Search

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

We previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic.The purpose of this study was to describe trends of COVID-19 patients with STEMI during the course of the pandemic.The NACMI (North American COVID-19 STEMI) registry is a prospective, investigator-initiated, multicenter, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management, and outcomes of patients treated in the first year of the pandemic (January 2020 to December 2020) vs those treated in the second year (January 2021 to December 2021).A total of 586 COVID-19-positive patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients' characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs 39%; P 0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%; P = 0.04), and patients were less likely to have shock pre-PCI (13% vs 18%; P = 0.07) or pulmonary manifestations (33% vs. 47%; P = 0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (P = 0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) unvaccinated patients (P = 0.009).Significant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of35 breaths/min, cardiogenic shock, oxygen saturation of93%, age of55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Women with ST-segment elevation myocardial infarction (STEMI) had worse outcomes than men prior to the COVID-19 pandemic. Although concomitant COVID-19 infection increases mortality risk in STEMI patients, no studies have evaluated sex differences in this context.The North American COVID-19 STEMI registry is a prospective, multicenter registry of hospitalized STEMI patients with COVID-19 infection. We compared sex differences in clinical characteristics, presentation, management strategies, and in-hospital mortality.Among 585 patients with STEMI and COVID-19 infection, 154 (26.3%) were women. Compared to men, women were significantly older, had a higher prevalence of diabetes and stroke/transient ischemic attack, and were more likely to be on statins on presentation. Men more frequently presented with chest pain, whereas women presented with dyspnea. Women more often had STEMI without an identified culprit lesion than men (33% vs 18%,In patients presenting with STEMI in the context of COVID-19, the in-hospital mortality rate was 30% and similar for men and women. Lack of an identifiable culprit lesion was common in the setting of COVID-19 for both sexes but more likely in women (1/3 of women vs 1/5 of men). Evaluation of specific underlying etiologies is underway to better define the full impact of COVID-19 on STEMI outcomes and better understand the observed sex differences.

Objectives This study investigated the feasibility, safety, and the acute outcome of primary retrograde tibio pedal approach (TPA) in the treatment of peripheral arterial disease (PAD) with femoropopliteal (FP) chronic total occlusion (CTO). Background With maturing in endovascular technology and further development in new devices, endovascular therapy has become a comparable and preferred treatment for patients with PAD. The retrograde TPA has not been studied to treat FP CTO extensively. Methods We performed a retrospective analysis of 98 consecutive patients who underwent peripheral angiogram and intervention of 123 FP CTO lesions from June 1st, 2016 to June 30th, 2018 in a single center. Peripheral angiography and percutaneous balloon angioplasty was done primarily via retrograde TPA. Demographic data, procedural success rate, peri-procedural major adverse complications, and 30-day outcomes were recorded. Results Out of 123 procedures, the dorsalis pedis artery/distal anterior tibial artery was the most common TPA site (59%) followed by the posterior tibial artery in 27% patients and peroneal artery in 14% patients. In 40 (33%) FP CTO lesions, additional transradial accesses were needed for controlled antegrade and retrograde tracking (CART) technique. Overall procedural success was achieved in 122 FP CTO (99%) lesions. No patients had significant access site bleeding, hematoma, worsening kidney dysfunction or acute limb ischemia within 30-day following this procedure. Conclusions The primary retrograde TPA for FP CTO lesions is safe and feasible. With a combination of tibio pedal and transradial approach, our procedural success rate is very high for FP CTO intervention.

OBJECTIVE We sought to use a novel technique to measure the functional hemodynamics of peripheral arterial lesions during endovascular interventions. BACKGROUND Functional hemodynamics has not been thoroughly evaluated during endovascular interventions. The aim of our study is to evaluate the feasibility and the potential benefits of pedal pressures measurements from tibio-pedal access. METHODS We retrospectively reviewed 100 consecutive patients who underwent endovascular interventions via tibio-pedal artery access between October 3, 2018 and December 15, 2018. Baseline and postintervention pedal pressures from the pedal sheaths were measured. We also evaluated the pedal-brachial index (PBI) which is defined as the pedal sheath pressure divided by the simultaneously brachial cuff pressure. We compared baseline pedal pressures, postintervention pedal pressures, baseline PBI, postintervention PBI, % change of PBI ([postintervention PBI minus baseline PBI]/baseline PBI), and resting ankle-brachial index (ABI) versus baseline PBI in this cohort of patients. RESULTS All 100 patients had successful tibio-pedal artery access. Baseline pedal pressure was 70 + 30 mmHg with post intervention pedal pressure of 133 + 27 mmHg (p

Myanmar's mango export industry depends disproportionately on China. By comparing the country's supply chain for export to China with that for export to Singapore, this chapter elucidates the obstacles that prevent diversification of export destinations. Major findings from interviews with key informants and analyses of the secondary data are as follows; First, the fruits exported to Singapore are interchangeable with those exported to China. Second, these countries' sanitary and phytosanitary measures do not bottleneck imports from Myanmar. Third, notable differences are evident between the supply chains with respect to the post-harvest handling of fruits, particularly sorting and grading, treatment for pest and disease control, and logistics management. On the whole, these findings suggest that a shortage of firms orchestrating the post-harvest management inhibits growth of export to Singapore. By contrast, for exports to China, the wholesale market in the borderland compensate for lack of coordinating firms. Myanmar's trade policies, which discourage foreign investment in the trade of fresh fruits, call for further consideration.

A 69-year-old short-statured Turner syndrome (TS) patient with a history of poliomyelitis in childhood and moderate bicuspid aortic stenosis (BAS) reported worsening dyspnea and fatigue over six months. A repeat transthoracic echocardiogram revealed progression to severe aortic stenosis with dilated ascending aorta (AA). As part of the work-up for aortic valve replacement, the patient underwent cardiac catheterization, which revealed a severely calcified AV with an area of 0.5 sq. cm and a mean gradient of 37 mmHg. On coronary angiography, there was 70% stenosis of the proximal left anterior descending artery (LAD). Due to poor rehabilitation potential, she was deemed high-risk for surgical aortic valve replacement. A recommendation for transcatheter aortic valve replacement (TAVR) with stenting of the proximal LAD was made. Dilated AA was managed conservatively with serial noninvasive imaging. The patient underwent TAVR with Edwards-Sapien valve (23 mm S3) and stenting of proximal LAD. The procedure was successful without complications. To our knowledge, our patient is the first case of TAVR in BAS with aortopathy in TS.

Background Patients with left main (LM) coronary artery disease are increasingly being treated with percutaneous revascularization (PCI). The safety, feasibility, and efficacy of unprotected LM intervention (ULMI) with hemodynamic support by Impella device have not been evaluated previously. Objective Using a large retrospective single center database from the USpella registry, we evaluated the safety, feasibility, and potential benefits of periprocedural left ventricular assist with axial flow Impella 2.5 and Impella CP (Abiomed Inc. Danvers, Mass) during ULMI. Methods We analyzed a total of 127 consecutive patients who received hemodynamic support with Impella (2.5 or CP) for ULMI from August 2008 to July 2015. Safety, feasibility and efficacy end points included procedural success rates, in-hospital and 30-day major adverse cardiovascular event (MACE) rates. Results Among 127 patients who received hemodynamic support for ULMI (mean age 69.98 ± 10.7 years, 71% men, and mean left ventricular ejection fraction 28.74 ± 15.55%, Society of Thoracic Surgeons' mortality/morbidity 4/23%) the in-hospital and 30 days mortality rates were 1.43% (2/140) and 2.1% (3/141), respectively. The average baseline and post PCI (residual) syntax scores were 31.4 and 7.86, respectively, (P

We sought to compare the use of transradial peripheral angiography to guide retrograde revascularization of below-the-knee (BTK) lesions using tibiopedal access (TPA).Tibiopedal retrograde revascularization of BTK lesions is an emerging technique in peripheral interventions.We performed an observational cohort study of 194 consecutive adult patients with critical limb ischemia (CLI) who underwent endovascular intervention for BTK diseases using peripheral angiography and primary TPA access with vs without transradial (TR) guidance at 2 centers (New York, USA and Budapest, Hungary). The primary endpoints were procedure success, 30-day major adverse event rate, 30-day access-site complication rate, and 30-day access-site patency rate by ultrasound. Secondary endpoints were periprocedural complications, fluoroscopy time, procedure length, and crossover rate to femoral access.There were 78 patients in the TR-guidance group and 116 patients in the non-TR guidance group. Overall procedure success rates with TR guidance vs without TR guidance were 97% and 98%, respectively. Fluoroscopy times (732.8 ± 615.7 seconds vs 769.8 ± 565.8 seconds; P=NS) and procedure times (46.5 ± 24.4 minutes vs 55.4 ± 12.6 minutes; P=NS) were similar in the TR-guidance group vs the non-TR guidance group, but contrast volumes were higher in the TR-guidance group (100.0 ± 60.1 mL vs 43.8 ± 10.2 mL in the non-TR guidance group; P.05). There was no difference in 30-day major adverse events, other than higher amputation rate in the TR-guidance group (15.3%), which was attributed to severe baseline complex CLI status in this patient group. There was 1 case of arteriovenous fistula, 1 case of pseudoaneurysm, and 1 case of tibiopedal artery occlusion at 30 days in the group without TR guidance. There were 3 cases (3.8%) of radial artery occlusion in the TR-guidance group.The treatment of CLI with BTK lesions is feasible and safe, with a high procedural success rate and low access-site complication rate using the TPA approach regardless of whether or not TR guidance is utilized.

OBJECTIVE To assess the in-hospital and short-term outcome differences between males and females who underwent high-risk PCI with mechanical circulatory support (MCS). BACKGROUND Sex differences have been noted in several percutaneous coronary intervention (PCI) series with females less likely to be referred for PCI due increased risk of adverse events. However, data on sex differences in utilization and outcomes of high-risk PCI with MCS is scarce. METHODS Using the cVAD Registry, we identified 1,053 high-risk patients who underwent PCI with MCS using Impella 2.5 or Impella CP. Patients with cardiogenic shock were excluded. A total of 792 (75.21%) males and 261 (24.79%) females were included in the analysis with median follow-up of 81.5 days. RESULTS Females were more likely to be African American, older (72.05 ± 11.66 vs. 68.87 ± 11.17, p

Objectives This study investigated the feasibility, safety, and the potential benefit of faster hemostasis with the distal transradial artery access (TRA). Background TRA has been shown to be associated with lower bleeding and vascular complications. Limited data are available regarding the new technique of accessing the distal radial artery in the anatomical snuffbox. Methods We retrospectively reviewed 202 consecutive patients who underwent coronary angiography and intervention with distal TRA. Two hundred and six conventional TRA cases were collected as a comparison arm. Results Out of 408 patients, successful distal radial access was obtained in 99.5% (201/202) in the distal TRA cases and 99.0% (204/206) in the conventional TRA cases. The rate of access site crossover was 2.0% (4/202) for distal TRA. Right distal radial artery was accessed in 176 cases (87.6%). Mean access time from local anesthesia to radial flush was 7.3 min. Ninety cases (44.8%) were percutaneous coronary interventions (PCIs) and the mean heparin dose used was 4,448 units (6,009 units for PCI and 3,182 units for diagnostic catheterization). Mean time to remove TR band was 104.7 min (120.8 min for PCI and 91.7 min for diagnostics). Follow-up ultrasound study showed two partial occlusions (1.0%) and one arteriovenous fistula (0.5%) that resolved with prolonged TR band inflation. Conclusions Despite longer time to access the distal radial artery in the anatomical snuffbox, it is a safe and feasible alternative to conventional TRA and might result in shorter time to hemostasis especially in cases of PCI.

OBJECTIVE To compare the transpedal approach to established femoral approach for endovascular treatment of infrainguinal peripheral arterial disease. BACKGROUND Endovascular treatment of infrainguinal peripheral arterial disease is on the rise. Femoral approach is widely used but has significant complications. Recently the primary transpedal approach has been described for endovascular interventions. We hypothesized that transpedal approach could reduce access site related complications. We compared the two approaches in a retrospective cross-sectional study at a single center. METHODS We analyzed demographics, procedural parameters, and complications in patients who underwent a primary transpedal approach for infrainguinal intervention and compared to patients with a traditional femoral approach in our outpatient based endovascular lab. RESULTS The success rate for access was lower in transpedal group compared to femoral (94% vs. 100%, p = .0002). The contrast dose (44 ± 11 mL vs. 68 ± 13 mL, p

Femoral and radial artery access continue to be the standard of care for percutaneous coronary interventions. Cardiac catheterization has progressed to encompass a wide range of diagnostic and interventional procedures including coronary, peripheral, endovascular, and structural heart disease interventions. Despite advanced technology to make these procedures safe, bleeding, and vascular complications continue to be a substantial source of morbidity, especially in patients undergoing large-bore access procedures. New variations of percutaneous devices have reduced complications associated with these procedures. However, safe vascular access with effective hemostasis requires special techniques which have not been well described in the literature. Large-bore femoral artery access is feasible, safe, and associated with low complication rates when a protocol is implemented. Wayne State University, Detroit Medical Center Heart Hospital is a tertiary care, high-volume center for endovascular, structural heart and complex high risk indicated procedures with more 150 procedures involving mechanical circulatory support (MCS) devices per year. In this manuscript, we describe our approach to femoral artery large-bore sheath insertion and management. Our protocol includes proper identification of the puncture site, device selection, insertion, assessment of limb perfusion while on prolong MCS support, and hemostasis techniques after sheath removal.

Background and Objective With aging, the progression of atherosclerosis in the coronary arteries is expected. The Medtronic™ self-expandable aortic bioprosthetic valve is deployed in the supra-annular position, and it has been challenging to selectively engage coronary arteries post-transcatheter aortic valve replacement (TAVR) even though there are diamond-shaped spaces in the mesh frame within the valve. Given the scarcity of data, we analyzed angiographic and clinical data from all patients requiring coronary angiography (CA) or intervention post-TAVR. Methods From January 2012 to December 2016, 403 patients were treated for severe aortic stenosis with TAVR at our center using the Medtronic™ self-expandable valve. This study included patients who underwent CA with or without percutaneous coronary intervention (PCI) after TAVR. Results Twenty-eight patients underwent 43 CAs after TAVR at our institution. Eleven patients (39%) were women. More than 90% of the procedures were performed for acute coronary syndrome. Thirty-six cases were performed using the transfemoral approach (83%). Forty-two of 43 (97%) left coronary arteries were selectively engaged, and 29 of 32 (90%) right coronary arteries were selectively engaged. We were able to engage 11 saphenous vein grafts and two left internal mammary artery grafts selectively (100%). The mean fluoroscopy time for diagnostic CA was 11.5 min, and for PCI, instantaneous wave-free ratio, or intravascular ultrasound (IVUS) interrogation, it was 19 minutes. The mean amount of contrast used for diagnostic CA was 102 cc per case, and for PCI, iFR, or IVUS, it was 146 cc per case. No periprocedural complication was noted. Conclusions CA with or without PCI after TAVR is feasible with supra-annular self-expandable valves. With the proper technique in experienced hands, it can be conducted safely.

We sought to determine the association of major cardiovascular risk factors and other comorbidities with the presence or absence of coronary collateral (CC) circulation. All electronic medical records from 2010 to 2011 were retrospectively reviewed. A total of 563 patients were divided into 2 groups: CC present (180) and CC absent (383). Smoking ( P = .012, odds ratio [OR] 1.58), hypercholesterolemia ( P = .001, OR 2.21), and hypertension ( P = .034, OR 1.75) were associated with the presence of CC. Increasing body mass index (BMI, P = .001) and decreasing estimated glomerular filtration rate (eGFR, P = .042) were associated with the absence of CC. On multivariable linear regression analysis, hypercholesterolemia ( P = .001, OR 2.28), BMI ( P = .012, OR 0.77), and eGFR ( P = .001, OR 0.70) were found to be independently associated with CC. Our findings will help predict patient populations more likely to have presence or absence of CC circulation.

The AngioVac is a vacuum-based device introduced in 2012 to percutaneously remove undesirable material from the intravascular system. In scattered reports, the AngioVac has been used for removal of device-led vegetations and right-sided thrombi. In this article, we describe three cases of right-sided endocarditis treated with AngioVac: a mobile mass extending from the vena cava into the right atrium, large native tricuspid vegetations, and bioprosthetic tricuspid vegetations. This device shows benefit in reducing vegetation load, decreasing septic lung embolization, and reducing reinfection in active intravenous drug users. These cases exhibit the AngioVac's arrival as a new and exciting tool in endocarditis treatment, providing an alternative to open surgery and accessorizing antimicrobial treatment.

With maturing of endovascular technology and further development of new devices, endovascular therapy (EVT) has been a comparable and preferred treatment for patients with PAD. Transpedal approach has been utilized for more than a decade to treat peripheral vascular disease. Like transradial

Transradial access (TRA) has been established the default access for cardiac catheterization in recent years. Radial artery occlusion (RAO) after transradial procedure has been a known complication and precludes TRA for further procedures as well as usage as arterial conduit. Reported rate of RAO

A new technique of accessing the distal radial artery in the anatomical snuffbox was introduced as a safe and feasible approach. Distal radial access site at the anatomical snuffbox offers few advantages: sparing the superficial palmar artery and reducing the risk of proximal radial artery occlusion

More patients with multiple comorbidities and compromised left ventricular function are being referred to the cath lab for percutaneous coronary intervention (PCI). Thus, the utility of mechanical circulatory support (MCS) for complex high-risk indicated patients (CHIP) has been increasing. However

Background: Stable patients (pts) undergoing an uncomplicated elective percutaneous coronary intervention (PCI) typically stay in the hospital overnight after their procedure. Many studies suggest that in carefully selected pts, discharge within hours after the PCI appears to be safe. There are no studies, however, comparing the economic impact of same day versus next day discharge. Objective: We sought to evaluate the safety and economic impact of same day discharge after an uncomplicated PCI compared with those after an overnight observation stay.. Methods: We performed a retrospective review of pts who underwent elective PCI and were discharged the same day vs. next day (from observation status) at Geisinger Medical Center between 1/1/2008 to 9/15/2013. The same-day discharge program for selected pts (“outpatient PCI”) was initiated in 2010. Guidelines for same day discharge included negative troponins at 4 hours; readiness for discharge before 8:00 pm; freedom from CHF; LVEF >40%; live within Results: A total of 1164 elective PCI pts were identified; 280 (24%) were discharged the same day (Group 1) and 884 (76%) stayed overnight (Group 2), by physician preference. The radial route was used in 47% of pts, and increased over time. No same day discharge pts were readmitted within 24 hours. At 30 days, there were no differences between Group 1 vs. 2 in frequency of access site complications (0% vs. 0.01%), peri-procedural MI (0 % vs. 0.006%), urgent care/ED visit or readmission (0.05% vs. 0.08%) (P=NS all comparisons). Stent thrombosis and death did not occur in either group in the first 24 hr post PCI. The average charges were $67,471 for pts discharged the same day, 17% less than the $81,175 for those who spent a night being observed in the hospital (P < 0.0001). Conclusions: Same day discharge after an uncomplicated PCI and 4 hour observation period was safe and resulted in significantly reduced charges.

To evaluate access site and other bleeding complications associated with radial versus femoral access in patients receiving oral anticoagulation (OAC) with warfarin.Patients receiving OAC with warfarin undergoing coronary angiography and percutaneous coronary intervention (PCI) may have OAC continued despite the risk of bleeding. To what extent arterial access site impacts bleeding in such patients is not well studied.Over 6 years, we identified 255 consecutive patients in whom warfarin was continued who underwent coronary angiography with an international normalized ratio1.8. A total of 97 patients also underwent PCI at the same setting (27% femoral vs 73% radial). The primary outcome was Bleeding Academic Research Consortium bleeds; a secondary end point was frequency of access site complications in the 72 hours post-PCI. Complications were evaluated based on the initial access site attempted.Minimal baseline clinical characteristics differences existed between the groups. International normalized ratio was significantly higher in the radial group (2.42 ± 0.67 vs 2.24 ± 0.49, P = .02). Bivalirudin use was greater during radial PCI than femoral (76% vs 42%, P.05), whereas unfractionated heparin alone was greater during femoral PCI than radial (46% vs 18%, P.05). No significant difference was seen in the primary end point between femoral (2.8%) and radial (1.6%, P = .54) during coronary angiography alone. However, PCI via the femoral artery had significantly more Bleeding Academic Research Consortium bleeding (19.2% vs 1.4%, P = .005) and transfusions (15% vs 0%, P = .004) than via the radial artery. Patients who underwent PCI using radial access were less likely to have any vascular or bleeding complications (1% vs 23%, P = .001).Patients who underwent coronary angiography during uninterrupted OAC had similar bleeding rates regardless of access site. However, when PCI was performed, radial access was associated with fewer bleeding and vascular complications than the femoral approach.We retrospectively identified 255 consecutive patients on warfarin who underwent coronary angiography, 97 of whom underwent a percutaneous coronary intervention. The data reveal a reduction in Bleeding Academic Research Consortium bleeds (1.6% vs 8.1%, P = .02) with radial versus femoral access. The radial approach was associated with an overall lower rate of any vascular or bleeding complication than the femoral approach during percutaneous coronary intervention (1% vs 23%, P = .001).

Dual antiplatelet therapy is a standard of care for treating patients with acute coronary syndrome (ACS). Combination therapy with aspirin and one of the P2Y(12) inhibitors (clopidogrel, prasugrel, or most recently, ticagrelor ) has been recommended by both ACC/AHA and ESC guidelines for ACS patients.Ticagrelor is the first generation of a new class of reversible P2Y(12) inhibitors, recently added to updated ACC and ESC guidelines for use in patients with ACS. The authors review the studies that evaluate the pharmacokinetics, pharmacodynamics, clinical efficacy and safety of ticagrelor in comparison to currently available antiplatelet agents.Ticagrelor 180 mg loading dose followed by 90 mg b.i.d. is significantly more efficacious and, in general, as safe as clopidogrel in the treatment of all patients with an ACS regardless of treatment strategy. In addition, besides aspirin compared to placebo, it is the only pharmaceutical intervention shown to have a cardiovascular mortality benefit within 1 year in a broad ACS population. Whether this surprising benefit is realized in other populations is currently being tested.

Joanne Kwan1, Wah Wah Htun2, Yili Huang3, Wilson Ko3, Tak W Kwan31Boston University, Boston, MA, USA; 2Lutheran Medical Center, Brooklyn, NY, USA; 3Beth Israel Medical Center, New York, NY, USABackground: The purpose of this study was to examine the effect of proton pump inhibitors (PPI) on the antiplatelet activity of clopidogrel in a consecutive series of Chinese patients after they had received coronary stents.Methods: A sample of 51 consecutive Chinese patients treated with coronary stents and taking PPI and clopidogrel for more than 30 days were enrolled in this study. Mean values for platelet residual units and percentage inhibition before PPI (+PPI) and 14 days after discontinuation of PPI (-PPI) were compared using the paired t-test.Results: There was no effect of concomitant use of esomeprazole and clopidogrel or omeprazole and clopidogrel on the inhibition assay, but platelet residual units and percentage inhibition showed statistically significant improvement after stopping lansoprazole in Chinese patients who were on chronic clopidogrel therapy. Clopidogrel resistance existed more frequently in the Chinese-American population examined, and was as high as 68% (+PPI) to 73% (-PPI).Conclusion: The clopidogrel resistance found is cause for concern, although its relationship with clinical events is currently unknown in this population. Further study with other thienopyridines or genetic variant analysis is suggested.Keywords: proton pump inhibitors, clopidogrel resistance, Chinese population, percutaneous coronary intervention

We report a case of severe leptospirosis acquired in an urban setting at a Halal poultry farm. After the initiation of antibiotic treatment, the patient developed a Jarisch-Herxheimer reaction and subsequent acute respiratory distress syndrome. He improved dramatically after receiving contin