortality, myocardial infarction, stroke, stent thrombosis (ST), and urgent revascularization. The International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNM) was the major primary safety outcome. RESULTS: A total of 4 RCTs were included in the meta-analysis with 7942 total patients for analysis (DT: 4377 & TT: 3565). Compared to TT, DT resulted in similar risk of MACCE (OR: 1.12; 95% CI: 0.94-1.34; P = 0.20) and other efficacy endpoints with a trend in increased risk of ST in the DT group (1.55; 0.99-2.44; P = 0.06). DT resulted in lower risk of ISTH major or CRNM bleeding (0.56; 0.41-0.76; P < 0.01), and all other bleeding outcomes except for a trend of reduced risk of TIMI minor bleeding. CONCLUSION: In conclusion, patients with atrial fibrillation who undergo PCI or develop ACS, NOAC-based dual therapy reduces bleeding outcomes without significantly increasing ischemic outcomes. Future trials should explore the possible differences in stent thrombosis.

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.