Edo Kaluski

The STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) Trial Improves Outcomes

OBJECTIVESnThe goal of this study was to evaluate the impact of the STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) network on outcomes in the treatment of patients presenting with ST-segment elevation myocardial infarction (STEMI).nnnBACKGROUNDnShortening door-to-balloon (D2B) time remains a national priority for the treatment of STEMI. We previously reported a fully automated wireless network (STAT-MI) for transmission of electrocardiograms (ECGs) for suspected STEMI from the field to offsite cardiologists, allowing early triage with shortening of subsequent D2B times. We now report the impact of the STAT-MI wireless network on infarct size, length of hospital stay (LOS), and mortality.nnnMETHODSnA fully automated wireless network (STAT-MI) was developed to enable automatic 12-lead ECG transmission and direct communication between emergency medical services personnel and offsite cardiologists that facilitated direct triage of patients to the cardiac catheterization laboratory. Demographic, laboratory, and time interval data of STAT-MI network patients were prospectively collected over a 33-month period and compared with concurrent control patients who presented with STEMI through non-STAT-MI pathways.nnnRESULTSnFrom June 2006 through February 2009, 92 patients presented via the STAT-MI network, and 50 patients presented through non-STAT-MI pathways (control group). Baseline clinical and demographic variables were similar in both groups. Overall, compared with control subjects, STAT-MI patients had significantly shorter D2B times (63 [42 to 87] min vs. 119 [96 to 178] min, U = 779.5, p < 0.00004), significantly lower peak troponin I (39.5 [11 to 120.5] ng/ml vs. 87.6 [38.4 to 227] ng/ml, U = 889.5, p = 0.005) and creatine phosphokinase-MB (126.1 [37.2 to 280.5] ng/ml vs. 290.3 [102.4 to 484] ng/ml, U = 883, p = 0.001), higher left ventricular ejection fractions (50% [35 to 55] vs. 35% [25 to 52], U = 1,075, p = 0.004), and shorter LOS (3 [2 to 4] days vs. 5.5 [3.5 to 10.5] days, U = 378, p < 0.001).nnnCONCLUSIONSnA fully automated, field-based, wireless network that transmits ECGs automatically to offsite cardiologists for the early evaluation and triage of patients with STEMI shortens D2B times, reduces infarct size, limits ejection fraction reduction, and shortens LOS.

Osteopontin in cardiovascular disease: a potential therapeutic target.

Osteopontin (OPN), also known as 44kDa bone phosphoprotein, sialoprotein I, secreted phosphoprotein I, 2ar, uropontin, and early T-lymphocyte activation-1 (Eta-1), is a multifunctional protein. OPN has been found to be expressed in various cell types and species with many physiologic and pathologic functions. OPN has emerged as a potential biomarker and mediator in cardiovascular disease. In this review, we will discuss the roles of OPN in cardiovascular disease, specifically in vascular and valvular heart disease, myocardial infarction and heart failure.

Comparison of efficacy and safety of intracoronary sodium nitroprusside and intravenous adenosine for assessing fractional flow reserve.

The purpose of this study was to compare the efficacy and safety of intracoronary (IC) nitroprusside and intravenous adenosine (IVA) for assessing fractional flow reserve (FFR).

Coronary stenting with MGuard: extended follow-up of first human trial

OBJECTIVESnTo evaluate feasibility and safety of MGuard based percutaneous coronary interventions (PCI) in vein grafts (VG) and native coronaries (NC).nnnBACKGROUNDnDistal embolization is a frequent complication of PCI of VG and NC during acute coronary syndromes (ACS). MGuard was a stent designed to reduce embolization.nnnMETHODSnProspective, single arm, two-center trial assessing the feasibility and safety of MGuard-based PCI with post-PCI clinical and laboratory monitoring including: cardiac biomarkers, ECG and 6-month angiography.nnnRESULTSnForty-one patients with mean age of 68.2±10.1 years were enrolled. Mean VG age (n=23) was 14.4±4.3 years. All patients received heparin, clopidogrel and aspirin; while none received glycoprotein IIb/IIIa inhibitors, or embolic protection device (EPD). Device and procedural success were 100% and 95.1% respectively. Two patients (4.9%) experienced procedure-related creatinine phosphokinase rise. At 6 months one patient had myocardial infarction and 19.5% had target vessel revascularization (TLR). Late follow up (12-27 months) revealed one additional TLR.nnnCONCLUSIONnMGuard based PCI of NC and VG appears encouraging especially in view of unfavorable patient and lesion characteristics. Efficacy needs to be further established in larger randomized trials.

Acute myocardial infarction due to left anterior descending coronary artery dissection after blunt chest trauma

Cardiac complications of chest trauma range from arrhythmias to valvular avulsions to myocardial contusion, rupture, and rarely myocardial infarction. We describe a case of a young patient with blunt chest trauma after a motor vehicle accident in whom the diagnosis of myocardial infarction was established a week later because no electrocardiogram or cardiac biomarkers were obtained on presentation. Retrospective review of contrast-enhanced computed tomography (CT) of the chest done on presentation demonstrated a perfusion defect in the distribution of the left anterior descending artery (LAD). Subsequent coronary angiography demonstrated dissection in the proximal LAD. Our case illustrates the importance of electrocardiography and contrast-enhanced chest CT in initial evaluation of patients with blunt chest trauma and suspected injury to the coronary arteries.

Automated contrast injectors for angiography: Devices, methodology, and safety†

Automated contrast injectors (ACIs) are widely employed in interventional cardiology, radiology and neurology. Information regarding the specifications of advanced ACIs and the appropriate injection settings of these devices is limited in the medical literature. This review describes the specifications of the most widely used ACIs and provides appropriate recommendations for injection settings for the various angiographic studies. These recommendations are based on expert consensus and commercial experience regarding characteristics of devices, catheters and contrast. The suggested settings were not subject to rigorous comparative clinical assessment. This review should increase the familiarity, comfort and appreciation of safety among ACI users.

A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea.

AimsnTo assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA).nnnMethods and resultsnA total of 235 articles were recovered using MEDLINE, EMBASE and Cochrane library (inception-December 2016) and references contained in the identified articles. Seven randomized controlled trials (RCTs) were selected for final analysis. Analysis of 4268 patients demonstrated non-significant 26% relative risk reduction in MACE with CPAP [risk ratio (RR) 0.74; 95% confidence interval (CI) 0.47-1.17; Pu2009=u20090.19, I2u2009=u200948%]. A series of sensitivity analyses suggested that increased CPAP usage time yielded significant risk reduction in MACE. and stroke. Subgroup analysis revealed that CPAP adherence time ≥4u2009hours (h)/night reduced the risk of MACE by 57% (RR 0.43; 95% CI 0.23-0.80; Pu2009=u20090.01, I2u2009=u20090%). CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF) (Pu2009>u20090.05). CPAP had positive effect on mood and reduced the daytime sleepiness [Epworth Sleepiness Scale (ESS): mean difference (MD) -2.50, 95% CIu2009-u20093.62, -1.39; Pu2009<u20090.001, I2u2009=u200981%].nnnConclusionnCPAP therapy might reduce MACE and stroke among subjects with CPAP time exceeding 4u2009h/night. Additional randomized trials mandating adequate CPAP time adherence are required to confirm this impression.

Meta-Analysis of Anti-Thrombotic Therapy in Atrial Fibrillation after Percutaneous Coronary Intervention

Current clinical practice prefers oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT) in atrial fibrillation (AF) after percutaneous coronary intervention (PCI). We conducted a meta-analysis to test the hypothesis that the superiority of OAC plus DAPT is mainly endorsed by observational studies (OSs); conversely, randomized clinical trials (RCTs) have suggested that OAC plus a single antiplatelet (SAP) agent is a safer and equally effective approach. Nine studies (4 RCTs and 5 OSs) were selected using MEDLINE, EMBASE, and CENTRAL (Inception, October 31, 2017). In analysis of RCTs, OAC plus SAP was safer in terms of major bleeding compared with OAC plus DAPT (relative risk [RR] 0.70, 95% confidence interval [CI] 0.60 to 0.81, p <0.001). Conversely, analysis of OSs showed comparable risk of major bleeding among both groups (RR 0.92, 95% CI 0.65 to 1.29, pu2009=u20090.61). For major adverse cardiovascular events, RCTs restricted analysis (RR 0.93, 95% CI 0.68 to 1.27, pu2009=u20090.64) and analysis of OSs (RR 1.43, 95% CI 0.84 to 2.42, pu2009=u20090.19) showed similar outcomes between both strategies. Both regimens had a similar risk of myocardial infarction (MI) in RCTs restricted analysis (RR 1.18, 95% CI 0.89 to 1.56, pu2009=u20090.24); however, analysis of OSs showed 76% higher risk of MI with OAC plus SAP. In conclusion, in patients with AF after PCI, RCTs recommend OAC plus SAP for better safety and equal efficacy compared with OAC plus DAPT. These findings oppose the results of OSs that showed similar safety and reduced risk of MI with OAC plus DAPT.

Renal Artery Stenosis-An Update

Abstract Renal artery stenosis (RAS) is a common form of peripheral arterial disease. The most common cause of RAS is atherosclerosis. It is predominantly unilateral. The pathophysiologic mechanism stems from renal underperfusion resulting in the activation of the renin- angiotensin-aldosterone pathway. Even though the majority of patients with RAS are asymptomatic, it can clinically present with hypertension, nephropathy and congestive heart failure. This progressive disease can lead to resistant hypertension and end stage kidney failure. Screening patients for RAS with either Doppler ultrasonography, computed tomographic angiography, or magnetic resonance angiography is preferred. Adequate blood pressure control, goal-directed lipid-lowering therapy, smoking cessation, and other preventive measures form the foundation of management of patients with RAS. Catheter-based percutaneous revascularization with angioplasty and stenting showed modest clinical benefit for patients in small retrospective studies, but data from randomized clinical trials failed to confirm these beneficial results. The current ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial may provide more concrete data regarding the role of stenting in RAS. Surgical revascularization is considered only if catheter-based revascularization is unsuitable or unsuccessful. The American College of Cardiology/American Heart Association guidelines on evaluation and management of patients with RAS provide the framework for determining individualized assessment and treatment plans for patients with RAS.

Cocaine-induced coronary thrombosis: what is the optimal treatment strategy☆

Arterial thrombosis and especially coronary thrombosis are known complications of cocaine abuse. We report three cases of severe life-threatening coronary arterial thrombosis manifesting as acute coronary syndromes. Thrombosis occurred predominantly in the proximal coronary tree with spontaneous distal embolization. The thrombotic occlusions were frequently not superimposed on flow-limiting atherosclerotic lesions. Treatment of these patients with thrombolytic, antithrombotic and anti-platelet therapy resulted in thrombus and symptom resolution. While stenting these vessels can be successfully executed and may be required in some cases of ST-elevation myocardial infarction, it may expose these patients to the risk of stent thrombosis, which is reported to be significantly higher than the risk of the general population.