Prediction of the Individual Risk of Bleeding in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Cardiovascular Drugs and Therapy -     

Immunomodulatory treatment for lymphocytic myocarditis—a systematic review and meta-analysis

Deleterious inflammatory responses are seen to be the trigger of heart failure in myocarditis and therapies directed towards immunomodulation have been assumed to be beneficial. The objective of the present review was to systematically assess the effect of immunomodulation in lymphocytic myocarditis. Studies were included if diagnosis of lymphocytic myocarditis was based on EMB as well as on the exclusion of other etiologies of heart failure and if the patients had at least moderately decreased left ventricular ejection fraction (<?45%). All immunomodulatory treatments at any dose that target the cause of myocarditis leading to cardiomyopathy were included. Retrieval of PUBMED, SCOPUS, Cochrane Central Register of Controlled Trials, and LILACs from January 1950 to January 2016 revealed 444 abstracts of which nine studies with a total of 612 patients were included. As primary effectivity endpoint, a change in left ventricular ejection was chosen. No benefits of corticosteroids or intravenous immunoglobulin alone were reported. Immunoadsorption and subsequent IVIG substitution was associated with a greater improvement in left ventricular ejection fraction (LVEF) in one study. Single studies found a beneficial effect of interferon and statins on LVEF. We performed a meta-analysis for the combination of corticosteroids with immunosuppressants and found a non-significant increase of LVEF of +?13.06% favoring combined treatment (95%CI 1.71 to +?27.84%, p?= 0.08). The current evidence does not support the routine use of immunosuppression in traditional lymphocytic myocarditis. Nevertheless, in histologically proven virus-negative myocarditis of high-risk patients, combined immunosuppression might be beneficial. Future research should focus on translation of these effects to clinical outcome.     

The distribution of sensory and motor axons of the intercostal nerves and their branches (author's transl)]

As it is well established that motor axons in general display a higher acetylcholinesterase-activity than sensory axons do, the histochemical method of KARNOVSKY and ROOTS (1964) was used for the differentiation of motor and sensory fibres in the intercostal nerves and their branches. In the paravertebral sections of the intercostal nerves of the upper segments 30--35% of the nerve fibres show a high enzyme activity and therefore were classified as motoric. The percentage of the motor fibres in comparable zones of the lower segments increases to 45%. Only 15% of the nerve fibres proved to be motoric in the parasternal sections of the intercostal nerves. In a histogram of the acetylcholinesterase-positive intercostal nerve fibres 2 peaks can be seen: one in the alpha-calibre class, the second in the gamma-class. There are more motor axons in the lateral cutaneous branch of the lower intercostal nerve than in upper ones. This may be explained by the participation of these nerve branches in the innervation of the abdominal muscles. In 2 cases nerve branches of the intercostal nerve to the diaphragm were found containing 15--25% motor axons.     

The prognostic impact of left ventricular thrombus resolution after acute coronary syndrome and risk modulation via antithrombotic treatment strategies

BackgroundLeft ventricular thrombus (LVT) is a rare but dreaded complication during the acute phase of acute coronary syndrome (ACS). However, profound data on long‐term outcome and associated antithrombotic treatment strategies of this highly vulnerable patient population are scarce in current literature.MethodsPatients presenting with ACS were screened for presence of LVT and subsequently included within a prospective clinical registry. All‐cause mortality and the composite of major adverse cardiac events (MACE) and thromboembolic events were defined as primary and secondary endpoint.ResultsWithin 43 patients presenting with LVT, thrombus resolution during patient follow‐up was observed in 27 individuals (62.8%). Patients that reached a resolution of LVT experienced lower incidence rates of death (−23.9%; p = .022), MACE (−37.8%; p = .005), and thromboembolic events (−35.2%; p = .008). Even after adjustment for clinical variables, thrombus resolution showed an independent inverse association with all‐cause death with a hazard ratio (HR) of 0.14 (95% CI: 0.03–0.75; p = .021) and as well with MACE with a HR of 0.22 (95% CI: 0.07–0.68; p = .008) and thromboembolic events with a HR of 0.22 (95% CI: 0.06–0.75; p = .015). Triple antithrombotic therapy (TAT) with ticagrelor/prasugrel showed a strong and independent association with thrombus resolution with an adjusted HR of 3.25 (95% CI: 1.22–8.68; p = .019) compared to other strategies.ConclusionThe presented data indicate a poor outcome of ACS patients experiencing LVT. In terms of a personalized risk stratification, thrombus resolution has a strong protective impact on both all‐cause death and MACE with the potential to tailor treatment decisions—including an intensified antithrombotic treatment approach—in this patient population.