Thomas Kiernan

Cardiac papillary fibroelastoma presenting as acute stroke

We present a case of a young woman who was initially diagnosed with acute stroke with no obvious risk factors. Preliminary investigation with transthoracic echocardiography and subsequent advanced imaging with transoesophageal echocardiography suggested the diagnosis of a benign cardiac tumour on the anterior leaflet of mitral valve. The patient underwent urgent surgical resection. Histology confirmed the diagnosis of cardiac papillary fibroelastoma. She made complete clinical recovery with no recurrence of symptoms.

The use of conscious sedation in elective external direct current cardioversion: a single centre experience

Abstract External direct current (DC) cardioversion is a commonly used method of terminating atrial arrhythmias. The chance of procedural success is inversely related to the duration of the arrhythmia. In many hospitals, the procedure is carried out under general anaesthesia, necessitating the presence of anaesthetic as well as medical staff. Frequently, it may be difficult to coordinate the availability of the two teams, causing delays to each patient, waste of staff time, an inefficient service and increased costs. The primary aim of the study was to determine the safety and tolerability of conscious sedation using intravenous midazolam in elective external DC cardioversion of patients with atrial flutter or atrial fibrillation attending University Hospital Limerick, Ireland. Patients who were electively admitted for DC cardioversion for atrial fibrillation or atrial flutter were recruited. A pre-defined sedation protocol using intravenous midazolam was used. The midazolam was given by the cardiology registrar without the presence of an anaesthetist. DC cardioversion was then performed according to the hospital protocol. Any complications arising during the procedure were noted. Prior to discharge, patients were given a questionnaire to determine their awareness of the procedure and if they would have the procedure done again in the future if needed. A total of 100 patients were recruited. The median number of shocks was one (highest number of shocks being four). The median dose of midazolam was 7.5 mg, with the highest dose being 20 mg. All of patients surveyed were not aware of the shock that was administered to them. All of the patients surveyed were happy with the service and would be happy to return for a repeat cardioversion in the future if required. The use of conscious sedation for DC cardioversion of patients with atrial fibrillation / atrial flutter was found to be safe and tolerable.

Randomized study comparing incidence of radial artery occlusion post-percutaneous coronary intervention between two conventional compression devices using a novel air-inflation technique

AIM To compare post-percutaneous coronary intervention (PCI) radial artery occlusion (RAO) incidence between two conventional radial artery compression devices using a novel air-inflation technique. METHODS One hundred consecutive patients post-PCI were randomized 1:1 to Safeguard or TR band compression devices. Post-radial sheath removal, each compression device was inflated with additional 2 mL of air above index bleeding point during air-filled device application and gradually down-titrated accordingly. RAO was defined as absence of Doppler flow signal performed at 24 h and at 6 wk post-PCI. Patients with missing data were excluded. Statistical significance was defined as P < 0.05. RESULTS All patients had 6F radial sheath inserted. No significant differences were observed between Safeguard Radial (n = 42) vs TR band (n = 42) in terms of age (63 ± 11 years vs 67 ± 11 years), clinical presentation (electives, n = 18 vs n = 16; acute coronary syndrome, n = 24 vs n = 26) and total procedural heparin (7778 ± 2704 IU vs 7825 ± 2450 IU). RAO incidence was not significantly different between groups at 24 h (2% vs 0%, P = 0.32) and 6 wk (0%, both). CONCLUSION Safeguard Radial and TR band did not demonstrate significant between-group differences in short-term RAO incidence. Lack of evidence of RAO in all post-PCI patients at 6 wk follow-up, regardless of radial compression device indicate advantage of using the novel and pragmatic air-inflation technique. Further work is required to more accurately confirm these findings.

The genetic basis of antiplatelet and anticoagulant therapy: A pharmacogenetic review of newer antiplatelets (clopidogrel, prasugrel and ticagrelor) and anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban)

ABSTRACT Introduction: The study of pharmacogenomics presents the possibility of individualised optimisation of drug therapy tailored to each patients’ unique physiological traits. Both antiplatelet and anticoagulant drugs play a key role in the management of cardiovascular disease. Despite their importance, there is a substantial volume of literature to suggest marked person-to-person variability in their effect. Areas covered: This article reviews the data available for the genetic cause for this inter-patient variability of antiplatelet and anticoagulant drugs. The genetic basis for traditional antiplatelets (i.e. aspirin) is compared with the newly available antiplatelet medicines (clopidogrel, prasugrel and ticagrelor). Similarly, the pharmacogenetics of warfarin is compared with the newer direct oral anticoagulants (DOACs) in detail. Expert Opinion: We identify strengths and weaknesses in the research thus far; including shortcomings in trial design and a review of newer analytical techniques. The direction of this research and its real-world implications are discussed.

Rapidly progressive coronary artery disease as the first manifestation of antiphospholipid syndrome

Antiphospholipid syndrome (APS) is an autoimmune multisystem disorder characterised by high incidence of arterial and venous thrombosis. Cardiovascular manifestations also include valvular heart disease, ventricular thrombi and higher risk for coronary artery disease (CAD). In this case report, we describe a 61-year-old woman who had no significant risk factors for CAD, and presented with aggressive disease in native and graft vessels that required multiple coronary interventions. The extent of her aggressive CAD could not be explained by her risk factors profile. Therefore autoantibodies screening was carried out and showed a strongly positive anticardiolipin and β2 glycoprotein-I antibody, and hence a diagnosis of antiphospholipid syndrome was made.

Revascularisation of left main stem disease: a prospective analysis of modern practice and outcomes in a non-surgical centre.

Purpose In this study, we sought to prospectively analyse the management and long term outcomes associated with revascularisation of left main stem disease via percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in our centre. Methods This prospective study enrolled all patients with unprotected left main stem disease undergoing revascularisation from January 2013 to June 2014. Baseline characteristics, hospital presentation and hospital stay length were collected. Patients were followed up at 1, 2 and 3 years. Primary outcomes of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) were defined as death, Q wave myocardial infarction, stroke, repeat revascularisation and readmission within 30 days. Results 56 patients with significant left main stem coronary artery disease were identified from the clinical registry. 27 patients underwent PCI (median age 67.7) and 29 CABG (median age 68.6). PCI patients had a higher surgical risk as measured by mean euroSCORE (4.95±5.8 vs 3.11±3.85). At 3 years, total MACCE occurred in 29.6% of the PCI cohort and 27.5% of the CABG cohort. Death occurred in three patients in the PCI group within the first 6 months. Death occurred in one patient in the CABG group over 2 years postprocedure. Two patients in the CABG cohort presented with Transient Ischemic Attacks (TIAs) at 2-year follow-up. At 3 years, revascularisation occurred in three patients in the PCI cohort. There were no revascularisation events in the CABG cohort. Conclusions PCI with modern drug eluting stents is a reasonable treatment option for unprotected left main stem disease in a non surgical centre.

Anchor-balloon technique to facilitate stent delivery via the GuideLiner catheter in percutaneous coronary intervention

AIM The GuideLiner (GL) is a widely used catheter primarily in complex percutaneous coronary intervention (PCI). Deep seating of the GL and distal stent placement may be facilitated by the anchor-balloon technique (ABT). METHODS We aimed to prospectively analyze procedural details, technical success, complications and in-hospital outcome in patients who underwent PCI using the GL catheter and the ABT. RESULTS A total of 118 patients underwent PCI with the aid of the GL and ABT. Procedure success rate was 95% (112/118) and only seven patients (5.9%) encountered complications. ABT was indicated and successfully used in 29 patients (25%). CONCLUSION GL and ABT successfully aided stent delivery in unfavorable and heavily calcified lesions which otherwise may have been considered unsuitable for PCI.

Triple antithrombotic therapy in patients with atrial fibrillation undergoing PCI: current evidence and practice

ABSTRACT Introduction: Patients with atrial fibrillation taking oral anticoagulation and undergoing percutaneous coronary intervention with stent insertion are recommended to receive antithrombotic therapy with aspirin and P2Y12 receptor antagonist. This combinatory regime encompasses triple therapy (TT). Although TT reduces the risk of ischemic events such as stroke and stent thrombosis, it is associated with an increased bleeding risk. Areas covered: The efficacy and safety profile of TT is uncertain with undetermined optimal duration and therapeutic combination. This review summarizes relevant trials evaluating TTs application and introduces exploration of duration and dosage in addition to other contributory factors including stent type and choice of antithrombotic agents. Expert commentary: TT has shown to be effective for reduction of ischemic risk. However, trials have failed to demonstrate the regime’s superiority in efficacy over alternatives such as dual therapy (single antiplatelet plus anticoagulant) and continue to denote an increased bleeding risk. Further research driven by a balance between thromboembolic and bleeding end points is required to demonstrate TTs potential beneficence, along with optimal duration identification and antithrombotic choice. Individualized patient risk stratification, along with risk factor optimization should also be incorporated.

Heart rate and composite cardiac events: is there a strong association?

Four-year research out of Beijing, China has found bisoprolol to significantly decrease resting heart rate (RHR) in Chinese patients with coronary artery disease (CAD); this lowered the occurrence of composite cardiac events. CAD is a major cause of death globally, and the second leading cause of cardiovascular (CV) deaths among the Chinese. RHR serves as a physically measurable determinant of oxygen demand, blood flow, myocardial performance and the adaptation of cardiac output to metabolic needs. Heart rate has been established as a biomarker for prognosis of CV outcomes (death, nonfatal acute myocardial infarction and hospitalization for unstable angina). Unfortunately, previous reports have shown that heart rate is inadequately controlled by betablockers, leading to angina, ischemia and poor general health. The Reduction of Atherothrombosis for Continued Health study even concluded that beta-blockers were not associated with improving outcomes for patients with stable CAD, but it was the opinion of the study that those findings were due to poor dosage. Regardless, only a few studies investigated the link between heart rate and CAD in a Chinese population. The present study aimed to increase the information on this topic. Using bisoprolol, researchers were able to measure a decrease in RHR that was associated with a lower incidence of composite cardiac events. This is promising research for CV patients both in China and globally, but it does not solve the problem outright. More research will need to be conducted regarding the effectiveness of other beta-blockers and higher dosages. Researchers set out to evaluate a change in RHR and its effect on the incidence of cardiac events in Chinese patients with CAD. This single arm observational study was a sub-study of the BISO-CAD trial undertaken across 20 Chinese hospitals between 2011 and 2015. A total of 663 CAD patients with a baseline RHR of 75.47 (±6.62) beats/minute (bpm) were enrolled in the study. Patients older than 20 years of age with stable or unstable angina, as well as diabetes, were enrolled. Data was collected in follow-ups 6, 12 and 18 months after starting the medication. To begin with, it was found that the risk and frequency of composite cardiac events in patients were significantly increased when a patient had a RHR of 69–74 bpm, especially when compared with those <65 bpm (p1⁄4 .029). Most RHRs decreased from their baseline during the study, most notably in the first 6 months of treatment (p .0001) with an overall baseline value drop from 75.47 (±6.62) to 67.92 (±9.19) bpm. The composite cardiac event rates per group were as follows: 3.23% in the <60 bpm group, 5.41% in the 60–65 bpm group, 7.21% in the 65–70 bpm group, 8.80% in the 70–75 bpm group, 4.00% in the 75–80 bpm group and back up to 8.33% in the 80–85 bpm group. Peculiarly, the event rates fall in the 75–80 bpm group and the 70–75 bpm group has a slightly higher rate of the composite cardiac outcome. It is worth mentioning that in order to achieve the desired statistical power (80% or more) the number of participants in each RHR group will need to be at least doubled. Adverse effects were reported in 146 of the 663 patients. These adverse effects were reported as mild, moderate or severe at a 12%, 7.7% and 3.9% respectively. Of the serious adverse effects, 6 (1%) resulted in death. However, no serious adverse effect was directly related to the study drug. The study also found that there was a 32% increase in total mortality when a patient had a RHR >83 bpm, compared with patients that maintained their RHR under 62 bpm. Patients over 70 years of age and those with diabetes exhibited the most common fatal events. Hospitalization due to acute coronary syndrome (ACS) was significantly higher in patients with higher RHRs (17 events in the 69–74 bpm group vs. 5 events in the <65 bpm group). RHR did not seem to affect coronary revascularization and occurrence of cerebral events. The BISO-CAD study was one of the first trials to examine the relationship between RHR and clinical outcomes with the use of a selective beta-1 blocker in Chinese patients with CAD. The overall correlation between RHR and risk of CV disease has been studied extensively before. This correlation was found in the general population as well as in patients with ACS, stable CAD and heart failure. A recent large post hoc analysis investigated the relationship between RHR and CV events in patients with stable CV disease. The study showed that, for each 10 bpm increase in baseline and average RHR, there was a significant increase in risk of CV and all-cause mortality but there was no association between RHR and myocardial infarction. However, in another study, ACS patients after percutaneous coronary intervention with a RHR of >76 bpm were at higher risk of CV events during 1 year follow-up compared to those with RHR between 61 and 76 bpm. Further studies have also found the 69–74 bpm RHR group to be the most dangerous group to be in.

Circadian and seasonal variations in patients with acute STEMI: A retrospective, single PPCI center study

ABSTRACT This was a retrospective observational analysis of all (n = 876) ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) at University Hospital Limerick (UHL) from 2012 to 2016 to determine whether chronological patterns existed in incidence and mortality at our center. Data were obtained from the electronic Cardiology STEMI database in UHL. Statistical analysis was performed using the Independent Samples t Test, ANOVA and Pearson’s Chi-Squared test. The rate of STEMI from 0800 and 2259 hours (46.9/hr) was greater than 2300 to 0759 hours (19.1/hr) (p < 0.001). No association was found between 30-day mortality and weekend/weekdays presentation (p = 0.81) or off/in hour presentation (p = 0.86). No seasonal variation was found in STEMI incidence at our center using international (p = 0.29) or Celtic (p = 0.82) seasonal calendars. 30-Day mortality is equivalent whether STEMI patients treated with PPCI present during “normal working hours” or during the “out of hours”/weekend period at our center. The majority of STEMIs occur during the hours 0800 to 2259, but no further chronological relationship was observed in incidence.