Amir Darki

Correlation of Elevated Troponin and Echocardiography in Acute Ischemic Stroke

BACKGROUND Previous research has revealed a higher prevalence of elevated cardiac troponin T or I levels amongst patients admitted with stroke, which has been associated with increased cardiovascular events, higher mortality rates, and poor inpatient prognosis. Because cardiac comorbidities account for almost 20% of deaths after ischemic stroke, it is important to understand the relationship between troponin elevation, cardiac events, and acute ischemic stroke (AIS). METHODS We evaluated 137 consecutive patients ≥ 18 years of age who presented within 48 hours of AIS onset. All patients had laboratory markers drawn on admission, including troponin and brain natriuretic peptide, along with transthoracic echocardiogram with Doppler. The mean age of our study population was 71.7 ± 14.6 years. RESULTS Twenty-four of 137 patients (17.5%) had a positive troponin level. Sixteen of 24 (67%) patients with a positive troponin level had a new wall motion abnormality on echocardiogram that was suggestive of unstable atherosclerotic disease. On statistical analysis, we found a significant association between troponin and brain natriuretic peptide elevation with positive segmental wall motion abnormality on echocardiogram. CONCLUSIONS These study findings represent a new paradigm of interpreting elevated cardiac biomarkers and may help with risk stratification and diagnosis of patients presenting with AIS.

Usefulness of Wide Pulse Pressure as a Predictor of Poor Outcome After Renal Artery Angioplasty and Stenting

Renal artery stenosis is a common cause of secondary hypertension and ischemic nephropathy. Percutaneous angioplasty and stent placement has allowed select patients with renal artery stenosis to use fewer antihypertensive agents and improve or stabilize renal function. The associations of baseline systolic, diastolic, and pulse pressures (PPs) with outcomes of blood pressure (BP) and renal function were examined in 243 patients who underwent renal angioplasty and stent placement. The average PP before the procedure in patients with improvements or stabilizations in renal function was 53 +/- 20 mm Hg, compared to 107 +/- 18 mm Hg (p <0.05) in those with poorer outcomes. The average PPs before procedure were 47 +/- 15 mm Hg in those with improvements in BP, 82 +/- 10 mm Hg in those with stabilizations of BP, and 111 +/- 14 mm Hg in those with worsening BP. All findings were statistically significant (p <0.05). In conclusion, wide PP may reflect more advanced vascular stiffness and renal disease distinguishing patients less likely to benefit from revascularization.

Endovascular Repair of Bilateral Internal Mammary Artery Aneurysms in a Patient with Marfan Syndrome—A Case Report

Marfan syndrome (MFS) is an autosomal dominant condition that is caused by abnormal synthesis of connective tissue. The syndrome classically affects the ocular, musculoskeletal, and cardiovascular systems. The most common cardiovascular manifestations include mitral valve prolapse/regurgitation and aortic aneurysms at high risk of rupture and dissection. However, internal mammary artery (IMA) true aneurysms are rarely reported. In this case report, we describe a 43-year-old male patient with MFS and three previous thoracotomies referred for endovascular repair of bilateral IMA true aneurysms. To the best of our knowledge, there are no cases of endovascular treatment of bilateral IMA true aneurysms reported in the literature.

Endovascular management of splenic artery aneurysms: Case series using telescoping guide and cage/coil technique

Splenic artery aneurysms are rare, but still the third most common abdominal aneurysm. Rupture is associated with significant morbidity and mortality. Traditionally, cardiologists have rarely been involved in the management of this entity. We present a series of four patients managed percutaneously by interventional cardiology using a combined telescoping guide and cage/coil technique.

Rosai–Dorfman disease and left ventricular noncompaction cardiomyopathy: A heart failure conundrum

The principles, Hickam’s dictum and Occam’s razor, have existed in counterbalance, guiding a physician’s diagnostic approach together for decades. Although Occam’s razor implores one to favor theories or hypotheses with the least amount of assumptions, there are often times a patient’s ailment may be better attributed to multiple co-existing problems. The latter was well understood by the late John Hickam, MD, who is credited to have famously stated: ‘‘A man can have as many diseases as he damn well pleases.’’ These two philosophical paradigms clashed; in this case, we present of a 19year-old male who initially was seen for acute epigastric pain, quickly decompensated into cardiogenic shock, and was subsequently diagnosed with two extraordinarily rare diseases in Rosai–Dorfman disease (RDD) and left ventricular noncompaction cardiomyopathy (LVNC). While in the last decade the data regarding LVNC have flourished, there is still scant literature reporting RDD, especially involving the cardiovascular system. This case serves to report two rare entities as well as to highlight a strategic approach to a challenging diagnosis.

Meta-Analysis of Studies Comparing Dual- Versus Mono-Antiplatelet Therapy Following Transcatheter Aortic Valve Implantation

Current guidelines recommend dual-antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI), although some studies suggest mono-antiplatelet therapy is equally efficacious with an improved safety profile. We performed a meta-analysis of studies comparing DAPT with mono-antiplatelet therapy after TAVI. Study quality and heterogeneity were assessed using Jadad score, Newcastle-Ottawa Scale, and Cochrans Q statistics. Mantel-Haenszel odds ratios (ORs) were calculated using fixed effect models as the primary analysis. Eight studies including 2,439 patients met the inclusion criteria. At 30 days, DAPT was associated with an increased risk of all-cause mortality (OR 2.06, 95% confidence interval [CI] 1.34 to 3.18, p = 0.001), major or life-threatening bleeding (OR 2.04, 95% CI 1.60 to 2.59, p <0.001), and major vascular complications (OR 2.15, 95% CI 1.51 to 3.06, p <0.001). There was no difference in the rate of the combined end point of stroke or transient ischemic attack, or myocardial infarction. Outcome data up to 6 months were available in 5 studies; all-cause mortality and stroke were similar between groups, although major or life-threatening bleeding was more frequent with DAPT. In conclusion, in patients undergoing TAVI, DAPT is associated with increased risk at 30 days of all-cause mortality, major or life-threatening bleeding, and major vascular complications without a decrease in ischemic complications; at 6 months, the excess bleeding risk persisted. These data suggest a safety concern with DAPT and justify further investigation of the optimal antiplatelet therapy regimen after TAVI.

The Importance of a Multidisciplinary Approach to Leg Ulcers

Critical limb ischemia is a complex disease process. The disease state inherently crosses several medical and surgical disciplines. As such, through a deliberate multidisciplinary approach, the wound healing and patient care will be optimized.

A-081:The utility of ankle-brachial index (ABI) in risk stratifying patients undergoing evaluation for coronary artery disease (CAD)

Authors: Michael Dae, University of California, San Francisco, United States; Marko Noc, Department of Cardiology, University Medical Center, Ljubljana, Slovenia, Slovenia; David Erlinge, Lund University Hopsital, Sweden; Thomas Keeble, The Essex Cardiothoracic Centre, Basildon, Essex, UK, United Kingdom; Beata Sredniawa, Silesian Center for Heart Diseases, Poland; Michael Dae, University of California, San Francisco, United States

Subclavian steal syndrome successfully treated with a novel application of embolic capture angioplasty.

Subclavian artery stenosis can lead to subclavian steal syndrome. Endovascular treatment of these lesions has become the preferred modality. We describe the successful use of embolic capture angioplasty for the treatment of a patient with subclavian artery stenosis resulting in subclavian steal syndrome.