Francisco Cambronero

Increased Major Bleeding Complications Related to Triple Antithrombotic Therapy Usage in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Artery Stenting

BACKGROUND The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S. METHODS We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [< or = 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded. RESULTS We studied 104 patients (mean age +/- SD, 72 +/- 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53). CONCLUSION A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.

Biomarkers of pathophysiology in hypertrophic cardiomyopathy: implications for clinical management and prognosis

The study of biomarkers and their signalling pathways has allowed the development of new therapeutic strategies in a range of disorders. The aim of the present systematic review is to provide an overview of different biomarkers in patients with hypertrophic cardiomyopathy that could give some insight into the pathophysiologic mechanism(s) underlying the typical clinical and histological manifestations of the disease. Several pathophysiological models are presented and discussed, including studies that have investigated these biomarkers for diagnostic and prognostic reasons, in relation to disease progression and/or mortality.

Impact of Chronic Kidney Disease on Major Bleeding Complications and Mortality in Patients With Indication for Oral Anticoagulation Undergoing Coronary Stenting

BACKGROUND Patients with indications for oral anticoagulation (OAC) undergoing percutaneous coronary artery stenting (PCI-S) represent a high-risk population for major bleeding complications. Chronic kidney disease (CKD) is also associated with poor outcome after PCI-S. Limited data are available regarding the impact of CKD on the frequency of major bleeding and mortality in this population. METHODS We investigated the influence of CKD on major bleeding and all-cause mortality in patients with indication for OAC who undergo PCI-S. Patients were grouped according to calculated creatinine clearance (CrCl): CrCl > 60 mL/min, (n = 98) and CrCl < or = 60 mL/min, (n = 68). Major bleeding and major adverse vascular events (all-cause mortality, myocardial infarction, repeat revascularization, stent thrombosis, or stroke) were collected during follow-up. RESULTS We analyzed 166 consecutive patients with indication(s) for OAC (77% men; mean age, 71 years; range, 66 to 76 years) after undergoing PCI-S. CKD was associated with higher risk for major bleeding (hazard ratio [HR], 3.44; 95% confidence interval [CI], 1.50 to 7.93; p = 0.004) and all-cause mortality (HR, 3.50; 95% CI, 1.53 to 7.99; p = 0.003). In multivariate analyses, age > 75 years (HR, 2.75; 95% CI, 1.15 to 6.56; p = 0.023), CKD (HR, 2.59; 95% CI, 1.00 to 6.95; p = 0.049), anemia (HR, 2.36; 95% CI, 1.00 to 5.54; p = 0.049), and triple antithrombotic therapy (HR, 3.29; 95% CI, 1.23 to 8.84; p = 0.018) were independent predictors for major bleeding, whereas age > 75 years (HR, 2.38; 95% CI, 1.03 to 5.59; p = 0.046) and CKD (HR, 2.44; 95% CI, 1.03 to 5.82; p = 0.044) were predictors for all-cause mortality. CONCLUSION In this high-risk population, CKD is independently associated with increased major bleeding and all-cause mortality following PCI-S.

An atypical presentation of Tako-Tsubo cardiomyopathy

We present the case of a patient with Tako-Tsubo cardiomyopathy whose initial diagnosis, based on the location of shoulder and chest pain and electrocardiographic (ECG) changes, suggested that she was suffering from pericarditis. However, 24 h after admission, evolutionary changes of ECG and the echocardiogram performed suggested a Tako-Tsubo cardiomyopathy. In this context, we review the literature to discuss the clinical presentation and evolutionary ECG changes associated with Tako-Tsubo cardiomyopathy.

Plasma levels of Von Willebrand factor are increased in patients with hypertrophic cardiomyopathy

UNLABELLED Hypertrophic cardiomyopathy (HCM) is characterised by inappropriate hypertrophy, small-vessel coronary artery disease, myocyte disarray and increased interstitial fibrosis. Microvascular dysfunction is a common finding in HCM and its extent has been proposed as an important prognostic marker. Plasma von Willebrand factor (vWf) is an established marker of endothelial damage or dysfunction; however it has scarcely been studied in HCM. We hypothesised that vWf could be raised in patients with HCM and be related to different variables associated with severity of HCM. METHODS We included 124 HCM patients, 93 males, aged 48+/-15 years, 59 healthy control subjects with similar age and sex and 20 patients with ischemic heart disease but clinical stability for the last 6 months. A complete history and clinical examination was performed, including 12-lead electrocardiogram, echocardiography, 24 hours ECG-Holter monitoring, and symptom limited treadmill exercise test. Risk factors for sudden death were evaluated. A blinded cardiac MRI was performed with late enhanced study with Gadolinium. Plasma vWf levels were assayed by commercial ELISA. RESULTS Patients showed higher levels of vWf (140.0+/-65.0 UI/ml vs 105.0+/-51.0 UI/ml, p<0.001) even after adjusting for ABO blood group. vWf levels were found raised in patients with severe functional class (168.4+/-65.9 UI/mL vs 132.4+/-60.7 UI/mL, p=0.020), atrial fibrillation (175.8+/-69.4 UI/mL vs 133.0+/-59.0 UI/mL, p=0.005), hypertension (161.4+/-60.8 vs 128.9+/-60.5, p=0.010) obstruction (153.9+/-67.9 vs 128.2+/-57.4 UI/mL, p=0.046) and non sustained ventricular tachycardia (159.3+/-59.1 vs 133.0+/-63.0, p=0.049). vWf correlated with age (r:0.26; p=0.006) and obstruction (r:0.22; p=0.021). CONCLUSIONS We show, for the first time, patients with HCM present significantly raised levels of vWf. These are associated with different conditions related to the severity of the disease.

Existe un efecto beneficioso a largo plazo con el tratamiento con marcapasos de la miocardiopatía hipertrófica obstructiva severa

Introduccion y objetivos Alrededor de un 25% de los pacientes con MCH obstructiva permanecen sintomaticos a pesar de una correcta medicacion. Algunos pueden beneficiarse del implante de un marcapasos. El objetivo fue valorar el efecto del marcapasos en la modificacion del gradiente en el tracto de salida del ventriculo izquierdo (TSVI), grosor maximo del ventriculo izquierdo (VI) y en la capacidad funcional. Metodos A 72 pacientes con MCH obstructiva y sintomas incapacitantes se les implanto un marcapasos. Se realizo un examen clinico, una ecocardiografia (61 pacientes) y una ergometria (34 pacientes) antes y despues de la implantacion del marcapasos. Resultados La capacidad funcional subjetiva, estimada segun la clasificacion de la NYHA, mejoro en el 43,1% de los pacientes, aunque no lo hizo la estimada mediante ergometria. Se observo una reduccion significativa del gradiente subaortico (mediana, 87 [intervalo intercuartilico, 61,5-115,2] frente a 30 [18-54,5] mmHg; p Conclusiones La implantacion de marcapasos en pacientes con MCH obstructiva con sintomas incapacitantes disminuye el gradiente obstructivo del TSVI y el grosor maximo del VI, pero solo el 43,1% consigue una mejoria clinica subjetiva, siendo una clase funcional mas avanzada el unico factor predictor de mejoria.

Anaemia as predictor of gastrointestinal bleeding in atrial fibrillation patients undergoing percutaneous coronary artery stenting.

Sir, We read with great interest the excellent review by Foley et al. who evaluate the risks of gastrointestinal bleeding in patients undergoing percutaneous coronary intervention (PCI) in relation to anti-platelet therapy.1 The authors emphasize the importance of several gastrointestinal bleeding major risk factors including use of dual anti-platelet therapy or non-steroidal anti-inflammatory drugs, increasing age, previous ulceration, helicobacter pylori infection, use of non-steroidal anti-inflammatory drugs and co-morbidity including sepsis and mechanical ventilation. However, they neither mention baseline anaemia nor triple antithrombotic drug use (aspirin, clopidogrel and warfarin) as conditions that could increase the rate of bleeding events after PCI-stenting. In a recent analysis of a cohort of patients with atrial fibrillation (AF) undergoing PCI-stenting with additional indication for long-term oral anti-coagulation, we recently reported that triple antithrombotic use was …

Antithrombotic therapy after coronary stenting in patients with indication for oral anticoagulation

not known after discontinuing the drugs. In addition, Urhausen et al. [3] reported that LV changes may not completely recover after stopping the drugs even after several years. Although more studies are required to clarify these findings, including the need for further imaging methods such as magnetic resonance imaging and additional studies due to the limitation of echocardiography for examining the RV, it is possible to say, based on the results of this current study, that AAS negatively affects RV diastolic function more than LV functions.

Does Pacemaker Implantation Provide Long-Term Benefits in Severe Obstructive Hypertrophic Cardiomyopathy?

INTRODUCTION AND OBJECTIVES About 25% of patients with obstructive hypertrophic cardiomyopathy (HCM) remain symptomatic despite optimal medical treatment. Some may benefit from pacemaker implantation. The aim of this study was to determine the effect of pacemaker implantation on the left ventricular outflow tract (LVOT) gradient, the maximum thickness of the left ventricle, and functional capacity. METHODS In total, 72 patients with obstructive HCM and incapacitating symptoms underwent pacemaker implantation. Clinical examination, echocardiography (in 61 patients) and treadmill testing (in 34 patients) were performed before and after implantation. RESULTS Subjective functional capacity, as assessed using the New York Heart Association (NYHA) classification, improved in 43.1% of patients, but treadmill testing showed no change. There were significant reductions in subaortic gradient, from a median of 87.0 mmHg (interquartile range [IQR] 61.5-115.2 mmHg) to 30.0 mmHg (IQR 18.0-54.5 mmHg; P< .001), and maximum left ventricular thickness, from 22.1+/-4.5 mm to 19.8+/-3.6 mm (P=.001). Univariate analysis identified two factors associated with clinical improvement: female sex (odds ratio [OR]=3.43; P=.020) and functional class III/IV (OR=4.17; P=.009). On multivariate analysis, only functional class III/IV remained a significant predictor (OR=3.12; P=.048). CONCLUSIONS In patients with obstructive HCM and incapacitating symptoms, pacemaker implantation reduced the LVOT gradient and the maximum left ventricular thickness, but only 43.1% of patients experienced clinical improvement. The only factor predictive of improvement was advanced NYHA functional class.