Raza Askari

An updated comprehensive meta-analysis of bivalirudin vs heparin use in primary percutaneous coronary intervention

BACKGROUND Despite several randomized controlled trials and meta-analyses, the ideal anticoagulant for patients undergoing primary percutaneous coronary intervention (PCI) remains controversial. We performed an updated meta-analysis including recently reported randomized clinical trials that compare bivalirudin and heparin with or without provisional administration of a glycoprotein IIb/IIIa inhibitor (GPI) for primary PCI. METHODS AND RESULTS Scientific databases and Web sites were searched for randomized clinical trials. Data from 6 trials involving 14,095 patients were included. The pooled risk ratios (RRs) were calculated using random-effects models. Moderator analyses examined the impact of routine use of GPI, radial access, and P2Y12 inhibitors on safety outcomes. At 30 days, patients receiving bivalirudin had rates of major adverse cardiac events similar to those receiving heparin with or without provisional GPI (RR 1.02, 95% CI 0.87-1.19, P = .800), myocardial infarction (RR 1.41, 95% CI 0.94-2.11, P = .089), target vessel revascularization (RR 1.37, 95% CI 0.91-2.04, P = .122), and net adverse clinical events (RR 0.81, 95% CI 0.64-1.01, P = .069). However, bivalirudin use decreased the risk of all-cause mortality (RR 0.81, 95% CI 0.67-0.99, P = .041) and cardiac mortality (RR 0.68, 95% CI 0.51-0.91, P = .009) at 30 days, There were higher rates of acute stent thrombosis (RR 3.31, 95% CI 1.79-6.10, P < .001) in patients receiving bivalirudin. Bivalirudin use also decreased the risk of major bleeding at 30 days by 37% (RR 0.63, 95% CI 0.44-0.90, P = .012), but bleeding risk varied depending on routine GPI use with heparin (RR 0.44, 95% CI 0.23-0.81, P = .009) vs bailout (RR 0.73, 95% CI 0.42-1.25, P = .252), predominantly radial access (RR 0.54, 95% CI 0.25-1.15, P = .114) vs non-radial access (RR 0.60, 95% CI 0.36-0.99, P = .049), and second-generation P2Y12 inhibitor use with bivalirudin (RR 0.70, 95% CI 0.40-1.24, P = .226) vs clopidogrel use (RR 0.39, 95% CI 0.18-0.85, P = .018). CONCLUSIONS In primary PCI, relative to heparin, bivalirudin reduces the risk for all-cause mortality, cardiac mortality, and major bleeding but yields similar rates of major adverse cardiac event and net adverse clinical event at 30 days. However, the benefit of a reduction in bleeding with bivalirudin appears to be modulated by the concurrent administration of second-generation P2Y12 inhibitors with bivalirudin, using radial access, and avoiding routine GPI use with heparin.

Cardiac tuberculoma presenting as thrombotic thrombocytopenic purpura-hemolytic uremic syndrome.

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a unique multisystem syndrome. It can present with either chronic or subacute infections. Tuberculosis (TB) is a chronic infection that has been reported to present with TTP-HUS as tuberculous endocarditis in the presence of immunodeficiency and implanted medical devices in regions where TB is endemic. Tuberculomas are space occupying lesions most commonly found in the brain in immunocompromised individuals. Herein, we present a rare association of tuberculosis with endocarditis manifesting as a tuberculoma and presenting as TTP-HUS in an immunocompetent patient and resident of the United States.

Peripheral interventions and antiplatelet therapy: Role in current practice

Peripheral arterial disease (PAD) is a common disorder associated with a high risk of cardiovascular mortality and continues to be under-recognized. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease. Management includes exercise program, pharmacologic therapy and revascularization including endovascular and surgical approach. The optimal revascularization strategy, endovascular or surgical intervention, is often debated due to the paucity of head to head randomized controlled studies. Despite significant advances in endovascular interventions resulting in increased utilization over surgical bypass, significant challenges still remain. Platelet activation and aggregation after percutaneous transluminal angioplasty of atherosclerotic arteries are important risk factors for re-occlusion/restenosis and life-threatening thrombosis following endovascular procedures. Antiplatelet agents are commonly prescribed to reduce the risk of myocardial infarction, stroke and death from cardiovascular causes in patients with PAD. Despite an abundance of data demonstrating efficacy of antiplatelet therapy in coronary artery disease and cerebrovascular disease, there is a paucity of clinical information, clinical guidelines and randomized controlled studies in the PAD population. Hence, data on antiplatelet therapy in coronary interventions is frequently extrapolated to peripheral interventions. The aim of this review article is to elucidate the current data on revascularization and the role and duration of antiplatelet and anticoagulant therapy in re-vascularized lower limb PAD patients.

Quinine Syncope Diagnosed by Life Vest

We present the case of a patient with ischemic cardiomyopathy using quinine as a remedy for leg cramps. A wearable cardioverter defibrillator (WCD) (LifeVest, Zoll Medical Corporation) recorded a sustained episode of polymorphic ventricular tachycardia resulting in syncope. Electrolyte concentrations were normal while QT interval was prolonged which improved after cessation of quinine and grapefruit juice.

Safety and efficacy of switching from unfractionated heparin to bivalirudin during primary percutaneous coronary intervention: Safety and efficacy of switching from unfractionated heparin to bivalirudin during primary percutaneous coronary intervention

To evaluate the safety and efficacy of switching to bivalirudin during primary percutaneous coronary intervention (PCI) for patients who received preprocedure unfractionated heparin (UFH).

Image Diagnosis: Rapidly Enlarging Scrotal Hematoma: A Complication of Femoral Access?

CASE PRESENTATION A 69-year-old man with known ischemic cardiomyopathy presented to our Emergency Department with chest pain. He underwent cardiac catheterization via right femoral approach with placement of a drug-eluting stent to his mid left anterior descending artery, and dual antiplatelet therapy with aspirin and clopidogrel was started. Postintervention, the arteriotomy site was sealed using a Mynx (CardinalHealth Inc, Dublin, OH) vascular closure device. No immediate postprocedure complications were noted. Overnight, the patient developed hypotension with penile swelling along with a progressively enlarging scrotal hematoma (Figure 1). No access site swelling or hematoma was evident. A computed tomography scan of the abdomen and pelvis showed soft tissue extending from the pelvis into the scrotum (Figure 2). The patient’s baseline hemoglobin level before the procedure was 10.5 g/dL, and hematocrit was 32.2%. At the time the swelling was noted, the patient’s hemoglobin had dropped to 7.5 g/dL, and hematocrit was down to 23.3%. He required transfusion of 2 units of packed red blood cells. The next morning, because of a continued drop in hemoglobin and worsening scrotal swelling, the patient was taken urgently to the catheterization laboratory for right femoral angiography via left femoral approach. The femoral angiogram showed continued spurting of blood from the right common femoral artery access site (Figure 3), probably because of posterior wall puncture during cardiac catheterization. Percutaneous balloon angioplasty was performed using an 8 mm x 40 mm compliant balloon with prolonged inflation (more than 5 minutes) to tamponade the site of the posterior ooze. A subsequent angiogram showed no evidence of bleeding from the common femoral artery (Figure 4). An orthogonal-view angiogram was repeated a few minutes later with similar results. During the next day, the patient’s hemodynamic and hematologic parameters stabilized. There was gradual reduction in the scrotal swelling until complete resolution was confirmed at follow-up 2 weeks later.

A rare presentation of bilateral spontaneous superficial femoral arteriovenous fistulas

Spontaneous arteriovenous fistulas are a rare clinical entity with very few cases reported in the literature. Prompt diagnosis and treatment is crucial and can prevent further complications in such patients. We report a case of a patient who presented with progressive bilateral claudication, discolouration of feet, hypaesthesia and non-healing ulcers. The patient had no history of trauma, aneurysm or surgery. After abnormal non-invasive studies, a peripheral angiogram revealed significant disease and obstruction of bilateral superficial femoral arteries. Spontaneous bilateral femoral arteriovenous fistulas were also found incidentally. After discussing the risks and benefits of multiple treatment options with the patient, percutaneous intervention with orbital atherectomy, balloon angioplasty and covered stent placements were performed. This treatment improved the patients symptoms significantly.

Complete revascularization of simultaneous multiple culprit lesions in a septuagenarian with ST-elevation myocardial infarction

Patient: Female, 74 Final Diagnosis: Multiple culprit lesions in ST-elevation myocardial infarction Symptoms: Chest pain • shortness of breath Medication: — Clinical Procedure: Cardiac catheterization Specialty: Cardiology Objective: Unusual clinical course Background: ST-elevation myocardial infarction (STEMI) is usually caused by rupture of unstable plaque with thrombus formation and abrupt cessation of blood flow through a single coronary artery that is deemed the culprit. The simultaneous thrombotic occlusions of multiple coronary arteries in the setting of STEMI is a rare occurrence with implications for patient management and outcome not fully addressed in the current STEMI guidelines, although more recent studies suggest a benefit of complete revascularization compared to culprit vessel-only treatment in the setting of STEMI. Case Report: A 74-year-old female presented with STEMI. Coronary angiography revealed simultaneous multiple coronary thrombotic occlusions involving the right coronary, left circumflex, and ramus intermedius arteries successfully treated with primary percutaneous revascularization at the same setting with good outcome and short hospital length of stay. Conclusions: Although the most appropriate timing to treat simultaneous multiple culprit lesions has yet to be definitively defined, multi-vessel percutaneous coronary intervention in the setting of a STEMI with multiple culprit lesions is feasible with good outcome as shown by our index case.

Cocaine-Induced Acute Aortic Dissection

*Section of Cardiovascular Medicine, University of Tennessee, Memphis, Tennessee, †Veterans Affairs Medical Center, Memphis, Tennessee, ‡WVU Heart Institute, Morgantown, West Virginia, and §Virginia Commonwealth University, School of Medicine, Richmond, Virginia Reprint Address: Rahman Shah, MD, University of Tennessee, School of Medicine, Section of Cardiovascular Medicine, Veterans Affairs Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104