Spontaneous Coronary Artery Dissection Treated With Bioresorbable Vascular Scaffolds Guided by Optical Coherence Tomography

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndromes. We report the first case, to our knowledge, of SCAD in an active fit man. We treated this patient with novel bioresorbable vascular scaffold, guided by optical coherence tomography.     

Creation of a primary tumor tissue expression biomarker-augmented prognostic model for patients with metastatic renal cell carcinoma

BackgroundClinical and pathological factors alone have limited prognostic ability in patients with metastatic clear cell renal cell carcinoma (ccRCC). Bim, a downstream pro-apoptotic molecule in the PD-1 signaling pathway, has recently been associated with survival in other malignancies. We sought to determine if tissue biomarkers including Bim, added to a previously reported clinical metastases score, improved prediction of cancer-specific survival (CSS) for patients with metastatic ccRCC.MethodsPatients with metastatic ccRCC who underwent nephrectomy between 1990 and 2004 were identified using our institutional registry. Sections from paraffin-embedded primary tumor tissue blocks were used for immunohistochemistry staining for Bim, PD-1, B7-H1 (PD-L1), B7-H3, CA-IX, IMP3, Ki67, and survivin. Biomarkers that were significantly associated with CSS after adjusting for the metastases score were used to develop a biomarker-specific multivariable model using a bootstrap resampling approach and forward selection. Predictive ability was summarized using a bootstrap-corrected c-index.ResultsThe cohort included 602 patients: 192 (32%) with metastases at diagnosis and 410 (68%) who developed metastases after nephrectomy. Median follow-up was 9.6 years (IQR 4.2–12.8), during which 504 patients died of RCC. Bim, IMP3, Ki67, and survivin expression were significantly associated with CSS after adjusting for the metastases score, and were eligible for biomarker-specific model inclusion. After variable selection, high Bim (hazard ratio [HR] = 1.44; 95% confidence interval [CI] 1.16–1.78; P <0.001), high survivin (HR = 1.35; 95% CI 1.08–1.68; P = 0.008), and the metastases score (HR = 1.13 per 1 point; 95% CI 1.10–1.16; P <0.001) were retained in the final multivariable model (c-index = 0.69).ConclusionWe created a prognostic model combining the clinical metastases score and 2 primary tumor tissue expression biomarkers, Bim and survivin, for patients with metastatic renal cell carcinoma who underwent nephrectomy.     

Recent developments in drug-eluting stents

Percutaneous coronary intervention (PCI) is an important treatment approach in the management of symptomatic coronary artery disease (CAD). A significant development in PCI in the mid 1970s was balloon angioplasty, followed by bare-metal stents a decade later, and now, the widespread use of drug-eluting stents (DES). While PCI has conferred remarkable benefit to millions of CAD patients, restenosis, and late stent thrombosis associated with DES remain problematic, and improvements are keenly sought. This article reviews recent developments in DES.     

Myocardial perfusion is a useful screening test for the evaluation of cardiovascular risk in patients undergoing simultaneous pancreas kidney transplantation

Cardiovascular disease is the leading cause of death in simultaneous pancreas kidney transplantation (SPKT) patients. SPKT is increasingly being undertaken to manage patients with advanced diabetic nephropathy and type 1 diabetes mellitus. Traditionally, invasive angiography has been used as a tool to diagnose significant coronary disease and inform decision making with regard to coronary revascularization prior to transplantation. In our retrospective analysis of 167 consecutive patients who underwent SPKT in our center, we show that using myocardial perfusion scintigraphy (MPS) as the first-line screening tool is highly sensitive without exposing the patient to undue investigative procedural risks (or an unacceptably high false-negative rate) and it provides 1-year cardiovascular outcomes that are comparable with those of patients managed via the more traditional but riskier invasive route.     

Interaction between statins and clopidogrel: is there anything clinically relevant?

Since their introduction several years ago, the 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors-the statins-have been widely used for hyperlipidemia and for the primary/secondary prevention of cardiovascular diseases. They have been shown to be safe as well as efficacious in a number of different clinical trials; however, studies have suggested that they can interact with other co-administered therapies. More recently, the thienopyridines have been successfully integrated with the conventional medical treatment of coronary disease as they showed effectiveness in reducing platelet activity both in stable and unstable settings. They also improve the outcome of patients treated with percutaneous coronary intervention. The potential interaction of statins and thienopyridines is a matter of concern. Despite some preclinical data suggesting an interaction between statins metabolized by the liver cytochrome P3A4-such as atorvastatin, lovastatin and simvastatin-and clopidogrel, there is no compelling clinical evidence to stop their co-administration.     

Repeat thrombolysis or conservative therapy vs. rescue percutaneous coronary intervention for failed thrombolysis: systematic review and meta-analysis

Background: Despite proven advantages of primary percutaneouscoronary intervention (PCI), thrombolysis remains the firstline treatment for ST-elevation myocardial infarction (STEMI)worldwide. Management of patients with failed thrombolysis isstill debated, and data from existing randomized controlledtrials are conflicting. Aim: To compare the risk/benefit profile of repeat thrombolysis(RT) vs. rescue PCI in patients with failed thrombolysis. Methods: Search of BioMedCentral, CENTRAL, mRCT and PubMed forrandomized controlled trials comparing rescue PCI vs. conservativetherapy and/or RT vs. conservative therapy. Outcomes of interestassessed by adjusted indirect meta-analysis: major adverse events(MAE, defined as the composite of overall mortality and re-infarction),stroke, congestive heart failure (CHF), major bleeds (MB), andminor bleeds. Overall mortality and re-infarction have beenalso analysed individually. Results: Eight trials were included (1318 patients). Follow-upranged from ‘in-hospital’ to 6 months. No significantdifference was found for the risk of MAE [OR 0.93(0.26–3.35),P = 0.4], overall mortality [OR 1.01(0.52–1.95), P = 0.15],stroke [OR 5.03(0.64–39.1), P = 0.58] and CHF [OR 0.74(0.28–1.96),P = 0.6]. Compared with conservative therapy, rescue PCI wasassociated with a 70% reduction in the risk of re-infarction[OR 0.32(0.14–0.74), P = 0.008], number needed to treat17. No difference in terms of MB was found [OR 0.5(0.1–2.5),P = 0.09], while a greater risk of minor bleeds was observedwith rescue PCI [OR 2.48(1.08–5.7), P = 0.04], numberneeded to harm 50. Conclusion: Although the observed benefit is modest, these datasupport the use of PCI after failed thrombolysis.