Sun Moon Kim

Takotsubo cardiomyopathy as a source of cardioembolic cerebral infarction

Takotsubo cardiomyopathy is a stress-related cardiomyopathy that mimics acute myocardial infarction. However, it is frequently without obstructive coronary artery disease and is mainly seen in postmenopausal women after an emotional or physiological event. In rare cases, it favours the formation of intracardiac mural thrombus and subsequent cardioembolic events. We report a rare case where a patient developed a cerebral infarction as a cardioembolic sequela of takotsubo cardiomyopathy following the death of her beloved dog. The patient was successfully managed with anticoagulation where a repeat echocardiogram 4 months later showed resolution of the apical thrombus along with recovery of systolic function and left ventricle regional wall abnormalities. This case serves to increase awareness about the rare cardioembolic complications of takotsubo cardiomyopathy and emphasise the need for serial echocardiographic examinations and anticoagulation.

Role of Routine Follow-up Coronary Angiography After Percutaneous Coronary Intervention ― Systematic Review and Meta-Analysis ―

BACKGROUND Prior studies have shown that routine follow-up coronary angiography (CAG) following percutaneous coronary intervention (PCI) increases the incidence of revascularization without a clear reduction in major adverse clinical events. However, none of these prior studies were adequately powered to evaluate hard clinical endpoints such as myocardial infarction (MI) or death and thus the clinical utility of such practice remains to be determined.Methods and Results:We conducted a systematic review and meta-analysis of randomized trials that compared clinical outcomes after PCI between patients who underwent routine follow-up CAG and those who only had clinical follow-up. Five randomized trials, totaling 4,584 patients met our inclusion criteria, including studies that used sub-randomization and ones that assigned consecutive patients per study protocol. Our results showed that routine follow-up CAG was associated with a lower rate of MI (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.46-0.91; P=0.01) without reduction in all-cause mortality (OR 0.87; 95% CI 0.59-1.28; P=0.48), and a higher rate of target lesion revascularization (OR 1.73; 95% CI 1.42-2.11; P<0.001). CONCLUSIONS Our meta-analysis demonstrated that routine follow-up CAG after PCI was associated with a higher rate of revascularization, but also with a reduction in the rate of subsequent MI. Further studies investigating the potential role of routine follow-up angiography may be warranted.

Higher Risk of Bleeding in Asians Presenting With ST-Segment Elevation Myocardial Infarction: Analysis of the National Inpatient Sample Database

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

Well recognised but still overlooked: norepinephrine extravasation

A 46-year-old man was transferred from an outside hospital for evaluation of acute renal failure and non-ST-segment elevation myocardial infarction. During his initial presentation at the outside hospital, the patient was profoundly hypotensive with signs of respiratory failure. Owing to the perceived urgency, he was started on norepinephrine for haemodynamic support through a peripheral intravenous line. Following the resolution of haemodynamic instability, the patient was noted …

QT prolongation is associated with increased mortality in end stage liver disease

AIM To determine the prevalence of QT prolongation in a large series of end stage liver disease (ESLD) patients and its association to clinical variables and mortality. METHODS The QT interval was measured and corrected for heart rate for each patient, with a prolonged QT cutoff defined as QT > 450 ms for males and QT > 470 ms for females. Multiple clinical variables were evaluated including sex, age, serum sodium, international normalized ratio, creatinine, total bilirubin, beta-blocker use, Model for End-Stage Liver Disease (MELD), MELD-Na, and etiology of liver disease. RESULTS Among 406 ESLD patients analyzed, 207 (51.0%) had QT prolongation. The only clinical variable associated with QT prolongation was male gender (OR = 3.04, 95%CI: 2.01-4.60, P < 0.001). During the study period, 187 patients (46.1%) died. QT prolongation was a significant independent predictor of mortality (OR = 1.69, 95%CI: 1.03-2.77, P = 0.039). In addition, mortality was also associated with viral etiology of ESLD, elevated MELD score and its components (P < 0.05 for all). No significant reversibility in the QT interval was seen after liver transplantation. CONCLUSION QT prolongation was commonly encountered in an ESLD population, especially in males, and served as a strong independent marker for increased mortality in ESLD patients.

Use of adenosine to shorten the post ablation waiting period for cavotricuspid isthmus-dependent atrial flutter

Dormant conduction unmasked by adenosine predicts clinical recurrences of cavotricuspid isthmus (CTI) dependent atrial flutter following catheter ablation. Conventional practice involves a waiting period of 20 to 30 minutes after achievement of a bidirectional line of block (BDB) to monitor for recovery of conduction.

Higher Risk of Bleeding in Asians Presenting With Non-ST-Segment Elevation Myocardial Infarction

Bleeding events are associated with unfavorable prognosis in patients with acute coronary syndromes. In a recent publication, we reported that Asian patients presenting with ST-segment elevation myocardial infarction are at a higher risk of bleeding than whites. Although similar results were noted in Asian patients with non-ST-segment elevation myocardial infarction (NSTEMI) using registry data from 2003 to 2005, characteristics of contemporary NSTEMI cohort and their bleeding risks may differ following advancements in troponin assays, changes in definition of myocardial infarction, and adoption of newer antiplatelet agents. In this context, we sought to reinvestigate the impact of Asian ethnicity on bleeding in a contemporary NSTEMI cohort. We analyzed the Nationwide Inpatient Sample database, a part of the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality, and identified all patients older than 18 years who were hospitalized with a primary diagnosis of NSTEMI (International Classification of Diseases diagnosis code 410.7x) between 2010 and 2014. The institutional review board of our facility determined that this study was exempted from formal review. The exclusion criteria, codes used to identify comorbidities and outcomes, and covariates included in multivariate models (except for systemic thrombolysis) were identical to our prior study. The primary outcome was in-hospital major bleeding, defined as a composite of intracranial hemorrhage and blood transfusion for bleeding events. All statistical analyses were performed with SPSS version 24.0 (IBM Corp, Armonk, New York). Data on race were missing in 7.9% of the population. After exclusions, 285 076 white and 8608 Asian patients were included. Hypertension, diabetes, renal failure, anemia, and cardiogenic shock were more commonly observed in Asians, while obesity was less prevalent (Table 1). Asian patients had a

Efficacy and Safety of Short-term Dual Antiplatelet Therapy (≤ 6 Months) after Percutaneous Coronary Intervention for Acute Coronary Syndrome; A Systematic Review and Meta-analysis of Randomized Controlled Trials

Patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are at increased risk for subsequent ischemic events.

Characteristics of and current practice patterns of pacing for high-degree atrioventricular block after transcatheter aortic valve implantation in comparison to surgical aortic valve replacement

We aimed to investigate the current practice patterns of permanent pacing, especially the timing of implantation, for high‐degree AV block (HDAVB) following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR).

Ticagrelor versus clopidogrel in East Asian patients with acute coronary syndrome: Systematic review and meta-analysis

BACKGROUND Bleeding complications are associated with unfavorable outcomes in patients with acute coronary syndrome (ACS). Compared to Whites, several studies demonstrated a higher risk of bleeding in Asians who present with acute myocardial infarction. To date, the efficacy and safety of ticagrelor in East Asian population have not been well established. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials that compared ticagrelor and clopidogrel in East Asian patients with acute coronary syndrome (ACS). We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrial.gov database. RESULTS Three randomized controlled trials, including a total of 1552 patients, met our inclusion criteria. Study countries included Japan, South Korea, and China. All studies defined primary efficacy endpoint and major bleeding events in accordance with the PLATO definition. Ticagrelor was associated with a numerically lower, albeit statistically nonsignificant, risk of primary efficacy endpoint defined as a composite of death from vascular causes, myocardial infarction, or stroke (odds ratio 0.84; 95% confidence interval 0.43-1.63; p = 0.60). Ticagrelor was associated with a significantly higher risk of PLATO-defined major bleeding compared to clopidogrel (odds ratio 1.52; 95% confidence interval 1.04-2.23; p = 0.03). CONCLUSIONS Our meta-analysis demonstrated that ticagrelor was associated with a higher risk of major bleeding compared to clopidogrel in East Asian patients with ACS. Further studies evaluating the role of ticagrelor in management of ACS in East Asian patients are warranted.