Sophie Degrauwe

Dual antiplatelet therapy for secondary prevention of coronary artery disease

Dual antiplatelet therapy (DAPT) combining aspirin and a P2Y12 receptor inhibitor has been consistently shown to reduce recurrent major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) compared with aspirin monotherapy, but at the expense of an increased risk of major bleeding. Nevertheless, the optimal duration of DAPT for secondary prevention of CAD remains uncertain, owing to the conflicting results of several large randomised trials. Among patients with stable CAD undergoing PCI with drug-eluting stents (DES), shorter durations of DAPT (3–6 months) were shown non-inferior to 12 or 24 months duration with respect to MACE, but reduced the rates of major bleeding. Contrariwise, prolonged DAPT durations (18–48 months) reduced the incidence of myocardial infarction and stent thrombosis, but at a cost of an increased risk of major bleeding and all-cause mortality. Until more evidence becomes available, the choice of optimal DAPT regimen and duration for patients with CAD requires a tailored approach based on the patient clinical presentation, baseline risk profile and management strategy. Future studies are however needed to identify patients who may derive benefit from shortened or extended DAPT courses for secondary prevention of CAD based on their individual ischaemic and bleeding risk. Based on limited evidence, 12 months duration of DAPT is currently recommended in patients with ACS irrespective of their management strategy, but large ongoing randomised trials are currently assessing the efficacy and safety of a short-term DAPT strategy (3–6 months) for patients with ACS undergoing PCI with newer generation DES. Finally, several ongoing, large-scale, randomised trials are challenging the current concept of DAPT by investigating P2Y12 receptor inhibitors as single antiplatelet therapy and may potentially shift the paradigm of antiplatelet therapy after PCI in the near future. This article provides a contemporary state-of-the-art review of the current evidence on DAPT for secondary prevention of patients with CAD and its future perspectives.

Coronary Subclavian Steal Syndrome and Acute Anterior Myocardial Infarction A New Treatment Dilemma in the Era of Primary Percutaneous Coronary Intervention

Coronary subclavian steal syndrome (CSSS) is an uncommon complication after coronary artery bypass graft (CABG) surgery using the left internal mammary artery (LIMA).1–3 CSSS results from the retrograde blood flow through the LIMA graft in the left subclavian artery (SCA), consecutive to a proximal SCA stenosis or total occlusion. CSSS usually manifests as stable angina pectoris1 but also rarely presents as ST-segment–elevation myocardial infarction secondary to an acute SCA occlusion or plaque rupture.1,2 Anterior ST-segment–elevation myocardial infarction resulting from an acute thrombotic occlusion of the left anterior descending (LAD) artery at the LIMA-to-LAD anastomotic site in a patient with concomitant CSSS may be a challenging problem during primary percutaneous coronary intervention and has not been reported to date. Here, we report on a 62-year-old woman with hypertension, dyslipidemia, and peripheral artery disease who underwent CABG surgery using a LIMA graft to the LAD 12 years earlier (Figure 1 and Movie I in the online-only Data Supplement). The patient presented to the emergency department with de novo exertional chest pain. The 12-lead ECG showed negative T waves in the anterior leads, and her cardiac biomarkers were normal. During admission, the patient developed chest pain at rest associated with paresthesias of the left hand. An ECG showed new anterior ST-segment elevation, and the patient was transferred for primary percutaneous coronary intervention. The left coronary angiogram (Movie II in the online-only Data Supplement) showed a patent LAD with critical …

Subepicardial Hematoma of the Left Ventricle Mimicking Acute Anterior Myocardial Infarction

A 63-year-old male with hypercholesterolemia was admitted to the emergency department complaining of a 12-hour persisting typical central chest pain. He had experienced a blunt chest trauma while practicing judo 6 weeks earlier. On admission, the 12-lead ECG was consistent with acute anterior ST-segment elevation myocardial infarction (STEMI), and the patient received loading doses of aspirin, prasugrel, and unfractioned heparin. The urgent coronary angiogram (CA) showed an occlusion of the mid-left anterior descending (LAD) artery, with retrograde collateralization arising from the first diagonal branch, and absence of significant lesions in the left circumflex and right coronary arteries (Movie I in the online-only Data Supplement). Percutaneous coronary intervention to the LAD was attempted without possibility to access the distal LAD beyond the occlusion site, suggesting a chronic total occlusion (Movie II in the online-only Data Supplement). The procedure was stopped because the patient became symptom free without hemodynamical compromise. The final CA showed persisting occlusion of the mid-LAD and absence of coronary perforation (Movie III in …

Multi-level vascular aneurysms and polycystic kidney disease

[1] Dickstein K, Vardas PE, Auricchio A, et al. Focused update of ESC guidelines on device therapy in heart failure. Eur Heart J 2010;31:2677. [2] Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. NEJM 2005;352:1539. [3] Ellenbogen KA, Huizar JF. Foreseeing super-response to cardiac resynchronization therapy—a perspective for clinicians. J Am Coll Cardiol 2012;59:2374. [4] Bax JJ, Bleeker GB, Marwick TH, et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004;44:1834. [5] Rickard J, Popovic Z, Verhaert D, et al. The QRS narrowing index predicts reverse left ventricular remodelling following cardiac resynchronization therapy. PACE 2011;34:604. [6] Yu CM, Bleeker GB, Fung JW, et al. Left ventricular reverse remodeling but not clinical improvement predicts longterm survival after cardiac resynchronization therapy. Circulation 2005;112:1580.

Orsiro cobalt-chromium sirolimus-eluting stent: present and future perspectives.

ABSTRACT Introduction: New-generation drug-eluting stents (DES) represent the current standard of care in patients undergoing percutaneous coronary intervention (PCI). Biodegradable polymer DES (BP-DES) were recently developed to overcome current limitations of newer-generation durable polymer DES (DP-DES) attributed to sustained inflammatory responses induced by permanent polymers. The Orsiro DES (Biotronik AG, Bülach, Switzerland) is a novel thin-strut cobalt-chromium sirolimus-eluting stent with biodegradable polymer that features some of the latest developments in DES technology. Areas covered: This article aims to review the currently available evidence on the clinical performance of the Orsiro BP-DES and its future perspectives. Expert commentary: The Orsiro DES is a recent newer-generation BP-DES that combines a highly deliverable thin-strut cobalt-chromium stent platform and a unique hybrid concept with passive and active coatings designed to enhance tissue biocompatibility. In preclinical and intravascular imaging studies, the Orsiro BP-DES was shown to induce low inflammation and promote very early arterial healing. Recently, large randomized non-inferiority clinical trials have shown similar short- and mid-term efficacy and safety outcomes with Orsiro BP-DES compared with currently established newer-generation DES among all-comers and high-risk subgroups. The potential clinical superiority of Orsiro BP-DES over Xience DP-DES in patients with STEMI is currently investigated in the BIOSTEMI trial (NCT02579031).

First report on biventricular stress cardiomyopathy with concomitant atrio-ventricular high-grade conduction disorder

Stress cardiomyopathy (takotsubo cardiomyopathy [TTC]) is an acute cardiac syndrome mimicking acute coronary syndrome (ACS) characterized by typical systolic dysfunction of left ventricle. Right ventricular involvement has been previously reported and represents an important predictor of adverse clinical outcomes. Biventricular involvement occurs in approximately one third of patients [1]. Atrio-ventricular (AV) block complicating TTC occurs in only 5% of patients [2]. Association of biventricular TTC, complete AV block and cardiogenic shock presenting as ACS is extremely rare and has never been reported to date. This study reports a case of an 82-year-old female known to have diabetes mellitus type II as well as CHILD B hepatic cirrhosis on beta-blocker treatment for oesophagal varices and was admitted to the Emergency Department for typical chest pain at rest and vasovagal syncope. Third degree AV block with high ventricular escape was noted on 12-lead electrocardiogram (Fig. 1A). Laboratory results showed an elevation of high-sensitivity cardiac troponin from 130 ng/L to 450 ng/L as well as N-terminal pro B-type natriuretic paptide (NTproBNP) elevation (3905 ng/L). During admission patient developed severe arterial hypotension, bradycardia, and cardiogenic shock. Urgent coronary angiography for very high-risk non-ST-segment elevation ACS was performed and demonstrated unobstructed coronary arteries. Severe biventricular systolic dysfunction with biventricular apical ballooning was noted on ventriculography (Fig. 1B; Supplementary Movie 1 and 2 — see journal website). Transthoracic echocardiogram demonstrated severe left ventricular systolic dysfunction (ejection fraction [EF] 25%) with apical ballooning as well as severe right ventricular systolic dysfunction with apical ballooning (Fig. 1C; Supplementary Movie 3 and 4 — see journal website). Cardiac magnetic resonance examination performed at day 8 demonstrated non-dilated left ventricle with preserved systolic function (EF 55%) and discrete residual apical hypokinesia. The right ventricle also showed a recovery of systolic function and complete regression of dilation (Fig. 1D; Supplementary Movie 5 — see journal website). However, the patient presented persistent high-degree AV block requiring temporary endovenous pacing and finally implantation of a dual-chamber pacemaker at day 10. The patient was discharged on day 12 on enalapril, sitagliptin/ /metformin and simvastatin. At one one-year follow-up patient had remained free from cardiovascular symptoms and adverse cardiac events, though there was persistent high-degree AV block. Control echocardiogram demonstrated preserved left ventricular function (EF 60%) without wall motion abnormalities. Despite numerous known triggers [3–5], the underlying pathophysiological mechanism of timely stunned myocardium and AV conduction damage remains unclear. Whether AV blocks are the cause or consequence of TTC is still a matter of debate. The persistence of AV conduction disorders in the setting of transient left ventricle dysfunction inclines reconsideration clinical cardiology

Intrapericardial paraganglioma: The role of integrated advanced multi-modality cardiac imaging for the assessment and management of rare primary cardiac tumors

N/A.

Thyroid storm: A rare and life-threatening cause of acute neurological manifestations during urgent percutaneous coronary intervention for acute coronary syndrome

Acute neurological complications during coronary angiography (CAG) are extremely uncommon with an incidence of < 0.1% [1] but they remain a challenging clinical problem, particularly in patients with acute coronary syndrome. Periprocedural ischemic or hemorrhagic stroke remains the most common cause with an incidence of 0.07–0.38% and is associated with high rates of morbidity and mortality [2]. However, sudden-onset neurological symptoms during diagnostic CAG or percutaneous coronary intervention (PCI) may result from rarer albeit fatal neurological or endocrine conditions, such as seizure, encephalopathy, contrast media-induced neurotoxicity or acute thyrotoxicosis [3]. Thyroid storm (TS) is a life-threatening endocrine emergency that represents the extreme manifestation of acute thyrotoxicosis and is associated with high morbidity and mortality (10%) rates if left untreated [3, 4]. Herein is reported a 70-year-old woman with arterial hypertension, pacemaker implantation for sick sinus syndrome and paroxysmal atrial fibrillation on long-term amiodarone therapy, who was admitted to the emergency department with acute typical chest pain. The patient underwent previous coronary artery bypass grafting with left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and saphenous vein graft to the right coronary artery (RCA) 16 years earlier, followed by PCI to the distal RCA with a drugeluting stent 9 years later. Three weeks prior to admission, the patient presented with weight loss, tremor and palpitations suggestive of thyrotoxicosis, with decreased levels of thyroid stimulating hormone (< 0.005 mIU/L, normal range 0.4– –4.0 mIU/L), and elevated levels of free thyroxine (T4) (93 pmol/L, normal range 11–27 pmol/L) and free tri-iodothyronine (T3) (16.5 pmol/L, normal range 0.8–2.7 pmol/L), suggestive of amiodarone-induced thyrotoxicosis (anti-TSH receptor antibody: < 3 U/L). Amiodarone therapy was discontinued and an antithyroid drug (carbimazole 20 mg/day) was initiated with reduction of free T4 (70 pmol/L) and T3 (15 pmol/L) levels at 3-week follow-up. The thyroid ultrasound showed a slightly enlarged and heterogeneous thyroid gland, but excluded a nodular formation as well as hypervascularisation. Upon present admission, electrocardiogram demonstrated ST-segment depression from V3 to V6 leads and cardiac biomarkers were elevated. The CAG demonstrated a 3-vessel coronary artery disease with occlusion of the saphenous vein graft to RCA, involution of the LIMA graft to LAD, 50% distal left main coronary artery stenosis, obtuse marginal branches and intermediate artery stenoses, 50% distal RCA in-stent restenosis, and hemodynamically significant proximal LAD stenosis. The patient underwent PCI to the proximal LAD with a drug-eluting stent. During the procedure, the patient developed acute neurological symptoms including headache, agitation, delirium, confusion, nausea and vomiting, that required CLINICAL CARDIOLOGY