Search

Background Heart failure (HF) is commonly managed by addressing water and sodium (Na) balance, with arterial circulation playing a major role in influencing renal Na and water excretion. Recently, chloride (Cl) has been recognized as an important factor in HF, associated with volume regulation and its modulation of renin-angiotensin-aldosterone system (RAAS) activity through macula densa signaling, which impacts Na retention and neurohormonal activation. Acetazolamide, a carbonic anhydrase inhibitor, can enhance decongestion in HF by increasing urinary Na and Cl excretion when added to loop diuretics, a mechanism supported by prior studies demonstrating improved urine output and decongestion. Objective This study investigates the neurohormonal effects of acetazolamide in acute HF, focusing on its ability to enhance decongestion, reduce neurohormonal activation (e.g., renin and aldosterone), and modulate RAAS markers. Methods In this prospective, single-center observational study, 80 patients with acute HF were enrolled and divided into two groups: a case group (n=40) receiving acetazolamide with standard therapy and a control group (n=40) on standard therapy alone. Patients were matched based on clinical characteristics to reduce selection bias. Baseline characteristics, neurohormonal profiles, including plasma renin activity (PRA) and aldosterone, electrolyte levels, and clinical outcomes were compared. Results The acetazolamide group exhibited higher urinary Cl excretion (108.9±25.3 mEq/L vs. 79.2±22.7 mEq/L; p<0.001) and reduced PRA and aldosterone levels (1.3±0.4 ng/mL/h and 88±21 pg/mL) compared to controls (1.7±0.6 ng/mL/h and 128±29 pg/mL; p=0.002 and p=0.006, respectively). These reductions in PRA and aldosterone are significant as they correlate with improved volume status and reduced neurohormonal stress, which are critical components in HF management. Improved clinical outcomes included a greater percentage of patients becoming symptom-free within 72 hours (77.5% vs. 52.5%; p=0.018) and shorter hospitalization (5.6±1.4 days vs. 7.1±1.7 days; p=0.028). Conclusion Acetazolamide in addition to standard therapy enhances decongestion and reduces neurohormonal activation in acute HF, suggesting its dual benefit in fluid management and neurohormonal modulation. Further research is needed to confirm these benefits, assess long-term effects, and overcome limitations, including the study's single-center observational design., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Institutional Review Board of Hayatabad Medical Complex issued approval 1455-3. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Asif et al.)

Background: Coronary artery disease remains the largest contributor to cardiac arrests worldwide; yet, long-term outcomes are often driven by neurological status after resuscitation. We examined the association between pre-percutaneous coronary intervention (PCI) level of consciousness (LOC) and outcomes among patients with cardiac arrest who underwent PCI., Methods: The study cohort included patients undergoing PCI after cardiac arrest between April 2018 and March 2022 at 48 hospitals in the state of Michigan. Pre-PCI LOC was categorized as mentally alert, partially responsive, unresponsive, and unable to assess. In-hospital outcomes included mortality, bleeding, and acute kidney injury., Results: Among 3021 patients who underwent PCI after cardiac arrest, 1394 (49%) were mentally alert, 132 (5%) were partially responsive, 698 (24%) were unresponsive, and 631 (22%) were unable to assess. The mentally alert cohort had lower mortality (4.59%) compared with the partially responsive (17.42%), unresponsive (50.14%), and unable to assess cohorts (38.03%; P <0.001). After adjusting for baseline differences, compared with mentally alert patients, the odds of mortality were markedly elevated in patients who were partially responsive (adjusted odds ratio, 4.63 [95% CI, 2.67-8.04]; P <0.001), unable to assess (adjusted odds ratio, 13.95 [95% CI, 9.97-19.51]; P <0.001), and unresponsive (adjusted odds ratio, 24.36 [17.34-34.23]; P <0.001). After adjustment, patients with impaired LOC also had higher risks of acute kidney injury and bleeding compared with mentally alert patients., Conclusions: Pre-PCI LOC is a strong predictor of in-hospital outcomes after PCI among cardiac arrest patients. A patient's pre-PCI LOC should be considered an important factor when weighing treatment options, designing clinical trials, and counseling patients and their families regarding prognosis after PCI., Competing Interests: There are no conflicts directly related to this work. Outside this work, Dr Gurm receives research support from Blue Cross and Blue Shield of Michigan paid to his institution. He is the co-founder of, owns equity in, and is a consultant to Amplitude Vascular Systems. He also owns equity in Jiaxing Bossh Medical Technology Partnership and is a consultant for Osprey Medical. He is the chair of the Clinical Events Committee for the PERFORMANCE trial (Protection Against Emboli Using a 3-In‐1 Delivery System Comprising an Integrated Filter, Normal Angioplasty Balloon and Novel Carotid Stent) sponsored by Contego Medical. Dr Sukul receives salary support from the Blue Cross Blue Shield of Michigan for his role in quality improvement within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. The other authors report no conflicts.

ST-segment elevation (STE) is a very rare complication observed during various cardiac ablation procedures. We report an interesting case of transient STE elevation by inter-atrial septal stretch during introduction of a multipolar mapping catheter during pulmonary vein isolation procedure. We also discuss various mechanisms for this observation., Competing Interests: The authors report no conflicts of interest for the published content. No funding information was provided., (Copyright: © 2023 Innovations in Cardiac Rhythm Management.)

Purpose: Genetic testing may alter clinical management for individuals with metastatic prostate cancer by identifying additional therapies. Traditional counseling models are unlikely to enable time-sensitive therapeutic decision-making. This study aimed to determine the feasibility and clinical impact of an alternative hereditary genetic testing model., Materials and Methods: As part of a multicenter, single-arm prospective trial, individuals with advanced prostate cancer were referred by their oncologist for testing of 14 genes associated with hereditary prostate cancer. Pretest education (brochure and video) was provided in the oncology clinic. Questionnaires assessing participant satisfaction with both pretest education and decision to undergo genetic testing were collected. A genetic counselor contacted participants by phone to obtain family history and discuss results. Medical records were queried to determine whether a change in clinical management was discussed., Results: Of 501 participants consented to germline analysis, 51 (10.2%) had at least 1 pathogenic/likely pathogenic variant. Change in treatment was discussed with 22/48 (45.8%) of eligible participants who tested positive. Feasibility of this model was assessed by participant satisfaction and turnaround time. Average±SD satisfaction with the pretest education (15.5±2.2, 4-20 scale) and with the decision to undergo genetic testing (17.1±2.9, 4-20 scale) were both high. Results were returned 20 days (median) after sample collection., Conclusions: Oncologist-initiated germline genetic testing in collaboration with a genetic counselor is a feasible approach to testing advanced prostate cancer patients with impactful clinical actionability. The testing model and educational material serve as resources to clinicians treating prostate cancer patients.

Objective: Tumor genomic profiling (TGP) can inform advanced cancer patients' treatment decisions, and also reveal secondary germline findings-information about inherited risks for cancer and other disorders. We sought to develop a measure of patient perceptions of the clinical and personal utility of secondary germline findings., Methods: We developed a draft survey based on literature and patient interview data ( n =40). We evaluated and refined the survey through cognitive interviews with advanced cancer patients who received secondary germline findings from TGP ( n =10). The survey was psychometrically validated with data from two independent samples of advanced cancer patients undergoing TGP (total n =349)., Results: Cognitive interviews offered opportunities for survey refinement and confirmation of its comprehensible nature. Exploratory and confirmatory factor analysis of the survey identified 16 items across three subscales with strong internal consistency (Cronbach's alpha ≥0.79): perceived utility for others, perceived utility for self and health, and confidence in secondary findings., Conclusion: We developed a novel valid scale with promise for measuring advanced cancer patients' perceptions of the utility of secondary germline findings., Innovation: We offer a new patient-derived measure of perceived utility of and confidence in secondary germline findings with potential applications for precision oncology research and clinical communication., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: An immediate family member serves as a consultant in Ophthalmology for Adverum, Genentech, Gyroscope Therapeutics Limited, Neurogene, Optos Plc, Outlook Therapeutics, RegenexBio, and Regeneron outside the submitted work (Z.K.S.) - Patent pending on therapeutic applications of targeting ERCC3 mutations in cancer. Diagnosis and treatment of ercc3-mutant cancer US20210137850A1, and other relationship with AnaNeo Therapeutics, Inc (K.O) - Honoraria from Research to Practice, Intellisphere, Physicians’ Education Resource, and MyMedEd; consulting or advisory for Artios Pharma (uncompensated), AstraZeneca (uncompensated), Change Healthcare, Daiichi-Sankyo (uncompensated), Epic Sciences (uncompensated), Merck (uncompensated), Pfizer (uncompensated), Tempus Lab (uncompensated), Zenith Pharma (uncompensated); other support from AstraZeneca (editorial services) and Pfizer (editorial services) (M.E.R.), (© 2023 The Authors.)

We present an interesting case of an 88-year-old man who was referred to our arrhythmia service for an upgrade of his dual-chamber pacemaker to a biventricular pacemaker for right ventricular pacing-induced cardiomyopathy. The patient was found to have stenosis of the left subclavian vein. Here, we describe the approach used to perform venoplasty in this patient. After venoplasty of the left subclavian vein, the patient did not have suitable coronary venous anatomy for deployment of the coronary sinus lead. Subsequently, a His lead was implanted. We achieved significant narrowing of the QRS with good thresholds and other lead parameters. Through this case report, we seek to present our approach of venoplasty in patients with occluded venous access for either an upgrade or a de novo implant., Competing Interests: The authors report no conflicts of interest for the published content. No funding information was provided., (Copyright: © 2022 Innovations in Cardiac Rhythm Management.)

Background: Hereditary Diffuse Gastric Cancer (HDGC) syndrome is an autosomal dominant hereditary cancer predisposition associated with germline pathogenic/likely pathogenic variants in the CDH1 gene. Identifying early stage HDGC is difficult, and prophylactic measures can be effective in preventing incidence. Preimplantation Genetic Testing (PGT) can provide information about CDH1 variant status, HDGC risk, and limit familial transmission of CDH1 variants. To date, however, little is known about the attitudes of individuals with CDH1 variants towards PGT., Methods: Given that little is known about the reproductive attitudes of individuals with HDGC, we recruited participants with CDH1 variants from a familial gastric cancer registry and administered a cross-sectional survey with open- and closed-ended response items. We assessed attitudes regarding PGT and the effect of HDGC on quality of life., Results: Participants (n = 21) were predominantly partnered (61.9%), had a personal cancer history (71.4%), and had biological children (71.4%). Interest in learning about PGT was high; 66.7% of participants were interested in PGT and 90.5% approved of healthcare providers discussing PGT with individuals with CDH1 variants. Attitudes regarding personal use were varied. Among all participants, 35% would not, 25% were uncertain, and 40% would use PGT. Personal philosophy and preferences for family and reproduction were key factors related to PGT attitudes. HDGC had moderate effects on participants' quality of life, including social relationships, health behaviors, and emotional experiences including worry about cancer risk and guilt regarding familial implications., Conclusion: PGT was identified by participants as acceptable for use in a variety of contexts and benefits of reproductive counseling involving PGT may extend beyond CDH1 carriers to family members' reproductive behaviors. Dispositions towards PGT are governed by personal philosophy or belief systems. These findings can help guide providers counseling individuals with CDH1 variants., (© 2022. The Author(s).)

Purpose: To address demands for timely germline information to guide treatments, we evaluated experiences of patients with ovarian, pancreatic, and prostate cancer with a mainstreaming genetic testing model wherein multigene panel testing was ordered by oncologists with standardized pretest patient education, and genetic counselors delivered results and post-test genetic counseling via telephone., Methods: Among 1,203 eligible patients, we conducted a prospective single-arm study to examine patient uptake and acceptability (via self-report surveys at baseline and three weeks and three months following result return) of this mainstreaming model., Results: Only 10% of eligible patients declined participation. Among 1,054 tested participants, 10% had pathogenic variants (PV), 16% had variants of uncertain significance (VUS), and 74% had no variant identified (NV). Participants reported high initial acceptability, including high satisfaction with their testing decision. Variability over time in several outcomes existed for participants with PV or NV: those with NV experienced a temporary increase in depression (p Time  < 0.001; p Time2  < 0.001), and those with PV experienced a small increase in genetic testing distress (p = 0.03). Findings suggested that result type, sex, and cancer type were also associated with outcomes including clinical depression and uncertainty., Conclusion: This mainstreaming model may offer a feasible approach for extending access to germline genetic information., (© 2021. The Author(s), under exclusive licence to the American College of Medical Genetics and Genomics.)

Objectives: The aim of this study was to evaluate the association between reported marijuana use and post-percutaneous coronary intervention (PCI) in-hospital outcomes., Background: Marijuana use is increasing as more states in the United States legalize its use for recreational and medicinal purposes. Little is known about the frequency of use and relative safety of marijuana among patients presenting for PCI., Methods: The authors analyzed Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry data between January 1, 2013, and September 30, 2016. One-to-one propensity matching and multivariable logistic regression were used to adjust for differences between patients with or without reported marijuana use, and rates of post-PCI complications were compared., Results: Among 113,477 patients, 3,970 reported marijuana use. Compared with those without reported marijuana use, patients with reported marijuana use were likely to be younger (53.9 years vs 65.8 years), to use tobacco (73.0% vs 26.8%), to present with ST-segment elevation myocardial infarction (27.3% vs 15.9%), and to have fewer cardiovascular comorbidities. After matching, compared with patients without reported marijuana use, those with reported marijuana use experienced significantly higher risks for bleeding (adjusted odds ratio [aOR]: 1.54; 95% confidence interval [CI]: 1.20-1.97; P < 0.001) and cerebrovascular accident (aOR: 11.01; 95% CI: 1.32-91.67; P = 0.026) and a lower risk for acute kidney injury (aOR: 0.61; 95% CI: 0.42-0.87; P = 0.007). There were no significant differences in risks for transfusion and death., Conclusions: A modest fraction of patients undergoing PCI used marijuana. Reported marijuana use was associated with higher risks for cerebrovascular accident and bleeding and a lower risk for acute kidney injury after PCI. Clinicians and patients should be aware of the higher risk for post-PCI complications in these patients., Competing Interests: Funding Support and Author Disclosures The BMC2 coordinating center is supported by a grant from Blue Cross Blue Shield of Michigan to the University of Michigan. The sponsor had no role in the study design or decision to publish this work. Dr Yoo has received support from the Fogarty International Center and the National Institute of Mental Health of the National Institutes of Health under award D43 TW010543. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Mr Seth, Drs Sukul and Gurm have received salary support from Blue Cross Blue Shield of Michigan for their roles in the BMC2. However, the opinions, beliefs and viewpoints expressed by the authors do not necessarily reflect those of Blue Cross Blue Shield of Michigan or any of its employees. Dr Gurm has received research support from Blue Cross Blue Shield of Michigan, the National Institutes of Health Center for Accelerated Innovations, and the Michigan Translational Research and Commercialization for Life Sciences Innovation Hub; is a cofounder of, owns equity in, and is a consultant to Calcium Solution; owns equity in Jiaxing Bossh Medical Technology Partnership; and is a consultant for Osprey Medical. Dr Vaduganathan is supported by the KL2/Catalyst Medical Research Investigator Training Award from Harvard Catalyst (National Institutes of Health/National Center for Advancing Translational Sciences award UL 1TR002541); receives research grant support from Amgen; serves on advisory boards for Amgen, AstraZeneca, Baxter Healthcare, Bayer, Boehringer Ingelheim, Cytokinetics, and Relypsa; and has participated on clinical endpoint committees for studies sponsored by Galmed, Novartis, and the National Institutes of Health. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Published by Elsevier Inc.)

Objectives: The aim of this study was to evaluate institutional variability in high radiation doses during percutaneous coronary intervention (PCI)., Background: It is unknown whether radiation safety practices are optimally applied across institutions performing PCI., Methods: Using data from a large statewide registry, PCI discharges between July 1, 2016, and March 31, 2018, with a procedural air kerma (AK) recorded were analyzed. PCI procedures were grouped by the performing hospital, and institutional frequency of procedural AK ≥5 Gy was calculated. Fitted hierarchical Bayesian modeling was performed to identify variables independently associated with an AK ≥5 Gy. The performing hospital was included as a random effect in the hierarchical model., Results: Among 36,201 PCI procedures at 28 hospitals, procedural AK was ≥5 Gy in 1,477 cases (4.1%), ≥10 Gy in 185 (0.5%), and ≥15 Gy in 105 (0.3%). The institutional frequency of procedural AK ≥5 Gy ranged from 0.0% to 10.9%. Bayesian modeling identified body mass index, dyslipidemia, diabetes, prior coronary bypass surgery, use of mechanical circulatory support, and the performing hospital as independent predictors of an AK ≥5 Gy. The median odds ratio for the performing hospital, representing an estimate of the contribution of interhospital variability in determining the odds of having a procedural AK ≥5 Gy, was 3.08 (95% confidence interval: 3.01 to 3.16)., Conclusions: Wide variability exists in the institutional frequency of procedural AK ≥5 Gy during PCI. After accounting for patient characteristics and procedural variables, the performing hospital appears to be a major factor in determining patient radiation dose in contemporary PCI., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Genetic risk modifier testing (GRMT), an emerging form of genetic testing based on common single nucleotide polymorphisms and polygenic risk scores, has the potential to refine estimates of BRCA1/2 mutation carriers' breast cancer risks. However, for women to benefit from GRMT, effective approaches for communicating this novel risk information are needed., Objective: To evaluate patient preferences regarding risk communication materials for GRMT., Methods: We developed four separate presentations (panel of genes, icon array, verbal risk estimate, graphical risk estimate) of hypothetical GRMT results, each using varying risk communication strategies to convey different information elements including number of risk modifier variants present, variant prevalence among BRCA1/2 carriers, and implications and uncertainties of test results for cancer risk. Thirty BRCA1/2 carriers evaluated these materials (randomized to low, moderate, or high breast cancer risk versions). Qualitative and quantitative data were obtained through in-person interviews., Results: Across risk versions, participants preferred the presentation of the graphical risk estimate, often in combination with the verbal risk estimate. Interest in GRMT was high; 76.7% of participants wanted their own GRMT. Participants valued the potential for GRMT to clarify their cancer susceptibility and provide actionable information. Many (65.5%) anticipated that GRMT would make risk management decisions easier., Conclusions: Women with BRCA1/2 mutations could be highly receptive to GRMT, and the minimal amount of necessary information to be included in result risk communication materials includes graphical and verbal estimates of future cancer risk. Findings will inform clinical translation of GRMT in a manner consistent with patients' preferences., (© 2020 S. Karger AG, Basel.)

We present a challenging case of a 75-year-old female with a history of paroxysmal atrial fibrillation (PAF) and symptomatic sick sinus syndrome (SSS) who presented for a dual chamber pacemaker implantation and was found to have persistent left superior vena cava and absent right superior vena cava with stenosis of the left subclavian vein. In this report, we discuss the implant technique in this group of patients., Competing Interests: The authors declare that they have no conflicts of interest.

Cholesterol crystals (CCs) have been associated with plaque rupture through mechanical injury and inflammation. This study evaluated the presence of CCs during acute myocardial infarction (AMI) and associated myocardial injury, inflammation, and arterial blood flow before and after percutaneous coronary intervention. Patients presenting with AMI (n = 286) had aspiration of culprit coronary artery obstruction. Aspirates were evaluated for crystal content, size, composition, and morphology by scanning electron microscopy, crystallography, and infrared spectroscopy. These were correlated with inflammatory biomarkers, cardiac enzymes, % coronary stenosis, and Thrombolysis in Myocardial Infarction (TIMI) blush and flow grades. Crystals were detected in 254 patients (89%) and confirmed to be cholesterol by spectroscopy. Of 286 patients 240 (84%) had CCs compacted into clusters that were large enough to be measured and analyzed. Moderate to extensive CC content was present in 172 cases (60%). Totally occluded arteries had significantly larger CC clusters than partially occluded arteries (p <0.05). Patients with CC cluster area >12,000 µm 2 had significantly elevated interleukin-1 beta (IL-1β) levels (p <0.01), were less likely to have TIMI blush grade of 3 (p <0.01), and more likely to have TIMI flow grade of 1 (p <0.01). Patients with recurrent AMI had smaller CC cluster area (p <0.04), lower troponin (p <0.02), and IL-1β levels (p <0.04). Women had smaller CC clusters (p <0.04). Macrophages in the aspirates were found to be attached to CCs. Coronary artery aspirates had extensive deposits of CCs during AMI. In conclusion, presence of large CC clusters was associated with increased inflammation (IL-1β), increased arterial narrowing, and diminished reflow following percutaneous coronary intervention., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: The bioresorbable vascular scaffold (BVS) (Abbott Vascular) provides temporary scaffolding while eluting everolimus. There are limited data on its use in daily practice, especially in patients with stable angina pectoris referred for elective percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). The current study aims to investigate the safety and efficacy of BVS implantation in a selected patient cohort with CTO., Methods: A total of 70 consecutive patients, who underwent successful recanalization of CTO with BVS between September 13, 2012 and September 20, 2014 in three cardiac centers (Department of Cardiology, Bezmialem Vakif University, Istanbul, Turkey; Department of Interventional Cardiology, San Raffaele Hospital, Milan, Italy; and EMO-GVM Centro Cuore Columbus, Milan, Italy) were included in this CTO registry. Endpoints analyzed included: (1) the composite of all-cause death and non-fatal myocardial infarction (MI); and (2) the composite safety endpoint of major adverse cardiovascular events (MACEs), including death, MI and symptom-driven target lesion revascularization (TLR)., Results: Clinical data were obtained for 70 patients (mean age, 56.9 ± 9.4 years; 90.0% male) with a total number of 76 CTOs. At a median follow-up of 11.0 months (interquartile range, 7-18 months), both MACE and TLR rates were 4.3%. Two patients suffered from ischemia-driven TLR (1 patient at 6 months and 1 patient at 9 months after implantation). No death, MI, or stent thrombosis was observed during the follow-up period., Conclusion: Treatment of CTOs with BVS seems to be safe and effective, with a high technical success rate and acceptable MACE at short-term follow-up.

Background: Percutaneous coronary interventions are almost always preceded by the loading dose of platelets inhibiter drugs such as clopidogrel or prasugrel and followed by maintenance therapy to decrease the mortality and morbidity due to stent thrombosis. This study was conducted to compare the efficacy of clopidogrel and prasugrel for inhibiting platelet aggregation among patients undergoing elective percutaneous coronary intervention., Methods: This randomized controlled trial study was done in Department of Cardiology, Postgraduate Medical Institute Govt. Lady Reading Hospital Peshawar. A total of 148 patients were randomly allocated to either group-A containing 74 patients using clopidogrel or group-B containing 74 patients using prasugrel, Results: Group-A had 55 (74.3%) male and 19 (25.7%) females while group-B had 56(75.7%) males and 18 (24.3%) females (p=0.85). Mean age was 54.9 +/- 11.2 years in group-A and was 57.7 +/- 8.7 years in group-B (p=0.09). Mean body weight was 71.8?6.4 Kg in group-A and 70.8 +/- 6.3 Kg in group-B (p=0.35). Mean Baseline platelet aggregation before drug administration was 10.43 +/- 1.9 ohm in group-A while 10.12 +/- 2.2 ohm in group-B (p=0.36). Mean Follow up platelet aggregation 6 hours after drug administration was 5.88 +/- 2.9 in group-A while it was 3.47 +/- 1.8 ohm in group-B (p=0.001). Mean Difference between basal and follow up platelet aggregation +/-SD was 52.9649 +/- 24.77 in group-A while it was 82.25 +/- 14.34 in group-B (p=0.001). 63(85.15%) of group-A had inhibition of platelets aggregation >10% as compare to 72(97.3%) of group-B had inhibition of platelets aggregation >10% (p=0.009)., Conclusion: Prasugrel is more efficacious than clopidogrel in term of inhibition of platelets aggregation.

Introduction: Acute coronary syndromes and non-Q-wave myocardial infarction are often initiated by platelet activation. Eptifibatide is a cyclic heptapeptide and is the third inhibitor of glycoprotein (Gp) IIb/IIIa that has found broad acceptance after the specific antibody abciximab and the nonpeptide tirofiban entered the global market. Gp IIb/IIIa inhibitors act by inhibiting the final common pathway of platelet aggregation, and play an important role in the management of acute coronary syndromes., Aims: This review assesses the evidence for therapeutic value of eptifibatide as a Gp IIb/IIIa inhibitor in patients with acute coronary syndromes., Evidence Review: Several large, randomized controlled trials show that eptifibatide as adjunctive therapy to standard care in patients with non-ST segment elevation acute coronary syndrome is associated with a significant reduction in the incidence of death or myocardial infarction. Data are limited regarding the use of eptifibatide in patients with ST segment elevation myocardial infarction. Cost-effectiveness analysis indicates that eptifibatide is associated with a favorable cost-effectiveness ratio relative to standard care. According to US cost-effectiveness analysis about 70% of the acquisition costs of eptifibatide are offset by the reduced medical resource consumption during the first year. Eptifibatide was well tolerated in most of the trials. Bleeding is the most commonly reported adverse event, with most major bleeding episodes occurring at the vascular access site. Major intracranial bleeds, stroke, or profound thrombocytopenia rarely occurred during eptifibatide treatment., Place in Therapy: Eptifibatide has gained widespread acceptance as an adjunct to standard anticoagulation therapy in patients with acute coronary syndromes, and may be particularly useful in the management of patients with elevated troponin or undergoing percutaneous coronary interventions.

Background: Although clinicians are expected to help patients make decisions about end-of-life care, there is insufficient data to help guide patient preferences. The objective of this study was to determine the frequency of patients who undergo 'limited code' and compare survival to discharge with those who undergo maximum resuscitative efforts ('full code')., Methods: We performed a retrospective analysis of all adult in-hospital cardiac arrests (IHCA) at a tertiary care teaching hospital from January 1999 to December 2003 to compare survival in patients with limited code to survival in patients with a full code. We collected data on demographic and clinical variables known to influence survival in IHCA. Logistic regression was used to assess the association of code status with subsequent survival through the code and to hospital discharge after adjusting for potential confounding factors., Results: Of the 309 patients having IHCA, there were 17 (5.5%) patients with limited code status and 292 (94.5%) with full code status. Among full code patients, 171 (58.6%) survived the code compared to five patients (29.4%) who had a limited code (p=0.023). After adjusting for demographic variables and pre-arrest co-morbidities, patients with full code status compared to limited code status had an odds ratio for return of spontaneous circulation of 3.69 (95% CI: 1.13-14.34)., Conclusions: Patients who opt for limited code have a significantly lower probability of survival compared to patients who choose full code. Patients who choose limited code should be informed of the likely negative outcome as compared to full resuscitation.

Calcitonin gene-related peptide (CGRP), a potent vasodilator released from capsaicin-sensitive C-fiber and Adelta-fiber sensory nerves, has been suggested to play a beneficial role in myocardial ischemia-reperfusion (I/R) injury. Because most previous studies showing a cardioprotective role of CGRP employed pharmacological experiments, the purpose of this study was to utilize a genetic approach by using mice with a targeted deletion of the alpha-CGRP gene to determine whether this neuropeptide had a modulatory function on the severity of I/R injury. To accomplish this goal, isolated, perfused hearts from alpha-CGRP knockout (KO) and wild-type (WT) mice were subjected to 30 min of ischemia followed by 5, 15, and 30 min of reperfusion. Cardiac functional parameters, including coronary flow rates, left ventricular developed pressure, maximum rates of pressure development, and left ventricular end-diastolic pressure, were measured before and after I/R injury, as were levels of creatine kinase, to assess myocardial damage, and malonaldehyde, to assess oxidative stress. Following I/R injury, cardiac performance was significantly reduced in the hearts from the alpha-CGRP KO mice compared with their WT counterparts. The marked reduction in myocardial function in the alpha-CGRP KO hearts compared with WT hearts after I/R injury was associated with a significant elevation in creatine kinase release into the perfusates and malonaldehyde production in the cardiac tissue. Therefore, these data indicate that, in this in vitro setting, deletion of alpha-CGRP makes the heart more vulnerable to I/R injury, possibly due, at least in part, to increased oxidative stress.