Cangrelor in STEMI as a bridge to CABG- a mini-case series.

Background: Patients with STEMI receive dual antiplatelet therapy as soon as possible with aspirin and a P2Y12 receptor antagonist prior to PCI. A fraction of these patients may have multi-vessel disease needing emergent CABG surgery. The choice of a P2Y12 receptor antagonist plays a role in the timing of CABG surgery as it poses a bleeding risk until it is completely eliminated from the system. Oral P2Y12 receptor antagonists have a long duration of platelet inhibition which is difficult to reverse. Cangrelor is an intravenous P2Y12 receptor antagonist with a short half-life and rapid cessation of its effect after discontinuation. Methods: Three patients who presented to our emergency department with STEMI were started on cangrelor infusion prior to cardiac catheterization instead of other P2Y12 receptor antagonists like clopidogrel or ticagrelor. The study received ethical approval as it is part of the current standard of care for STEMI patients. Results: All three patients were found to have multi-vessel disease during coronary angiography requiring CABG surgery. As cangrelor was used in these patients they were able to have their surgery within 24-48 h. Intravenous cangrelor was stopped about an hour before surgery. No bleeding complications occurred and all three patients made a speedy recovery in the ICU. Conclusion: Cangrelor is a potent P2Y12 receptor antagonist which can be used in patients presenting with STEMI as one of the two anti-platelet agents along with aspirin without any dilemma that it would cause a delay in CABG surgery if the patients need one.

The shifting paradigm in the treatment of type 2 diabetes mellitus-A cardiologist's perspective.

In patients with diabetes mellitus, cardiovascular (CV) disease is the leading cause of morbidity and mortality. A multitude of contemporary antidiabetic agents presents different CV safety profiles. Metformin forms the cornerstone agent to reduce CV events. Newer agents, such as glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors, have appealing CV benefits. Insulin, dipeptidyl peptidase-4 inhibitors, and sulfonylureas have neutral CV effects. Cardiologists should familiarize themselves with these agents to promote comprehensive CV care in patients with diabetes mellitus.

Hyperdynamic left ventricle on radionuclide myocardial perfusion imaging (RNMPI): A marker of diastolic dysfunction in patients presenting with dyspnea on exertion.

BACKGROUND: We hypothesized that among patients presenting with dyspnea on exertion (DOE), those who were found to have hyperdynamic left ventricle (i.e. LVEF ≥ 70%) on stress radionuclide myocardial perfusion imaging (RNMPI), are more likely to have features of diastolic dysfunction on transthoracic echocardiography. METHODS: Medical records of 1892 consecutive patients who presented between February 2011 and September 2012 with the chief complaint of DOE and were referred to stress RNMPI were reviewed. Among these, patients who had no evidence of reversible ischemia and had hyperdynamic left ventricle on perfusion imaging, were selected and their recent echocardiograms were reviewed for evidence of diastolic dysfunction. Logistic regression analysis was used to develop an equation to predict diastolic dysfunction with the ejection fraction as the predictor. A two-way analysis of variance model was used to detect differential patterns of ejection fraction across diastolic dysfunction and gender. RESULTS: A hyperdynamic left ventricle identified on stress RNMPI was found to be a significant predictor of diastolic dysfunction on echocardiography in logistic regression analysis (odds ratio = 1.24, 95% CI = 1.13-1.35, p < 0.0001). A hyperdynamic left ventricle on stress RNMPI has a specificity of 96.77% (CI 83.24-99.46%) and a positive predictor value of 97.83% (CI 88.43-99.64%) in identifying diastolic dysfunction. CONCLUSION: In patients presenting with DOE who have no evidence of reversible ischemia on radionuclide stress testing but have hyperdynamic left ventricle, a search should be made for alternate cardiac etiology for this complaint such as diastolic dysfunction and heart failure with preserved ejection fraction.

Apical hypertrophic cardiomyopathy mimicking acute coronary syndrome: a case report and review of the literature.

Apical hypertrophic cardiomyopathy is a form of hypertrophic cardiomyopathy localized to the left ventricular apex. It is common in Japanese and other Asian populations, where it is generally considered relatively benign. However, its presence has also been recognized, though less commonly, in non-Asian patients. In these patients, the electrocardiographic changes and symptoms associated with apical hypertrophic cardiomyopathy often mimic acute coronary syndromes. Invasive or noninvasive evaluation of the left ventricular cavity confirms the diagnosis, with the "ace-of-spades" sign on left ventriculography being pathognomonic. Its prognosis is relatively benign in terms of cardiovascular mortality; however, morbid sequelae, such as diastolic dysfunction, left atrial enlargement, apical thrombi, ventricular aneurysms, and myocardial infarction, are not uncommon. The authors present a case of apical hypertrophic cardiomyopathy in a Caucasian patient who presented with findings suggestive of acute coronary syndrome and review the literature on apical hypertrophic cardiomyopathy.

Anomalous great cardiac vein.

Anomalous coronary venous anatomy is a little studied and rarely reported subject that is of crucial importance in interventions that rely upon the assumption of normal coronary venous anatomy. In particular, the recognition of coronary vein anomalies that disconnect large segments of the left ventricular myocardium from the main coronary sinus is critical for cardiothoracic surgeons who perform interventions involving retrograde cardioplegia and other forms of coronary venous retroperfusion. We present a rare case of an anomalous great cardiac vein that bypassed the coronary sinus to drain directly into the superior vena cava, and suggest a possible role for antecedent imaging of the coronary venous system in patients who might be expected to undergo such interventions.

Pseudo-pseudoaneurysm: a rare and unexplored mechanical complication of myocardial infarction.

The mechanical complications of myocardial infarction are less frequently encountered in the current era of early revascularization. Complete myocardial rupture, although infrequent, is a potentially lethal complication. The pathology, prognosis, and treatment of complete myocardial rupture are well described in the medical literature. Incomplete cardiac rupture has been less well described, and its prognosis and treatment are less clear. Pseudoaneurysms, subepicardial aneurysms, and pseudo-pseudoaneurysms form the pathologic spectrum of incomplete cardiac rupture. Pseudoaneurysms involve complete myocardial rupture with containment by overlying pericardium, whereas subepicardial aneurysms involve aneurysmal outpouchings contained by epicardium. Pseudo-pseudoaneurysms are a subtype of subepicardial aneurysm consisting of diverticula contained by myocardial elements. Pseudo-pseudoaneurysms follow a variable course. Fibrous tissue may be deposited in the wall of the aneurysm allowing the patient to remain asymptomatic, or the myocardium may progressively dissect with resultant complete ventricular rupture. We describe a case of postinfarction pseudo-pseudoaneurysm that was diagnosed by echocardiography and managed conservatively.

Complete heart block due to lyme carditis.

Lyme carditis is becoming a more frequent complication of Lyme disease, primarily due to the increasing incidence of this disease in the United States. Cardiovascular manifestations of Lyme disease often occur within 21 days of exposure and include fluctuating degrees of atrioventricular (AV) block, acute myopericarditis or mild left ventricular dysfunction and rarely cardiomegaly or fatal pericarditis. AV block can vary from first-, second-, third-degree heart block, to junctional rhythm and asystolic pauses. Patients with suspected or known Lyme disease presenting with cardiac symptoms, or patients in an endemic area presenting with cardiac symptoms with no other cardiac risk factors should have a screening electrocardiogram along with Lyme titers. We present a case of third-degree AV block due to Lyme carditis, illustrating one of the cardiac complications of Lyme disease. This disease is usually self-limiting when treated appropriately with antibiotics, and does not require permanent cardiac pacing.