BACKGROUND:A substantial proportion of patients with coronary artery disease do not achieve complete revascularization and continue to experience refractory angina despite optimal medical therapy. Recently, stem cell therapy has emerged as a potential therapeutic option for these patients. However, findings of individual trials have been scrutinized because of their small sample sizes and lack of statistical power. Therefore, we conducted an updated comprehensive meta-analysis of available randomized controlled trials (RCTs) with the largest sample size ever reported on this subject.HYPOTHESIS:In patients with chronic angina stem cell therapy improves clinical outcomes.METHODS:Scientific databases and websites were searched for RCTs. Data were independently collected by 2 investigators, and disagreements were resolved by consensus. Data from 10 trials including 658 patients were analyzed.RESULTS:Stem cell therapy improved Canadian Cardiovascular Society angina class (risk ratio: 1.53, 95% CI: 1.09 to 2.15, P = 0.013), exercise capacity (standardized mean difference [SMD]: 0.56, 95% CI: 0.23 to 0.88, P = 0.001), and left ventricular ejection fraction (SMD: 0.63, 95% CI: 0.27 to 1.00, P = 0.001) compared with placebo. It also decreased anginal episodes (SMD: -1.21, 95% CI: -2.40 to -0.02, P = 0.045) and myocardial perfusion defects (SMD: -0.70, 95% CI: -1.11 to -0.29, P = 0.001). However, no improvements in all-cause mortality were observed after a relatively short follow-up.CONCLUSIONS:In patients with chronic angina on optimal medical therapy, stem cell therapy improves symptoms, exercise capacity, and left ventricular ejection fraction. These findings warrant confirmation using larger trials.

ABSTRACTInfective endocarditis complicating a quadricuspid aortic valve (QAV) is rare. Previous reports highlight the increased risk for complications, including progressive aortic regurgitation, decompensated heart failure, and valve perforation. Thus, cardiologists must be able to quickly identify QAVs to guide rapid evaluation and treatment. We report a case of infective endocarditis in a QAV identified on echocardiography and effectively managed with medical therapy alone without complications over an 8‐year follow‐up period. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:145–148, 2018

Rarely, penetrating atherosclerotic ulcers can rupture into the wall of the aorta, resulting in acute aortic dissection. This article describes a woman with an incidental diagnosis of type A aortic dissection secondary to a penetrating atherosclerotic ulcer of the ascending aorta. Although surgical repair of the aortic root was recommended, the patient refused treatment and left against medical advice.

CASE PRESENTATION A 59-year-old man with an unremarkable medical history except for tobacco abuse presented to our hospital with chest pain, dyspnea, orthopnea, and edema. His physical examination was notable for jugular venous distention, distant heart sounds, and bilateral pitting lowerextremity edema. An electrocardiogram showed negative P waves in leads I and aVL, reversed R wave progression across the anterior leads, and Q waves in leads II, III, and aVF (Figure 1). A chest radiograph demonstrated dextrocardia with a right-sided stomach bubble, indicating situs inversus (SI) totalis (Figure 2). The patient’s troponin I level was elevated to 2 ng/mL (normal value, < 0.04 ng/mL). He was started on optimized medical treatment for acute coronary syndrome, which included anticoagulation in the form of heparin and starting on aspirin and prasugrel, as well as a beta blocker. A transthoracic echocardiogram showed severely depressed left ventricular systolic function with ejection fraction of 10% to 20% and global hypokinesis. Our patient underwent left heart catheterization through the left common femoral artery approach. A Judkins JL4 catheter (Cordis Corporation, Hialeah, FL) was used to engage the right-sided anatomically located left main coronary artery. Engagement was successful with clockwise rotation of the catheter. This rotation revealed 90% stenosis in the mid left anterior descending artery (Figure 3). The right coronary artery was engaged successfully using a Judkins JR4 catheter with counterclockwise rotation. This revealed 95% stenosis in the mid vessel (Figure 4). Using an XB 3.5 catheter guide (Medtronic, Minneapolis, MN) and a balance middleweight guidewire (Abbott Industries, Abbott Park, IL), the left anterior descending lesion was crossed, and a drug-eluting stent was successfully placed. Then, a 6-French JR4 catheter guide (Abbott Industries, Abbott Park, IL) was used for right coronary artery engagement.

A cornerstone of medical therapy for patients with acute coronary syndrome (ACS) is dual antiplatelet therapy, which includes aspirin and a P2Y12 inhibitor. Randomized controlled trials (RCTs) have shown that prasugrel and ticagrelor are superior to clopidogrel, but none directly compared these 3 commonly used oral P2Y12 inhibitors for safety and efficacy. Therefore, we performed a Bayesian network meta-analysis of RCTs to compare the efficacies and safeties of 3 commonly used oral P2Y12 inhibitors in patients with ACS. Scientific databases and websites were searched for relevant RCTs. We included data from 9 RCTs that enrolled 106,288 patients. Clopidogrel decreased the rates of major adverse cardiac event, recurrent myocardial infarction, and all-cause mortality compared with placebo. Both ticagrelor and prasugrel decreased the rates for major adverse cardiac event and recurrent myocardial infarction compared with clopidogrel, but there was no difference between the 2. Both also decreased the stent thrombosis rate compared with clopidogrel, but prasugrel was more effective than ticagrelor. Ticagrelor use was also associated with improved all-cause and CV mortalities compared with clopidogrel. There was no difference in CV mortality or all cause mortality between clopidogrel and prasugrel. Prasugrel use was also associated with significantly increased risk of major bleeding compared with clopidogrel but showed a nonsignificant trend toward increasing the risk of bleeding compared with ticagrelor. In treatment ranking, ticagrelor was the most efficacious, and prasugrel was the least safe. In conclusion, this meta-analysis shows that in patients with ACS, adding P2Y12 inhibitors to aspirin and other standard treatments reduces ischemic events and all-cause mortality. Among the commonly used oral P2Y12 inhibitors, ticagrelor has the best net efficacy and safety profile. Published by Elsevier Inc.

Background In ST-elevation myocardial infarction (STEMI), acute kidney injury (AKI) may increase subsequent morbidity and mortality. Still, it remains difficult to predict AKI risk in these patients. We sought to 1) determine the frequency and clinical outcomes of AKI and, 2) develop, validate and compare a web-based tool for predicting AKI. Methods & findings In a racially diverse series of 1144 consecutive STEMI patients, Stage 1 or greater AKI occurred in 12.9% and was severe (Stage 2–3) in 2.9%. AKI was associated with increased mortality (5.7-fold, unadjusted) and hospital stay (2.5-fold). AKI was associated with systolic dysfunction, increased left ventricular end-diastolic pressures, hypotension and intra-aortic balloon counterpulsation. A computational algorithm (UT-AKI) was derived and internally validated. It showed higher sensitivity and improved overall prediction for AKI (area under the curve 0.76) vs. other published indices. Higher UT-AKI scores were associated with more severe AKI, longer hospital stay and greater hospital mortality. Conclusions In a large, racially diverse cohort of STEMI patients, Stage 1 or greater AKI was relatively common and was associated with significant morbidity and mortality. A web-accessible, internally validated tool was developed with improved overall value for predicting AKI. By identifying patients at increased risk, this tool may help physicians tailor post-procedural diagnostic and therapeutic strategies after STEMI to reduce AKI and its associated morbidity and mortality.

Several randomized controlled trials (RCTs) demonstrated that trans-radial access (TRA), particularly if performed by radial expert, decreased major adverse cardiac events (MACEs) and mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). As a

Coronary-cameral fistula (CCF) is an anomalous connection between a coronary artery and a cardiac chamber or major vessel, seen in about 0.8% of the cases undergoing coronary angiography. Most patients are asymptomatic and diagnosis is made incidentally during coronary angiography. We present an image case of CCF which was found incidentally during pre-liver transplantation work up.

A 69-year-old female with history of immobilization presented with shortness of breath and generalized weakness and was found to have large saddle pulmonary embolus on CT scan. Further evaluation with a transthoracic echocardiography revealed a moderately enlarged and hypokinetic right ventricle with a pulmonary artery clot of about 1.5 cm seen at the bifurcation while the ultrasound of the legs was negative for deep vein thrombosis.

Spontaneous arteriovenous fistulas are a rare clinical entity with very few cases reported in the literature. Prompt diagnosis and treatment is crucial and can prevent further complications in such patients. We report a case of a patient who presented with progressive bilateral claudication, discolouration of feet, hypaesthesia and non-healing ulcers. The patient had no history of trauma, aneurysm or surgery. After abnormal non-invasive studies, a peripheral angiogram revealed significant disease and obstruction of bilateral superficial femoral arteries. Spontaneous bilateral femoral arteriovenous fistulas were also found incidentally. After discussing the risks and benefits of multiple treatment options with the patient, percutaneous intervention with orbital atherectomy, balloon angioplasty and covered stent placements were performed. This treatment improved the patient's symptoms significantly.

This case report describes a 72-year-old woman who developed an acute postmyocardial infarction ventricular septal defect (VSD) with consequent cardiogenic shock. Intra-aortic balloon pump (IABP) counter-pulsation was urgently initiated in the cardiac catheterisation laboratory, with neither clinical nor haemodynamic improvement, prompting immediate removal of the IABP and the insertion of an Impella 2.5 heart pump (AbioMed Inc; Danvers, Massachusetts, USA), a temporary ventricular assist device. Thereafter, the patient improved clinically and was admitted to the cardiovascular intensive care unit (ICU). While in the cardiovascular ICU, the patient developed worsening mechanical haemolysis of blood cells, stable but persistent cardiogenic shock and a transient ischaemic attack. A consensus decision was made to proceed with percutaneous repair of the VSD as she was deemed at high risk for surgical repair. She underwent successful percutaneous VSD repair on day 4 of hospitalisation, using a single 18 mm Amplatzer muscular VSD occluder (AGA Medical, Plymouth, Minnesota, USA) with trace residual flow across the occluder. Adequate systolic blood pressure and cardiac output was maintained postprocedure with the Impella 2.5 device. The patient, however, succumbed to multiorgan dysfunction occasioned by sepsis.

Spontaneous coronary artery dissection is a poorly understood phenomenon that usually affects women during pregnancy or the immediate post-partum period. We present the case of a 60-year-old female with chronic obstructive pulmonary disease who presented with vague complaints of shortness of breath, dizziness, and weakness with a mildly elevated troponin. She denied any anginal symptoms. As part of her initial workup, a nuclear stress test revealed inferior wall reversible changes. Coronary angiography revealed spontaneous right coronary artery dissection which was treated with a drug-eluting stent.

No abstract available. (Published: 6 July 2016) Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6 : 31443 - http://dx.doi.org/10.3402/jchimp.v6.31443

Lead fractures are uncommon complications of pacemaker implantation. This article describes a patient with an incidental diagnosis of multiple atrial lead fractures many years after pacemaker implantation.

ST-elevation myocardial infarction (STEMI) requires emergent diagnostic catheterization and therapeutic percutaneous coronary intervention. These therapies may cause acute kidney injury (AKI), a serious procedural complication that contributes to morbidity and mortality in STEMI patients. Identifying patients at risk for renal complications may save lives and reduce healthcare costs, but there is no validated tool for predicting AKI in STEMI patients. Methods: The UT-Methodist STEMI program is a racially diverse series of 1144 consecutive patients. We derived and validated the UT-AKI score to predict the risk of AKI in patients referred for STEMI (and not currently on dialysis). AKI was categorized by the modified AKI Network and RIFLE indices. The UT-AKI score was derived from logistic regression analysis performed on a randomly selected derivation dataset using variables with significant univariate relationships to AKI and markers of renal function. Receiver operator characteristic (ROC) curves for the UT-AKI were assessed in the derivation and validation datasets. Statistical significance was measured by appropriate parametric and non-parametric tests; a p<0.05 was considered significant. Results: The incidence of AKI was similar in patients undergoing diagnostic catheterization with or without PCI (12% vs. 14%, p=0.34). ROC curve analysis of the validation data set showed that the UT-AKI score (AUC 0.76 (95% CI 0.70-0.82)) was significantly better at classifying patients at risk for AKI than the ACEF (AUC 0.65 (95% CI: 0.58-0.73)), AGEF (AUC 0.65 (95% CI: 0.58-0.72)), or Mehran (AUC 0.67 (95% CI: 0.59-0.75)). The classification accuracy for the UT-AKI index was comparable for milder and severe forms of AKI. Conclusions: In the largest analysis of STEMI patients to date, we found no significant difference in the risk of AKI from PCI vs. diagnostic catheterization. The validation study indicates that the UT-AKI index was significantly better than other scores at classifying which patients will develop AKI. Accurate prediction of AKI may help physicians to personalize therapies and develop novel strategies to reduce kidney injury in patients with STEMI.

A 73-year-old man with past medical history of mechanical aortic valve replacement, metastatic melanoma of unknown primaries with liver metastasis, presented with progressive shortness of breath and dyspnea on exertion. Transthoracic echocardiography (TTE) showed a large homogenous mass completely occupying the right atrial cavity and extending to and nearly obstructing the inflow area of the tricuspid valve. He was treated with chemotherapy.

Introduction: Time to reperfusion has been shown to be a major predictor of mortality after an ST elevation myocardial infarction (STEMI). Reducing delays to ER presentation should significantly improve time to reperfusion. This study sought to explore the factors that predict late presentation to ER after STEMI. Methods: A retrospective analysis was conducted using data from our tertiary institution 2008-2013. All patients admitted for STEMI during this period were identified. The “Symptom onset to door time (SODT)” was computed and a binary outcome variable (late presentation) was defined as a SODT >180 minutes. The role of patient demographics, insurance status, socioeconomic factors, mode of transportation, and comorbidities were controlled for in the multivariable regression analysis to identify the predictors of late presentation. A subset analysis was conducted excluding patients transferred from outlying facilities. Results: During this period, 1144 patients were admitted for acute STEMI, with 348 of these patients having been transferred from outlying facilities. Mean age was 59 (+12.8) years, males accounted for 67% of this population, 28% had private insurance, 50% had public insurance and 22% were uninsured; 56% of this population was Black. 47.5% of patients presented after 180 minutes. On bivariate analysis, blacks, older age, insurance status, female gender and a family history of coronary artery disease were predictors of late presentation after STEMI. On controlling for confounders in our model, the only significant predictors for late presentation were race and insurance status. A subset analysis excluding transferred patients showed qualitatively similar results. Conclusion: Minority patients, publically insured and uninsured patients are more likely to present late after a STEMI, this difference in time to presentation may be a surrogate for health literacy in these populations and may be ameliorated by better health education.

Summary Coronary embolism is an uncommon cause of myocardial infarction. The usual source of a coronary embolus is an intracardiac thrombus or vegetation. Embolisation to the left main coronary artery is an extremely rare event and is usually fatal. We present a case of a 38-year-old woman with embolisation to the left main coronary artery which further embolised distally to the left anterior descending artery leading to a non-ST elevation myocardial infarction. The non-occlusive nature of the left main coronary artery embolus might have led to a favourable prognosis in our patient.