1,721,049 research outputs found
Does the evidence really suggest that we should completely revascularise bystander disease in patients with ST elevation myocardial infarction undergoing primary angioplasty? Why we still need more definitive trial data to change routine practice
No full textIntroduction: There remains considerable heterogeneity in the management of significant lesions in non culprit coronary arteries in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). Three recent randomised trials have shown clinical outcome benefit in a complete revascularisation approach when compared to PPCI of the culprit artery alone. By contrast, observational data suggest that an aggressive complete revascularisation may not confer clinical benefit and may, in some cases, be harmful.Areas covered: In this review we discuss the three recent randomised trials that have advocated a complete revasculariation approach in addition to data available from registries.Expert commentary: An adequately powered, randomised controlled trial is required to answer the question of whether complete revascularisation in STEMI patients is beneficial and, if so, whether it should be ischaemia directed and whether it should be at the index procedure or staged.<br/
Stent thrombosis patients with hyporesponsiveness to Clopidogrel, Prasugrel, and Ticagrelor: a case series using short thromboelastography
No full textPatients after percutaneous coronary intervention (PCI) with stent implantation and functional hyporesponsiveness to P2Y12 inhibitors are at higher risk of ischaemic events, particularly stent thrombosis (ST). It is currently not routine practice to assess the functional response to these agents. However, concern over functional hyporesponsiveness to clopidogrel has led to widespread uptake of prasugrel and ticagrelor as the default P2Y12 inhibitor after stent implantation in patients with acute coronary syndrome. Here we report, for the first time, 3 cases in which patients who have had ST exhibit hyporesponsiveness to clopidogrel, prasugrel, and ticagrelor
Treatment of non-culprit lesions in STEMI: An incomplete journey
No full textApproximately 50% of patients presenting with an acute ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). A number of randomized studies (Table 1) have all shown that complete revascularization (CR), either at the time of primary percutaneous coronary revascularization (PPCI) or within 45 days of the index admission, is safe and reduces the risk of repeat coronary revascularization and myocardial infarction (MI), particularly in the non-infarct related artery (NIRA). Despite consistently showing clinical benefit for CR, the results from the trials show variations in what drives this effect. Specifically, no study to date has provided a mechanistic insight as to how complete revascularization of chronic bystander disease may lead to the observed clinical benefit. Indeed, the randomized studies, through the variable nature of their results (reduction in MI versus revascularization etc.), have suggested the possibility that there are differing mechanisms for the observed benefit. In this review, we summarize the evidence base, highlight the limitations, and make the case that we need to understand the mechanism(s) underpinning the advantage of revascularization of NIRA in order to establish which patients are most likely to benefit. Without this insight, the current "one size fits all" approach may lead us in the wrong direction.</p
Optimizing myocardial recovery post-ST-elevation myocardial infarction – an unfulfilled promise
No full textDerivation and validation of the novel Functional FFRCT Score incorporating the burden of coronary atheroma and flow impairment to predict adverse cardiovascular events
No full textThe current diagnostic pathways for patients with suspected coronary artery disease (CAD) exhibit considerable variation and often involve a stepwise approach, utilizing both anatomical and ischemia tests to assess risk and guide management decisions. Coronary computed tomography angiography (CCTA) has emerged as the preferred anatomical test for a broad spectrum of patients presenting with symptomatic CAD, with a consistent rise in utilization over the past decade. By adding fractional flow reserve derived from computed tomography (FFRCT) to the CCTA datasets for selected patients, it becomes possible to evaluate the functional implications of atheroma by estimating the reduction in coronary flow. Several parameters derived from CCTA, such as stenosis location and severity, as well as various levels of FFRCT reduction, have been shown to correlate with adverse prognosis. However, the relative roles of atheroma and ischemia in predicting downstream adverse events and guiding patient management remain unclear. While several risk prediction models based on CCTA data have been developed, the exclusively anatomical and simple CAD-RADS system is the most widely used in clinical practice. Models integrating both functional and anatomical severity of CAD have been proposed but are complex and have not been widely adopted clinically.The main objectives of the analyses presented in this thesis are as follows. Firstly, to develop a risk prediction tool called the Functional FFRCT Score (FFS) that combines estimates of atheroma and ischemia burden from CCTA and FFRCT. Secondly, to validate the novel scoring model in two large cohorts of patients with symptomatic CAD by assessing its association with adverse cardiovascular events. Thirdly, to investigate sex-stratified differences between anatomical CAD severity on CCTA and estimated epicardial flow impairment via FFRCT. Lastly, to explore the role of FFS in stratifying management and predicting adverse events in female versus male patients.Chapter 3 outlines the feasibility phase, where four candidate scoring systems were evaluated based on computation speed, reproducibility, and correlation with established models like CAD-RADS and CT-SYNTAX scores. The best-performing model, subsequently named the Functional FFRCT Score, was chosen for further validation.Chapter 4 details the validation of the FFS in relation to revascularization and adverse cardiovascular events in two distinct cohorts of patients with symptomatic CAD.Chapter 5 delves into analysing the sex-related differences in computed tomography coronary stenosis severity versus flow impairment and their impact on revascularization, clinical events, and healthcare costs.Chapter 6 demonstrates that, despite disparities in atheroma and ischemia burden between men and women, the FFS remains an independent predictor of adverse clinical events in both sexes.The results presented in this thesis suggest that the FFS is a promising risk stratification tool. Further validation in larger cohorts of symptomatic CAD patients, and potentially even in asymptomatic patients at risk of CAD, is warranted.<br/
The role of DNA damage and repair in atherosclerosis: a review
No full textThe global burden of cardiovascular disease is increasing despite therapeutic advances in medication and interventional technologies. Accumulated deoxyribonucleic acid (DNA) damage and subsequent repair pathways are now increasingly recognised as a causal factor in the initiation and progression of atherosclerosis. These molecular alterations have been shown to occur within affected vasculature, plaque microenvironment as well as in circulating cells. The DNA damage response (DDR) pathway is reliant on post-translational modification of sensing proteins which activate a signalling cascade to repair, if possible, DNA damaged sites in response to various environmental and physiological insults. This review summarises the current evidence for DNA damage in atherosclerosis, the key steps involved in the DDR pathway, DNA repair and their subsequent effects on atherosclerotic plaques, as well as the therapeutic options in managing DNA damage-induced atherosclerosis
Isolated coronary artery aneurysms presenting with ST-elevation myocardial infarction – a case of when less is more
No full text- …
