Current Cardiology Reviews - Volume 17, Issue 3, 2021

Dual antiplatelet therapy is one of the cornerstones of modern percutaneous coronary interventions. The development of new therapeutic agents has significantly reduced ischemic events at the risk of increased bleeding complications. Therefore, efforts are currently focused on optimizing therapeutic algorithms to obtain the greatest anti-thrombotic benefit associated with the lowest risk of bleeding, that is, the greater net clinical benefit. A significant number of trials evaluating different drug combinations or adjustments in treatment duration have been completed. However, clinical translation of these results is often difficult due to the heterogeneity of the therapeutic approaches. The aim of this manuscript is to provide an updated review of the literature regarding the use of dual antiplatelet therapy in patients undergoing coronary angioplasty and stenting.

Coronary artery disease (CAD) remains the leading cause of cardiovascular death in octogenarians. This group of patients represents nearly a fifth of all patients treated with percutaneous coronary intervention (PCI) in real-world practice. Octogenarians have multiple risk factors for CAD and often greater myocardial ischemia than younger counterparts, with a potential of an increased benefit from myocardial revascularization. Despite this, octogenarians are routinely under- -treated and belittled in clinical trials. Age does make a difference to PCI outcomes in older people, but it is never the sole arbiter of any clinical decision, whether in relation to the heart or any other aspect of health. The decision when to perform revascularization in elderly patients and especially in octogenarians is complex and should consider the patient on an individual basis, with clarification of the goals of the therapy and the relative risks and benefits of performing the procedure. In ST-segment elevation myocardial infarction (MI), there is no upper age limit regarding urgent reperfusion and primary PCI must be the standard of care. In non-ST-segment elevation acute coronary syndromes, a strict conservative strategy must be avoided; whereas the use of a routine invasive strategy may reduce the occurrence of MI and the need for revascularization at follow-up, with no established benefit in terms of mortality. In stable CAD patients, invasive therapy on top of optimal medical therapy seems better in symptom relief and quality of life. This review summarizes the available data on percutaneous revascularization in the elderly patients and particularly in octogenarians, including practical considerations on PCI risk secondary to ageing physiology. We also analyse technical difficulties met when considering PCI in this cohort and the ongoing need for further studies to ameliorate risk stratification and eventually outcomes in these challenging patients.

The advancement in corrective surgical procedures and anaesthesia technology has resulted in the increased survival of patients with Congenital Heart Diseases (CHD). Most of the surviving CHD patients have successfully reached adulthood and those surviving adults now outnumber the infants born with the CHD. Unfortunately, the surviving adults with CHD do not get proper care due to either inconsistent follow-up or not getting care from a specialist in the field of CHD. It is imperative for general practicing clinicians to be aware of the congenital diseases as well as the current clinical recommendations. This manuscript reviews some of the common congenital diseases seen in adults such as cardiac shunts, left heart obstructive lesions, and aortopathies.

In the past decade, the Transradial Approach (TRA) has constantly gained ground among interventional cardiologists. TRA’s anatomical advantages, in addition to patients’ acceptance and financial benefits, due to rapid patient mobilization and shorter hospital stay, made it the default approach in most catheterization laboratories. Access-site complications of TRA are rare and usually of little clinical impact, thus, they are often overlooked and underdiagnosed. Radial Artery Occlusion (RAO) is the most common, followed by radial artery spasm, perforation, hemorrhagic complications, pseudoaneurysm, arterio-venous fistula, and even rarer complications, such as nerve injury, sterile granuloma, eversion endarterectomy or skin necrosis. Most of them are conservatively treated, but rarely, surgical treatment may be needed and late diagnosis may lead to life-threatening situations, such as hand ischemia or compartment syndrome and tissue loss. Additionally, some complications may eventually lead to TRA failure and switch to a different approach. On the other hand, it is the opinion of the authors that non-occlusive radial artery injury, commonly included in TRA’s complications in the literature, should be regarded more as an anticipated functional and anatomical cascade, following radial artery puncture and sheath insertion.

Current European guidelines on chronic coronary syndromes recommend the use of low-dose aspirin (or clopidogrel if intolerance or contraindication occurs) throughout life. However, as the risk of recurrent vascular events is high, particularly in some patients (i.e. diffuse multivessel coronary artery disease, diabetes, recurrent myocardial infarction, peripheral artery disease, or chronic kidney disease,…), these guidelines also consider that in those patients at moderate or high risk of ischemic events, but without a high bleeding risk, dual antithrombotic therapy should be considered. According to these guidelines, treatment options for dual antithrombotic therapy in combination with aspirin may include clopidogrel 75 mg/daily, prasugrel 10 mg/daily, ticagrelor 60 mg bid or rivaroxaban 2.5 mg bid. Remarkably, despite the results of the clinical trials that sustain these recommendations clearly diverge, guidelines do not differentiate between them. However, although all these drugs have demonstrated a significant reduction in major cardiovascular events in patients with stable atherosclerotic disease, only the addition of rivaroxaban has been associated with a reduction in cardiovascular and overall mortality in the secondary analysis. This may be related to the fact that the activation of platelets and factor X plays a key role in the development of atherothrombosis, and, consequently, both targets should be considered for the appropriate management of these patients.

Ischemia refers to a reduced supply of oxygen and nutrient to the vital organ of the body. Reperfusion to the ischemic organ is the only way to salvage injury due to ischemia. Paradoxically, reperfusion itself induces the injury, which is more severe than the previous injury referred to as ischemia-reperfusion injury. Ischemia-reperfusion injury is the major cause of mortality in the case of ischemic diseases. The major hurdle for a clinician to treat ischemia is the reperfusion injury, which is encountered in different surgical as well as non-surgical situations. Several therapies, such as anti-platelets, anti-thrombolytic agents have been developed to contain ischemia-reperfusion injury, but with limited success. Over some time, some conditioning techniques such as preconditioning and postconditioning have been used by clinicians to overcome ischemia-reperfusion injury. The present review focuses on the clinical applications of different conditioning techniques in diverse pathological conditions of ischemia-reperfusion injury.

Introduction: Hydroxychloroquine has been used for rheumatological diseases for many decades and is considered a safe medication. With the COVID-19 outbreak, there has been an increase in reports associating cardiotoxicity with hydroxychloroquine. It is unclear if the cardiotoxic profile of hydroxychloroquine is previously underreported in the literature or is it a manifestation of COVID-19 and therapeutic interventions. This manuscript evaluates the incidence of cardiotoxicity associated with hydroxychloroquine prior to the onset of COVID-19. Methods: PubMED, EMBASE, and Cochrane databases were searched for keywords derived from MeSH terms prior to April 9, 2020. Inclusion eligibility was based on appropriate reporting of cardiac conditions and study design. Results: A total of 69 articles were identified (58 case reports, 11 case series). The majority (84%) of patients were female, with a median age of 49.2 (range 16-92) years. 15 of 185 patients with cardiotoxic events were in the setting of acute intentional overdose. In acute overdose, the median ingestion was 17,857 ± 14,873 mg. 2 of 15 patients died after acute intoxication. In patients with long-term hydroxychloroquine use (10.5 ± 8.9 years), new onset systolic heart failure occurred in 54 of 155 patients (35%) with median cumulative ingestion of 1,493,800 ± 995,517 mg. The majority of patients improved with the withdrawal of hydroxychloroquine and standard therapy. Conclusion: Millions of hydroxychloroquine doses are prescribed annually. Prior to the COVID-19 pandemic, cardiac complications attributed to hydroxychloroquine were uncommon. Further studies are needed to understand the impact of COVID-19 on the cardiovascular system to understand the presence or absence of potential medication interactions with hydroxychloroquine in this new pathophysiological state.

Background: Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome (ACS) and sudden cardiac death. Physical or emotional stressors are the most commonly reported triggers for SCAD. Unemployment has been identified as a source of emotional stress and is linked to poor mental and physical health. Objective: To examine the association between employment status and in-hospital and follow-up adverse cardiovascular events in patients with SCAD. Methods: We conducted a retrospective, multi-center, observational study of patients undergoing coronary angiography for ACS between January 2011 and December 2017. The total number of patients enrolled was 198,000. Patients were diagnosed with SCAD based on angiographic and intravascular imaging modalities whenever available. There were 83 patients identified with SCAD from 30 medical centers in 4 Arab gulf countries. In-hospital (myocardial infarction, percutaneous intervention, ventricular tachycardia/ventricular fibrillation, cardiogenic shock, death, internal cardioverter/ defibrillator placement, dissection extension) and follow-up (myocardial infarction, de novo SCAD, death, spontaneous superior mesenteric artery dissection) cardiac events were compared among those who were employed and those who were not. Results: The median age of patients in the study was 44 (37- 55) years. There were 42 (50.6%) female patients, and 41 (49.4) male patients. Of the cohort, 50 (60%) of the patients were employed and the remaining 33 (40%) were unemployed. 66% of all men were employed and 76% of all women were unemployed. After adjusting for gender unemployment was associated with worse in- -hospital and follow-up cardiac events (adjusted OR 7.1, [1.3, 37.9]), p = 0.021. Conclusion: Adverse cardiovascular events were significantly worse for patients with SCAD who were unemployed.