Heart International最新文献

Amongst the many challenges of the global pandemic, understanding the effects of coronavirus disease 2019 (COVID-19) on the cardiovascular system has emerged as a key priority. Emerging data indicate possible roles for cardiac biomarkers and cardiac imaging in the prognostic assessment of these patients, as well as implications of the vascular endothelium in the pathogenesis of the condition. From a therapeutic perspective, early data suggest that the provision of well-established treatments for cardiovascular disease, whether with angiotensin-converting enzyme inhibitors or primary angioplasty, is likely to be beneficial. These early data are of limited quality however, and robust studies are needed to address many of the key remaining questions.

The ISCHEMIA trial (International study of comparative health effectiveness with medical and invasive approaches; ClinicalTrials.gov Identifier: NCT01471522) has informed practice in patients with stable angina and confirms what other less definitive data have taught us, that in the absence of severe symptoms, significant left main disease or significant left ventricular dysfunction, there is no prognostic benefit of an early invasive/revascularisation strategy with optimal medical therapy (OMT) over OMT alone. Like all quality randomised trials, it has nuances: the invasive treatment group had much better relief of angina than the OMT alone group, and the rate of spontaneous myocardial infarction (MI) in follow-up was lower in the invasive group, although only after a prevalence of periprocedural MI. The clinical outcome consequence of the MI data, if indeed there is one, will only become clear at later follow-up. OMT is a powerful treatment, and reflex revascularisation in patients with little or no angina is not.

The coronary sinus reducer represents an emerging therapeutic option for patients suffering from chronic refractory angina. Current data indicate that the population suffering from angina symptoms despite maximal medical therapy and maximal achievable revascularisation - surgical or percutaneous - is constantly increasing. Also, the clinical outcome for these patients is strongly affected by the lack of adequate treatment, the occurrence of adverse events and the need for repeated hospitalisation. Growing evidence supports the clinical benefits of the coronary sinus reducer in relieving angina symptoms in this specific population, with emerging evidence of reduction in myocardial ischaemia following the implantation of the coronary sinus reducer. In this review, we provide an up-to-date description of the role of this relatively new device in the treatment of refractory angina, focusing not only on symptom relief but also on the increasing data that supports objective improvements in myocardial ischaemia.

Background: Several studies have reported an association between elevated liver enzymes and increased risks for developing inflammatory diseases. The aim of our study was to examine how serum liver transaminases, as inexpensive and routinely measured markers, and the De Ritis ratio are associated with the presence of coronary artery ectasia (CAE) and its severity.

Methods: Participants were recruited from patients admitted to Tehran Heart Center for diagnostic coronary angiography due to suspected myocardial ischaemia. These participants also underwent concurrent laboratory routine biochemical and liver enzyme tests.

Results: A total of 104 participants were included; 59 had CAE and 45 were controls without coronary artery disease (CAD). The CAE group was split into a further two subgroups: those with isolated CAE (n=27) and those with CAD and coexisting CAE (n=32). In the adjusted multivariate analysis, a lower ratio of aspartate aminotransferase to ALT (AST/ALT) was, uniquely among the variables, a statistically significant marker for isolated CAE. In the CAD + CAE group, the AST/ALT ratio was not significant after adjustments for the confounding factors. The multivariate linear regression for the Markis score showed that the AST/ALT ratio was inversely associated with the severity of CAE.

Conclusions: We conclude that the AST/ALT ratio and, to some extent, ALT independently of other inflammatory factors, can be associated with the presence and severity of isolated CAE.

Introduction: Coeliac disease (CD) is a systemic disease of inappropriate immune response to gluten, and is associated with 10% increased risk of cardiovascular disease. Here we present a case of a young patient with persistent myocardial ischaemia due to iron-deficiency anaemia despite oral iron supplementation, who was eventually diagnosed with CD.

Case report: A 36-year-old man was admitted to the cardiology department due to ST-elevation myocardial infarction of the inferior wall. Emergency coronary angiography showed occlusion of the right coronary artery and intermediate-diameter lesions in other arteries. Primary percutaneous coronary intervention with stent implantation to the right coronary artery was performed. Despite the successful intervention, the patient presented with recurrent chest pain, persistent tachycardia up to 120 beats per minute and syncope. Coronary angiography was repeated and the intermediate-diameter lesions were proved insignificant. Laboratory tests revealed microcytic anaemia with haemoglobin level of 6.5 g/dL, despite oral iron supplementation in the pre-hospital period. An emergency gastroscopy with duodenoscopy revealed flat duodenal mucosa. The duodenal biopsy confirmed the diagnosis of CD. Strict gluten-free diet and further iron supplementation were recommended. Two months later the patient presented with no recurrent chest pain and normal haemoglobin concentration.

Conclusions: Diagnosis of CD with atypical presentation can be difficult. Iron-deficiency anaemia refractory to oral iron supplementation should always raise the suspicion of CD, even without typical gastrointestinal manifestation.

Antiplatelet agents are routinely given to prevent thrombosis of coronary stents. Often this occurs during or immediately after the procedure, while the patient is still on the catheterisation laboratory table. Ingestion of pills while supine sometimes causes mild dysphagia and discomfort but, rarely, it can cause a more severe complication. We report a case of clopidogrel ingested during PCI, which caused chest pain and pill oesophagitis after the procedure. Conservative treatment was effective, symptoms resolved, and follow-up endoscopy showed resolution of the oesophageal inflammation.

Factor Xa (FXa) inhibitors are widely used for stroke prevention in patients with nonvalvular atrial fibrillation, and for the treatment and prevention of deep venous thrombosis and pulmonary embolism. Compared with warfarin, individual FXa inhibitors are associated with a lower risk of major bleeding. Nevertheless, bleeding remains a feared complication of any anticoagulant therapy. Despite their demonstrated safety, implementation of FXa inhibitors in clinical practice may have been limited by the lack of a specific antidote. Recently, however, the United States Food and Drug Administration and the European Medicines Agency approved andexanet alfa for reversal of anticoagulation in patients treated with rivaroxaban or apixaban who have life-threatening or uncontrolled bleeding. This review will discuss andexanet alfa's mode of action, indication for use and efficacy, with a focus on its appropriate use in clinical practice. Unnecessary usage should be prevented as this may compromise patient safety. Assessment of potentially suitable patients by a multidisciplinary team, use according to the institutional protocol and central storage, all contribute to proper use of andexanet alfa. A practical tool to direct appropriate use of andexanet alfa is proposed.

Percutaneous coronary intervention (PCI) with implantation of a metallic drug-eluting stent (DES) is the mainstay of treatment in patients with significant coronary artery disease or acute coronary syndromes. DESs comprise a metallic platform and an anti-proliferative drug, usually released from a polymer coating. A wide range of DESs, differing in platform, polymer or drug, are currently available for clinical use. Although there are significant differences in the physical, biological and pharmacological properties of contemporary DESs, it remains unclear whether these impact meaningfully on clinical outcomes for patients undergoing PCI. Numerous randomised clinical trials have compared DESs in recent years, but these trials are typically designed to show non-inferiority, rather than superiority. Data from meta-analyses have helped to study this in larger populations, but have limitations. Improvement in stent design continues and ongoing work is exploring the effects of new innovations as well as gathering further data on existing devices. This review explores the development, properties and clinical efficacy of current-generation DESs, comparing different types where possible, whilst identifying areas of further work.

A 47-year-old man was admitted to the Santa Casa de Misericórdia Hospital in Belo Horizonte, Brazil, with recurrent signs and symptoms of tachycardia, palpitation and fatigue. During medical examination, an electrocardiogram and 24-hour Holter monitoring were performed, which identified a predominant atrial flutter rhythm and, after transthoracic echocardiography, the patient was diagnosed with cor triatriatum sinister. The condition is a rare congenital heart disease characterised by the presence of a fibrous membrane that divides the left atrium into two separate chambers. The disease is especially evident during childhood; however, some cases show no signs until adulthood, which makes the presentation even more unique. In this case, clinical medication and electrical cardioversion were chosen as treatments, which caused progression to sinus rhythm and improvement of symptoms. Therefore, due to the stability of the condition, continuous follow-up with a cardiologist was implemented.