Initial Findings From the North American COVID-19 Myocardial Infarction Registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). OBJECTIVES: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. METHODS: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. RESULTS: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). CONCLUSIONS: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

Will Mary Jane Leave You Heartbroken? Marijuana Use and Risk of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TTC) is prevalent in 2% of patients who present with symptoms suggestive of acute myocardial infarction. It may be triggered by stressful events, resulting in catecholamine surges, myocardial stunning, and disturbances in contractility. TTC in males has been associated with marijuana use and leads to a fivefold increased risk of cardiac events. Marijuana is thought to generate a similar surge in catecholamines leading to tachycardia and elevation of both systolic and diastolic blood pressure. The question remains whether this catecholamine surge is sufficient enough to cause TTC. It is apparent a correlation between marijuana use and TTC may exist. Exogenous cannabinoid stimulation may lead to myocardial stunning via stimulation seen with hypercatecholaminergic states. Understanding the risk factors involved and increasing awareness of cardiovascular complications related to cannabinoid substances becomes more relevant as its use is increasing both recreationally and medically.  We present a case of a 50 year-old African-American male with hypertension and regular marijuana use who presented with chest pain radiating to the back. Due to abnormal electrocardiogram and positive cardiac biomarkers concerning for acute coronary syndrome, the patient underwent subsequent coronary angiography that showed no significant coronary obstruction; however, left ventriculogram showed the characteristic apical ballooning of TTC. Our case highlights the pathophysiological mechanism suspected to trigger TTC.

Rescue percutaneous coronary intervention for graft failure immediately after coronary artery bypass grafting: case report and review of literature.

Perioperative graft failure remains a significant problem and carries a very high morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). Different therapeutic options are available for the clinician to manage this complication. These include direct reoperation, balloon angioplasty, angioplasty along with stenting, intra-aortic balloon pumping, and conservative medical management. Immediate percutaneous coronary intervention has been reported to be a viable alternative to emergent redo CABG in these patients. Herein, we report an additional case of early graft failure immediately following CABG and review the existing literature.

Postprandial hypertriglyceridemia increases circulating levels of endothelial cell microparticles.

BACKGROUND: This study evaluated a possible relationship between levels of endothelial microparticles (EMPs), known to be a sensitive indicator of endothelial disturbance, and changes in postprandial lipid levels in healthy volunteers after a low- or high-fat meal. METHODS AND RESULTS: Eighteen healthy subjects without known cardiovascular risk factors were evaluated. Lipid and EMP levels were measured before and 1 and 3 hours after a single low- or high-fat isocaloric meal. The low-fat meal had no significant postprandial effect on EMPs or lipids compared with fasting levels. In contrast, a single high-fat meal significantly increased EMP levels after 1 and 3 hours, from 389+/-54 (thousands per milliliter) when fasting to 541+/-139 (P=0.0002) and 677+/-159 (P<0.0001), respectively, and correlated with a postprandial elevation in serum triglycerides. CONCLUSIONS: A single high-fat meal led to a significant elevation of plasma EMP levels in healthy, normolipidemic subjects and correlated with a postprandial elevation of serum triglycerides. EMPs may be an indirect marker of endothelial dysfunction or injury induced by postprandial triglyceride-rich lipoproteins.

Endothelial microparticles correlate with high-risk angiographic lesions in acute coronary syndromes.

BACKGROUND: Endothelial Microparticles (EMP) are small fragments of endothelial cell membrane shed during apoptosis or activation. Our group has previously reported elevations of EMP in patients with coronary artery disease (CAD), thrombotic thrombocytopenic purpura (TTP), pre-eclampsia, multiple sclerosis (MS), and severe hypertension (HTN). In the present study, we evaluate the possible relationship between EMP levels and the angiographic severity and characteristics of coronary obstructive lesions. METHODS: We studied a total of 43 patients undergoing coronary angiography. Fifteen had presented with acute myocardial infarction (MI), 20 with unstable anginas (UA), 5 with stable angina (SA) and 3 with congestive heart failure. Coronary angiography was reviewed and coronary lesions were classified using the Ambrose classification. Coronary stenoses were classified as high and low risk. High-risk included lesions with eccentric appearance (type II), presence of thrombi, or multiple irregularities. Low-risk lesions were defined as concentric or type I. Lesions were also analyzed by degree of stenosis and history of acute coronary syndrome (ACS). EMP in plasma was assayed by flow cytometry. RESULTS: EMP in eccentric type II or multiple irregular lesions (high-risk) were 2.5-fold higher than in type I or concentric (low-risk) lesions, p<0.05. Lesions with thrombi had three-fold higher EMP than those without (p=0.05). Mild stenosis (>20%-<45%) had three-fold higher EMP than more severe (>45%), and five-fold higher than those without stenosis (p<0.01). Among patients with type II lesions, those with first ACS episode had four-fold higher EMP levels than those with recurrent ACS (p<0.01). CONCLUSION: High EMP was associated with high-risk angiographic lesions including eccentric type II, multiple irregular, and lesions with thrombi. Mild to moderate stenosis was associated with higher EMP levels than severe stenosis. EMP may be a useful marker in detecting endothelial injury and risk of ACS as defined by angiography.