R. Alcock

Perioperative myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery.

Objective Cardiovascular complications are important causes of morbidity and mortality in elective non-cardiac surgery. Although difficult to diagnose, perioperative myocardial infarction (MI) remains prognostically important. High-sensitivity troponin T (hs-TnT) assays allow detection of very minor damage to cardiac muscle. These assays are yet to be fully evaluated in the perioperative setting. Our aim was to determine the incidence and predictors of myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery using hs-TnT. Design Prospective observational cohort study. Patients 352 consecutive patients undergoing elective major non-cardiac surgery prescribed antiplatelet therapy for primary or secondary cardiovascular event prevention. Main outcome measure The incidence of elevated preoperative hs-TnT (≥14 ng/litre), hs-TnT-defined perioperative myocardial necrosis (≥ 14ng/litre and 50% increase from preoperative level), and perioperative MI were determined in relation to patient and surgical factors. Results Preoperative hs-TnT was elevated in 31% and postoperative myocardial necrosis occurred in 22% of patients. Predictors of elevated baseline hs-TnT included age (OR 1.10, p<0.001), male gender (OR 2.91, p<0.001), diabetes requiring insulin therapy (OR 4.85, p=0.004) and chronic kidney disease (OR 3.60, p<0.001). Independent predictors of perioperative myocardial necrosis were age (OR 1.07, p<0.001), intraoperative hypotension (OR 3.67, p=0.001) and orthopaedic surgery (OR 2.46, p=0.005). Only 2% of patients suffered clinically apparent MI. Elevated preoperative hs-TnT did not predict perioperative myocardial necrosis or MI. Conclusions Perioperative myocardial damage occurs frequently in patients undergoing elective non-cardiac surgery, although the majority of events are clinically undetected. Age and intraoperative hypotension are independent predictors of myocardial necrosis in this setting.

Incidence and determinants of myocardial infarction following percutaneous coronary interventions according to the revised Joint Task Force definition of troponin T elevation.

BACKGROUND Elevations in troponin T (TnT) occur frequently following percutaneous coronary intervention (PCI) and are associated with an adverse prognosis. The Joint ESC/ACC/AHA/WHF Task Force have released a proposal for a universal definition of myocardial infarction (MI), including diagnostic criteria for PCI associated MI. This is based on a TnT cut-point of more than three times the 99th percentile (0.03 ng/ml), which better reflects the precision of the assay. Our study investigated the incidence and predictive factors of a PCI associated MI, using the revised definition. METHODS 325 patients were studied following PCI with stenting. TnT was collected at both 8 and 18 h following PCI in patients with either stable or unstable angina and normal baseline TnT levels. Comparison was made of both clinical and procedural characteristics of patients with and without a rise in TnT following intervention, using cut points of 0.01 and 0.03 ng/ml. RESULTS TnT was elevated > or = 0.03 ng/ml in 27% and > or = 0.01 ng/ml in 39% of patients following PCI. Troponin elevation was significantly more likely in those patients who experienced peri-procedural ischemic symptoms or EKG changes, or in whom abciximab was used. The variables associated with a troponin rise showed a greater difference between TnT positive and negative patients when using 0.03 ng/ml compared to 0.01 ng/ml, suggesting that this may be a better definition of PCI-related MI. CONCLUSIONS Approximately one-quarter of low risk patients experience a procedural MI according to the revised definition. Rises in troponin were significantly associated with peri-procedural ischemic symptoms and EKG changes, and abciximab use, consistent with this level of TnT reflecting true myocardial necrosis.

Acute coronary syndrome and stable coronary artery disease: Are they so different? Long-term outcomes in a contemporary PCI cohort

BACKGROUND Patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are known to have poorer short-term prognosis compared to stable coronary artery (CAD) patients undergoing elective PCI. Few studies have made direct comparison of long-term mortality between ACS and stable CAD patients undergoing PCI. The aim of our study was to compare the long-term mortality following PCI between patients with ACS and those with stable CAD. METHODS We examined consecutive patients undergoing PCI with stenting at a tertiary referral hospital. Clinical, angiographic and biochemical data were collected and analysed. The primary outcome was all-cause mortality retrieved from the Statewide Death Registry database. RESULTS Included were 1923 consecutive PCI patients (970 stable CAD and 953 ACS). The mean follow-up time was 4.1 years ± 1.8 years. In-hospital mortality was 1.4% overall, seen exclusively in patients with ACS (n=28, 2.9%). Post-discharge mortality was 6.7% among patients with stable CAD and 10.5% for ACS (P<0.01). Multivariate predictors of post-discharge deaths for both groups included age (HR 1.08 per year, P<0.001) and impaired renal function (HR 2.49, P<0.001). Following adjustment for these factors, an ACS indication for PCI was not associated with greater post-discharge mortality (adjusted HR 1.18: 0.85-1.64, P=0.32). CONCLUSIONS Patients undergoing PCI following an ACS have higher long-term mortality to those with stable CAD, which is potentially explained by a greater prevalence of comorbidities. This suggests that for the ACS population, contemporary interventional and medical management strategies may effectively and specifically counter the adverse prognostic impact of coronary instability and myocardial damage.

The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery

BACKGROUND Cardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. OBJECTIVES The aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. METHODS We evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. RESULTS Included were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. CONCLUSIONS Approximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification.

Giant right coronary aneurysm: a case of mistaken identity

A 64-year-old male presented for pre-operative assessment prior to orthopaedic surgery, with a history of hypertension, hyperlipidaemia, was a lifelong non-smoker, and reported no cardiac symptoms. Clinical examination was unremarkable; with electrocardiography demonstrating sinus rhythm with small, non-pathological inferior lead Q-waves. Transthoracic echocardiogram showed normal left ventricular size and function, without regional …

The rebound phenomenon after aspirin cessation: The biochemical evidence

Aspirin is the most commonly used anti-platelet agent in the primary and secondary prevention of cardiovascular events, with approximately 5% of middle-aged adults on long-term therapy [1]. Despite the clinical observations of a clustering of events following cessation of aspirin treatment, there are few prospective studies investigating the potential mechanisms. There are two possible explanations for these events: the first is that the withdrawal of aspirin allows the prothrombotic manifestations of the underlying disease process to re-emerge, with clinical consequences. The second is that aspirinwithdrawal is associatedwith a “rebound” phenomenon that is prothrombotic and/or proinflammatory, and plays a causative role in adverse events. This rebound hypothesis, as a scientific entity, can be defined as an increase in platelet reactivity following aspirin withdrawal, to a level exceeding that at baseline prior to initiation of aspirin therapy [2]. The primary aim of this study was to investigate the effect of aspirin withdrawal on platelet function. Specifically, we assessed whether aspirin cessation resulted in a “rebound” phenomenon of platelet hyperaggregation, or merely a recovery of normal platelet function. We also sought to describe the haemostatic balance after aspirin withdrawal using global haemostatic assays. Eleven healthy volunteers were enrolled in this prospective study of platelet function. Participants were given aspirin for one week (300 mg loading dose on day 1, 150 mg on days 2–7). Blood sampling was performed in all subjects at baseline (before the first dose of aspirin therapy), and at days 7 (the day of the last dose of aspirin therapy), 14 and 21. The institutional Human Research and Ethics Committee approved the study protocol and written informed consent was obtained from all participants. Peripheral venous blood samples were drawn through a short venous catheter inserted into a forearm vein. Platelet-rich plasma (PRP) was prepared by centrifugation of citrated blood and the resulting plasmawas used to dilute the PRP 2:3 (a platelet count of approximately 250 × 10 International Journal of Cardiology 174 (2014) 376–463

Antiphospholipid syndrome and rheumatic fever: a case spanning three decades of changing concepts and common immunological mechanisms

We present a case of primary antiphospholipid syndrome (APS), initially diagnosed as acute rheumatic fever, resulting in severe mitral valve incompetence. This case raises questions of the specificity of the Jones diagnostic criteria for rheumatic fever in a population where it is infrequently encountered. There are similarities in clinical, pathological and echocardiographic presentations between rheumatic fever and APS, in addition to common immunological mechanisms. Our case highlights the possibility that rather than rheumatic fever being primarily responsible for her recurrent attacks of chorea and arthritis, the streptococcal infections in our patient occurred either in the setting of underlying antiphospholipid antibodies (‘second hit’ phenomenon), or may have triggered the development of pathogenic antibodies (molecular mimicry), subsequently leading to the clinical evolution of APS. During the three decades of our patient and her recurrent problems, there has been an evolving knowledge of the mechanisms of APS and rheumatic fever, allowing us to extend our understanding beyond symptoms and syndromes, to a better realization of the underlying immunological relationship between the two.

TCT-212 Application of the DAPT score to a contemporary Percutaneous Coronary Intervention cohort

Duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation remains uncertain. Current guidelines suggest that patients with stable ischemic heart disease (SIHD) receiving DES can be managed with shorter durations of DAPT. Individualising DAPT duration using the DAPT

Acute leg pain due to iliac artery spasm during coronary angiography: an unusual consequence of an uncommon problem.

A 79-year-old male underwent diagnostic coronary angiography via the right femoral artery. A 6F sheath (Terumo, Tokyo, Japan) was inserted with the standard 45 cm J wire without complication, and coronary angiography undertaken in the standard manner. The patient experienced gradual onset intense pain in the right leg. Sheath arteriography demonstrated likely multiple discrete areas of spasm of the external and common iliac artery (Figure 1) which resolved completely with 200 mcg intrasheath glyceryl trinitrate and 25 mcg intravenous fentanyl (Figure 2). Significant leg pain during angiography is uncommon. It may occur ipsilaterally secondary to arterial dissection, or bilaterally due to atheroembolisation. Iliac artery spasm has been documented and is often asymptomatic but has also been described previously as being associated with pain. In this case, ipsilateral leg pain associated with iliac artery spasm was profound, resolved promptly with treatment, and had

Complex, diffuse in-stent atherosclerosis over a decade following bare metal stenting.

Correspondence to Harry C. Lowe, FRACP, PhD, MBChB, Department of Cardiology, Concord Repatriation General Hospital, Hospital Road, Concord, Sydney, NSW 2139, Australia Tel: + 61 2 9767 5000; fax: + 61 2 9767 6994; e-mail: h.lowe@bigpond.net.au An 83-year-old man presented with troponin-negative unstable angina at rest, clinically and angiographically assessed to be on the basis of circumflex disease. He had undergone bare metal stent (BMS) implantation 11.5 years previously (3.0× 18 mm Duet ACS; Guidant Indianapolis, Indiana, USA) for BMS in-stent restenosis, the index stent (2.5× 18mm GFX; AVE, Santa Rosa, California, USA) having been placed 2 months earlier.