Jose A. Suarez

Plasminogen activator inhibitor-1: physiologic role, regulation, and the influence of common pharmacologic agents.

Plasminogen activator inhibitor‐1 (PAI‐1) is the major inhibitor of endogenous thrombolysis, thereby promoting thrombosis. PAI‐1 is also a primary contributor to the development and recurrence of acute myocardial infarction. The renin angiotensin system, hypertriglyceridemia, hyperglycemia and hyperinsulinemia, and estrogen all influence the fibrinolytic system and PAI‐1 in particular. Available data strongly suggest that angiotensin‐converting enzyme (ACE) inhibitors and hormone replacement therapy with estrogen beneficially reduce PAI‐1 production. Metformin, an agent commonly used for non‐insulin‐dependent diabetes mellitus (NIDDM), appears to favorably decrease PAI‐1 production in NIDDM patients but not nondiabetic patients. Among the cholesterollowering statins, clinical literature evaluating pravastatin provides the most compelling data to support this agents favorable effect on PAI‐1. Other available statins either have not displayed an effect on PAI‐1 or do not have clear data to conclusively define their effects on the fibrinolytic system.

Questioning a Class Effect: Does ACE Inhibitor Tissue Penetration Influence the Degree of Fibrinolytic Balance Alteration following an Acute Myocardial Infarction?

There is a common belief in a class effect among angiotensin‐converting enzyme (ACE) inhibitors. This is unsubstantiated for acute myocardial infarction (AMI). Because vascular tissue is a source of the endogenous fibrinolytic markers, and ACE inhibition in vascular tissue favorably influences the fibrinolytic system, the authors hypothesized that a high‐tissue‐penetrating ACE inhibitor would provide a more favorable reduction in plasminogen activator inhibitor‐1 (PAI‐1) and an increase in tissue plasminogen activator (t‐PA) after AMI compared to a low‐tissue‐penetrating ACE inhibitor. In a randomized open‐label trial, patients received the high‐tissue‐penetrating quinapril (n = 15) or low‐tissue‐penetrating enalapril (n = 15) immediately following an AMI. PAI‐1 and t‐PA antigen (ng/mL) were measured at baseline and through 14 days of treatment. There was no difference in baseline PAI‐1 or t‐PA antigen between treatments. PAI‐1 antigen trended toward being lower with quinapril versus enalapril on day 1 (24.44 ± 14.96 vs. 36.94 ± 19.49, respectively, p = 0.059) and was significantly lower on day 3 (17.32 ±9.57 vs. 27.49 ± 9.61, respectively, p = 0.009). Analysis of PAI‐1 antigen over time by two‐factor ANOVA with replication found significantly lower concentrations of PAI‐1 antigen over the entire treatment period with quinapril versus enalapril (p < 0.003). This investigation of ACE inhibitor tissue‐penetrating influence on markers of reinfarction risk suggests there may be a greater early reduction in PAI‐1 with a more highly tissue‐penetrating ACE inhibitor.

Review of Catheter Thrombectomy Devices

Acute massive pulmonary embolism (PE) is a frequently fatal event that causes significant compromise of hemodynamic stability. Unfortunately, mortality rates for PE have remained relatively constant despite advances in prophylactic and treatment measures. In addition to embolus size, symptom recognition for diagnosis and emergent treatment are two distinct factors that dictate survival. Treatment generally includes thrombolytic agents; however, not all patients are candidates for aggressive thrombolytic management. Development of catheter thrombectomy devices provides an alternative treatment modality for severe cases when thrombolytics are contraindicated. Catheter thrombectomy devices have undergone major advances over the last decade, but literature support of their success is limited.

Effect of Pioglitazone on Platelet Aggregation in a Healthy Cohort

Background: Peroxisome proliferator-activated receptor (PPAR) agonists can favorably influence atheroma proliferation, lipoprotein metabolism and macrovascular complications. Pioglitazone, one of the thiazolidinedione compounds, is a PPAR ligand activator and a clinically important PPAR agonist. There is controversy in the literature about its potential antiplatelet effects. Its direct platelet inhibition is a novel hypothesis tested in animal models and in human populations with underlying diabetic and/or cardiovascular diseases. The present study was aimed to test the hypothesis of direct platelet aggregation inhibition with the use of pioglitazone in a healthy population. Methods: This prospective study was started after obtaining institutional review board approval. The platelet aggregation response to adenosine diphosphate, epinephrine, collagen and arachidonic acid was measured in healthy subjects before and after treatment with pioglitazone. The fasting lipid profile including total cholesterol, low-density lipoprotein, very-low-density lipoprotein and high-density lipoprotein was also measured. Results: Twenty subjects, 12 males and 8 females, were enrolled with a mean age of 31.5 ± 7.6 years (range 24–46). Two subjects did not complete the study and were excluded. The mean HbA1C was 5.4% (range 4.7–5.7). The study showed a non-significant platelet aggregation reduction after taking a 7-day pioglitazone course. The adenosine diphosphate-mediated platelet aggregation difference was not significant (p = 0.99); the arachidonic acid-mediated platelet aggregation difference was 0.6% (p = 0.93), for epinephrine 0.9% (p = 0.88) and for collagen 0.2% (p = 0.94). Further, it did not show a favorable response of lipoprotein profile with a non-significant reduction in all lipid panel values even though there is a slight reduction in total cholesterol, triglyceride, low-density lipoprotein and very low-density lipoprotein and a slight increase in high-density lipoprotein. Conclusions: We conclude that pioglitazone does not have a direct platelet aggregation inhibition effect in a healthy population, nor does it have a favorable effect on lipoprotein profile after a short treatment period.

Emotional Stress and Tako-Tsubo Cardiomyopathy: Observations on 2 Distinct Clinical Phenotypes

Background Tako-tsubo syndrome is a transient cardiomyopathy usually precipitated by an acute emotional or physiological stress. Our study objectives were to review and analyze the impact of emotional stress on clinical variables, echocardiographic characteristics, and short-term outcomes in patients with tako-tsubo syndrome. Methods Retrospective chart review. Results Eleven patients presented with tako-tsubo syndrome (1 man and 10 women) during the 8-year period (January 2000 to January 2008). The patients were split into 2 groups, defined by presenting either after emotional stress (6/11, 54.5%) or after idiopathic/physical stress (5/11, 45.5%). The mean age was 53.8 (12.6) years. The mean peak troponin T level was 0.54 ng/mL (range, 0.03-2.06 ng/mL), and the mean left ventricular end-diastolic pressure was 15.8 (8.1) mm Hg. Emotional stress was associated with younger age (P = 0.024), a lower left ventricular end-diastolic pressure (P < 0.05), more ST segment changes on electrocardiogram (66.7% vs 40%), and a higher ejection fraction (P = 0.012). The patients in the idiopathic/physical stress group required more frequent hemodynamic support. Conclusions We conclude that clinical, echocardiographic, and outcome characteristics can differentiate tako-tsubo patients presenting with emotional stress from those with idiopathic/physical stress into 2 distinct clinical phenotypes. Clinicians should monitor idiopathic/physically stressed tako-tsubo patients carefully for hemodynamic compromise.

LASER endovascular atherectomy with secondary stenting of technically challenging calcified celiac trunk stenosis

Endovascular therapy for chronic mesenteric ischemia is a proven, feasible alternative approach to open surgical repair with significantly lower morbidity and mortality. A clinical dilemma is encountered when technically challenging lesions are encountered during the procedure. We present here an 86 year‐old woman who had intractable abdominal pain with postprandial exacerbation. The patient had successful endovascular light amplification by stimulated emission of radiation atherectomy of a highly calcified celiac truck, showing the feasibility of this technique.

Takotsubo cardiomyopathy associated with hyperthyroidism treated with thyroidectomy

Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle. We report a case that highlights takotsubo syndrome in the setting of thyrotoxicosis that required thyroidectomy. The association of takotsubo syndrome and hyperthyroidism has been reported before. We found 13 previously reported cases of thyrotoxicosis-induced cardiomyopathy, most associated with Graves disease and none treated with thyroidectomy. Awareness of this possible association is important in establishing the diagnosis and instituting proper management.

Klippel-Trenaunay syndrome and radial artery coronary graft spasm.

A 75-year-old woman with known diagnosis of Klippel-Trenaunay syndrome presented with acute onset of chest pain, dyspnea and elevated cardiac enzymes. She had triple vessel coronary artery disease on subsequent coronary angiography. Given the unavailability of venous conduits secondary to lower extremity varicosities, coronary artery bypass grafting with radial and internal mammary arterial grafts was carried out. The radial artery graft went into spasm two days later and required intracoronary vasodilators to relieve the spasm. The patient remained hypotensive and finally expired.

A retrospective analysis of laser endartherectomy assisted balloon angioplasty for popliteal and infrapopliteal peripheral arterial disease

OBJECTIVES To describe our single center experience with the use of laser endartherectomy assisted balloon angioplasty in popliteal and infrapopliteal arterial disease. BACKGROUND Peripheral arterial disease (PAD) carries significant morbidity to patients. Some patients may have multiple comorbid conditions potentially limiting therapeutic options for PAD. Endovascular interventions are aimed at decreasing arterial disease symptoms, improve wound healing and ultimately limb salvage. There is limited data on below the knee PAD and simultaneous laser endartherectomy use in this anatomic location. METHODS The cohort comprised 41 patients that underwent laser assisted balloon angioplasty from 2010 to 2013. All patients had popliteal and infrapopliteal arterial disease. Outcomes evaluated were limb salvage and symptom relief 12months following the procedure. A comparison between the patients that underwent amputation and those with limb salvage was also performed. RESULTS All the patients had TASC II (Trans Atlantic Inter-Society Consensus) type D lesions. Most patients reported persistent PAD symptoms by six months, with 17% remaining symptom free by 12months. Affected limb salvage was 69%. Five patients (12%) died and one third of the patients had a new peripheral angiogram. In the repeat angiogram, most patients showed initial target vessel occlusion. No statistically significant differences were found between the patients that preserved their limb to those who underwent amputation. CONCLUSIONS Laser assisted balloon angioplasty use for complex popliteal and infrapopliteal arterial disease is a therapeutic option when limb salvage is the goal. Despite this, symptom recurrence and the need for repeated angiography continue to be high.

The feasibility of transradial laser atherectomy for chronic total occlusion using the 5 Fr sheath system.

OBJECTIVE We present a case of chronic total occlusion (CTO) approached with LASER endovascular intervention by radial artery approach using a 5 French sheath. CASE REPORT A 57-year-old man presented to our hospital having had retrosternal chest pain for two days. Physical examination was normal at the time of presentation. The laboratory tests were within normal limits, including cardiac enzymes except the lipid panel which showed hypertriglyceridemia. The patient underwent a myocardial perfusion scintigraphy stress test that revealed inferior wall ischemia, with normal left ventricular ejection fraction. A 5-French vascular sheath was placed in the right radial artery. Selective coronary artery angiography was performed, which showed right coronary artery (RCA) CTO. A 5-French JR4 guide catheter successfully engaged the RCA and Laser angioplasty was performed across the CTO into the RCA. A marked improvement of flow was evident thereafter. CONCLUSION To best of our knowledge this is the first case report showing the feasibility of laser atherectomy using the 5 French sheath system in a coronary arterial CTO.