Roshan Prakash

The impact of increased age on outcome from a strategy of early invasive management and revascularisation in patients with acute coronary syndromes: retrospective analysis study from the ACACIA registry

Objective To evaluate the impact of increased age on outcome from a strategy of early invasive management and revascularisation in patients with acute coronary syndromes (ACS). Design Retrospective analysis of a national Acute Coronary Syndrome registry (ACACIA). Setting Multiple Australian (n=39) centres; 25% rural, 52% with onsite cardiac surgery. Patients Unselected consecutive patients admitted with confirmed ACS, total n=2559, median 99 per centre. Interventions Management was at the discretion of the treating physician. Analysis of outcome based on age >75 years was compared using Cox proportional hazard with a propensity model to adjust for baseline covariates. Main outcome measures Primary outcome was all-cause mortality. Secondary outcomes were bleeding and a composite of any vascular event or unplanned readmission. Results Elderly patients were more likely to present with high-risk features yet were less likely to receive evidence-based medical therapies or receive diagnostic coronary angiography (75% vs 49%, p<0.0001) and early revascularisation (50% vs 30%, p<0.0001). Multivariate analysis found early revascularisation in the elderly cohort to be associated with lower 12-month mortality hazard (0.4 (0.2–0.7)) and composite outcome (0.6 (0.5–0.8)). Propensity model suggested a greater absolute benefit in elderly patients compared to others. Conclusions Following presentation with ACS, elderly patients are less likely to receive evidence-based medical therapies, to be considered for an early invasive strategy and be revascularised. Increasing age is a significant barrier to physicians when considering early revascularisation. An early invasive strategy with revascularisation when performed was associated with substantial benefit and the absolute accrued benefit appears to be higher in elderly patients.

Catheter-Induced Iatrogenic Coronary Artery Dissection in Patients With Spontaneous Coronary Artery Dissection

Iatrogenic coronary artery dissection (ICAD) during coronary angiography is a rare (<0.2%) [(1,2)][1] but potentially fatal complication. ICAD may be particularly problematic in patients with spontaneous coronary artery dissection (SCAD). A high prevalence of predisposing arteropathies, particularly

Pre-Disposing and Precipitating Factors in Men With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) in younger women. The underlying cause, presentation, and natural history of SCAD in women are increasingly being described because >90% of cases affect women. However, SCAD in men is

Prognostic impact of moderate or severe mitral regurgitation (MR) irrespective of concomitant comorbidities: a retrospective matched cohort study

Objective We sought to objectively quantify the independent impact of significant mitral regurgitation (MR) on prognosis in patients with multiple comorbidities and ascertain the extent to which median survival is affected by increasing comorbidities. Methods This was a retrospective matched cohort study using a clinical-echocardiography reporting database linked to a clinical and administrative database in an Australian tertiary hospital. We identified our study cohort (patients with significant MR) and control cohort (without MR) on transthoracic echocardiographies performed between 2005 and 2010. The main outcome measures were mortality and heart failure rehospitalisation. A Cox proportional hazards model was used to adjust for clinical covariates and the ‘win ratio’ methodology was utilised to estimate the impact of MR on main outcomes. Results A total of 218 matched patients with and without significant MR were followed-up for 1 year. Significant MR was associated with an adjusted HR for mortality of 1.83 (95% CI 1.28 to 2.62, p<0.001). The win ratio for death and death or heart failure readmission was 0.57 (95% CI 0.40 to 0.78, p=0.0002) and 0.53 (95% CI 0.39 to 0.71, p<0.0001), respectively. Significant MR with left ventricular (LV) systolic dysfunction and age between 75 and 85 years were associated with a substantial reduction in median survival by 2.3 years. Significant MR with LV systolic dysfunction, age beyond 85 and advance comorbidities were associated with a lesser reduction in median survival by 0.2 years. Conclusions Significant MR in patients with multiple comorbidities leads to increase in death and heart failure rehospitalisation with reduced estimated median survival. However, its impact diminishes with increasing comorbidities.

Characteristics of extension and de novo recurrent spontaneous coronary artery dissection

AIMS Spontaneous coronary artery dissection (SCAD) is an under-recognised and important cause of myocardial infarction in young women. Recurrent SCAD is frequent but poorly understood. We aimed to explore the clinical and angiographic characteristics, and outcomes of recurrent SCAD. METHODS AND RESULTS Patients with SCAD extension or recurrence prospectively followed at Vancouver General Hospital were included in this retrospective study. SCAD diagnosis was confirmed by two experienced cardiologists. Detailed medical history, baseline demographics, angiographic results, and clinical details of index SCAD and recurrent events were recorded. SCAD extension was defined as angiographic extension of a previously dissected coronary segment, and de novo recurrent SCAD was defined as new spontaneous dissection. We identified 43 patients with SCAD recurrence with mean age 48.9±8.4 years; 38/43 were women, and 32/43 had fibromuscular dysplasia. Nine patients had SCAD extension at median time of five (1-19) days, while 34 patients had de novo recurrent SCAD at median time of 1,487 (107- 6,461) days after the index SCAD event. All SCAD extension patients had worsening of the index dissected segment, with 5/9 involving extension to adjacent segments, while all de novo recurrent SCAD patients had new dissections affecting coronary segments distinct from the index dissection. CONCLUSIONS De novo recurrent SCAD invariably affected new segments distinct from previously dissected segments.

Antiplatelet therapy in percutaneous coronary intervention: recent advances in oral antiplatelet agents

Purpose of review Dual antiplatelet therapy with aspirin and clopidogrel, in conjunction with heparin, is the most common antithrombotic strategy in percutaneous coronary intervention (PCI) used to reduce peri-procedural ischaemic complications. However, there remains significant inter-individual variability in post-treatment platelet inhibition with this current established therapy. This review focuses on recent developments in oral antiplatelet agents used in PCI, which promise to overcome, at least in part, current shortfalls. Recent findings Genetic polymorphisms and medication interactions involving CYP3A4 or CYP2C19, patient compliance and higher platelet reactivity in certain subgroups, such as those with diabetes, are important factors contributing to inter-individual variability in post-treatment platelet inhibition. Higher clopidogrel doses have been associated with improved clinical outcomes, especially in those presenting with acute coronary syndrome. Newer agents, namely prasugrel and ticagrelor, have been shown to have greater potency and superior clinical outcomes. However, this comes with a price of increased bleeding complications. Summary Whereas more potent antiplatelet therapies are associated with improved outcome, balancing the risk of bleeding and peri-procedural ischaemic complications remains a key aspect to consider when choosing among the ever-increasing number of agents available. The role of intravenous glycoprotein IIb/IIIa (GPIIb/IIIa) needs to be re-examined in the current context of such potent oral antiplatelet agents. Further research will hopefully help to determine the preferred antithrombotic strategy in patients undergoing PCI.

Instantaneous Decrease in Left Ventricular Afterload during Transcatheter Aortic Valve Implantation Results in Immediate Changes in Left Ventricular Strain

Severe aortic stenosis causes chronic increased afterload on the left ventricle (LV) resulting in myocardial hypertrophy and ultimately dysfunction if left untreated. Transcatheter aortic valve implantation (TAVI) immediately decreases the afterload on the LV by reducing the pressure gradient through the aortic valve. In our study, we aim to evaluate immediate changes in LV mechanics using intra‐procedural transesophageal echocardiography (TEE) to assess circumferential and radial strain via speckle tracking. Intra‐operative TEE was performed during TAVI for 53 patients (mean age 84 ± 8 years). Two‐dimensional images in the transgastric view were acquired at the level of the papillary muscle. Circumferential and radial strain was calculated using speckle tracking with Philips Qlab software. Global LV afterload was measured by calculating valvulo‐arterial impedance (Zva). Immediately post‐TAVI, there was a change in both radial strain rate (Pre: 0.73 ± 0.04 vs. Post: 0.88 ± 0.04 per second, P < 0.001) and circumferential strain rate (−0.53 ± 0.04 (pre) vs. −0.74 ± 0.04 (post) per second, P < 0.001). There was also an immediate improvement in circumferential global strain parameters (−14.5 ± 5% (pre) vs. −16.0 ± 4.7% (post), P < 0.05), whereas there was no significant change seen in global radial strain (15.6 ± 0.8% (pre) vs. 15.2 ± 0.9% (post), P = 0.69). No significant change was seen in LV ejection fraction (51.5 ± 14.2% (pre) vs. 52.1 ± 14.0% (post), P = 0.77). Speckle tracking using TEE images is feasible and identifies significant improvements in LV strain and strain rate immediately following TAVI that is not detected by conventional measure of LV function.

COMPARISON OF PSYCHOSOCIAL QUESTIONNAIRES BETWEEN SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD) AND NON-SCAD POPULATIONS UNDERGOING CARDIAC REHABILITATION PROGRAM AFTER MYOCARDIAL INFARCTION

Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) in women. We previously reported that emotional stressors were important precipitants for SCAD. We sought to compare the psychosocial profile of patients with SCAD and standard coronary

Imaging for percutaneous left atrial appendage closure: Imaging for Percutaneous Left Atrial Appendage Closure

Percutaneous left atrial appendage (LAA) closure is increasingly performed worldwide as an alternative to long-term oral anticoagulation, especially for patients who are considered ineligible for anticoagulation. This is a complex procedure with success that hinges upon good understanding of the LAA and surrounding structures anatomy. Multimodality imaging can provide important three-dimensional appreciation of the LAA anatomy, which facilitates procedural safety and success. Thus, proceduralists and imagers involved with LAA closure should have good comprehension of such imaging modalities (cardiac CT angiography, transesophageal echocardiography, and/or intracardiac echocardiography) prior to embarking on this procedure.