Journal articles on the topic 'Infarctus du myocarde de type 2'

la survenue d’un infarctus du myocarde chez un militaire en opération extérieure n’est pas une situation exceptionnelle. Patients et méthode : la prise en charge des militaires européens admis pour un infarctus du myocarde à l’hôpital militaire français de Djibouti a été évaluée de manière prospective pendant deux ans (2009, 2010). Résultats : parmi 35 patients admis pour un infarctus du myocarde, quatre (11 %) étaient des militaires masculins (29-46 ans), avec au moins deux facteurs de risque cardiovasculaire. Ils ont tous bénéficié d’une thrombolyse en urgence (délai 2 h 30- 6 h 30) avec succès confirmé par la coronarographie réalisée après évacuation sanitaire vers un centre européen (délai 36- 72 heures). Une angioplastie coronaire a été réalisée dans trois cas et l’évolution a été favorable dans tous les cas avec un recul de neuf mois. Conclusion : à Djibouti, la prise en charge de l’infarctus du myocarde aigu chez des militaires européens, incluant un traitement thrombolytique dans tous les cas, a été efficace malgré l’absence de possibilité d’angioplastie coronaire primaire sur site.

La rupture septale secondaire a linfarctus du myocarde est une complication aigue redoutable dont la mortalite est non negligeable a la phase precoce. Nous rapportons le cas dune rupture septale chez une patiente de 66 ans admis aux urgences pour prise en charge dun post infarctus de myocarde anterieur etendu qui a decede dansun tableau de choc cardiogenique. Ce cas illustre la gravite des complications mecanique de linfarctus de myocarde. Nous mettons le point sur les facteurs de risque et sur le traitement a proposer pour ce type de complication.

La place des anticorps thérapeutiques dans les maladies cardiovasculaires et métaboliques est encore modeste en 2019 en comparaison à leur incroyable développement dans d’autres champs pathologiques. Cependant, l’arrivée récente des anticorps anti-PCSK9 (proprotein convertase subtilisin/kexin de type 9) dans l’arsenal thérapeutique va probablement changer la donne. Ces anticorps permettent non seulement d’améliorer la prise en charge des patients porteurs d’hypercholestérolémie familiale mais également de réduire le risque de complications cliniques de l’athérosclérose en prévention secondaire après un infarctus du myocarde, une artériopathie périphérique ou un accident vasculaire cérébral ischémique. D’autres stratégies thérapeutiques sont en cours d’investigation, ciblant notamment des cellules et cytokines impliquées dans les réponses immuno-inflammatoires avec pour objectif de prévenir les complications de l’athérosclérose ou les lésions du myocarde au décours d’un infarctus.

Les descriptions de l’incidence, de la gravité et des modalités de prise en charge des blocs auriculoventriculaires du troisième degré (BAV3) compliquant la phase aiguë des infarctus du myocarde, avec sus-décalage du segment ST (STEMI), sont rares et anciennes. Par ailleurs, les modalités de prise en charge des STEMI aigus ont beaucoup évolué. Le but de notre étude est d’évaluer l’incidence, de décrire la gravité et les modalités de prise en charge des BAV3 survenant à la phase aiguë des STEMI dans un contexte contemporain. Matériel et méthodes : Nous avons réalisé une étude observationnelle rétrospective de la prise en charge des STEMI aigus à partir du registre prospectif des STEMI du Réseau nord alpin des urgences (RENAU) sur les 19 hôpitaux des Alpes du Nord entre 2009 et 2012. Les patients présentant un BAV3 à la phase initiale de leur prise en charge ont été identifiés. Résultats : Deux mille sept cent neuf patients avec STEMI aigu ont été inclus sur la période d’étude. Cinquante-sept ont présenté un BAV3 (2 %). Cent cinquante-deux des 2 648 patients sans BAV3 (6 %) sont décédés à la phase hospitalière contre 7 des 57 patients (12 %) avec BAV3 (p = 0,047). Parmi les patients en BAV3, un traitement par atropine a été utilisé pour 26 patients et s’est révélé efficace pour (15 %) d’entre eux. L’isoprénaline a été utilisée pour huit patients et a induit une hypotension artérielle pour quatre d’entre eux. Une stimulation ventriculaire droite percutanée a été utilisée pour six patients et a toujours été efficace. Quatorze patients ont été thrombolysés (25 %). Une angioplastie de sauvetage a été nécessaire chez 10 des 14 patients en BAV3 traités par thrombolyse (71 %), comparés aux 325 des 840 patients sans BAV3 traités par thrombolyse (39 % ; p = 0,013). Conclusion : L’incidence des BAV3 à la phase aiguë des STEMI est faible. Le BAV3 représente un facteur de sévérité. Les stratégies thérapeutiques sont d’efficacité inégale, avec des effets indésirables induits par l’isoprenaline. La thrombolyse chez ces patients est moins efficace.

Introduction La vaccination annuelle contre la grippe est recommandée aux personnes ayant des antécédents de maladie cardiovasculaire. Nous avons étudié 1) l’évolution de la vaccination antigrippale entre 2009 et 2018 chez les Canadiens ayant été victimes d’une maladie cardiovasculaire et 2) les déterminants de la vaccination dans cette population au cours de la période. Methods Nous avons utilisé des données de l’Enquête sur la santé dans les collectivités canadiennes (ESCC). L’échantillon à l’étude était constitué de répondants de 2009 à 2018, âgés de 30 ans et plus, ayant été victimes d’une maladie cardiovasculaire (infarctus du myocarde ou accident vasculaire cérébral) et ayant fourni leur statut vaccinal contre la grippe. Une analyse pondérée a été effectuée pour déterminer l’évolution du taux de vaccination. Nous avons utilisé une analyse de régression linéaire pour l’évolution et une analyse de régression logistique à plusieurs variables pour les déterminants de la vaccination antigrippale. Les variables choisies étaient des facteurs sociodémographiques, des caractéristiques cliniques, des comportements liés à la santé et les interactions avec le système de santé. Results Durant la période à l’étude, le taux de vaccination a été généralement stable dans notre échantillon de 42 000 sujets, se situant aux alentours de 58,9 %. Plusieurs déterminants de la vaccination ont été établis : un âge avancé (rapport de cotes ajusté [RCA] = 4,28; intervalle de confiance à 95 % [IC à 95 %] : 4,24 à 4,32], un accès régulier à un professionnel de la santé (RCA = 2,39; IC à 95 % : 2,37 à 2,41) et le fait de ne pas fumer (RCA = 1,48; IC à 95 % : 1,47 à 1,49). Le seul facteur associé à une diminution de la probabilité de vaccination était le travail à temps plein (RCA = 0,72; IC à 95 % : 0,72 à 0,72). Conclusion Le taux de vaccination antigrippale reste inférieur au niveau recommandé pour les patients ayant des antécédents de maladie cardiovasculaire. D’autres recherches sont à mener sur l’efficacité des interventions pour augmenter la vaccination dans cette population.

Abstract Background Sport-related (SR) acute cardiovascular (CV) events are the main cause of sudden cardiac death in the setting of sport activities. However, data are very scarce regarding onset and follow-up of SR acute myocardial infarction (AMI). Methods From the prospective study IMACS (Infarctus du Myocarde et Arret Cardiaque au cours du Sport) patients admitted for a SR-AMI in our university hospital from April 2018 to March 2020 were included. A 12 months follow-up (FU) was achieved through telephone interview to address CV outcomes and sport practice information. Information was obtained from relatives in case of out of hospital sudden cardiac arrest (OH-SCA). Results Among the 55 patients included, all were male, with median (IQR) age at 62 (55–69) y. Most common sports were cycling (n=21), fitness (n=7), swimming (n=5) and hiking (n=5). The SR-AMI occurred during effort for 39 subjects and during recovery for 16. Most SR-AMI occurred in public area (n=24), at home (n=16), or in a specific sport location (n=14). An Automated External Defibrillator (AED) was available in the SR-AMI location in only 10, but was missing in 43 (unknown for 2). In 1 subject with OH-SCA, cardiopulmonary resuscitation (CPR), initiated by witnesses, using a public AED, was unsuccessful. The 4 other patients with OH-SCA underwent successful CPR. Among the 55 subjects, 4 were vapers, of whom 1 was a dual user, 17 were current tobacco smokers, 18 were ex-smokers and 2 experienced cannabis and cocaine use. Among the smokers, most smoked (n=10) or consumed cannabis (n=1) <2h before the event. Strikingly, CV history and/or recent symptoms were present in almost half (n=25). Only 10 felt symptoms exclusively during the sport session. Moreover, a medical advice for recent symptoms was found only for 3 subjects. Three patients who experienced prior AMI have neglected symptoms during the index event. Most were ST segment elevated MI (n=35). Only one patient (with OH-SCA) died <3 days after hospital admission. During hospitalization, most underwent revascularization with coronary stenting (n=44) (drug eluting stent in 43 patients), or coronary artery bypass graft (n=6) and no death nor significant CV event occurred. At 1-FU, most attended a rehabilitation program (n=41) and the majority of smokers quitted (14/17), with 3 persistent smokers starting to vape. Almost half patients (n=23) decreased their physical activity, and 21 increased it. A significant rate of patient (n=9) added fitness in their usual activity, and as a main sport for 4 of them. Conclusions In this on-going monocentric prospective survey in SR-AMI, a high proportion of subjects had prodromal symptoms, of whom only few led to sport cessation and medical advices, when requested, failed to prevent the AMI. Our findings highlight that public and medical education are urgently warranted for SR-AMI prevention. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon Bourgogne Franche Comté et ARS Bourgogne Franche Comté

Objectif - Il a été démontré que le polymorphisme rs5963409 du gène codant l’Ornithine TransCarbamylase (OTC) est associé à l’hypertension et à la vasomotricité coronaire dans les populations caucasiennes. Sur la base de ces résultats, nous avonschoisi d’étudier l’association de deux polymorphismes rs5963409, localisé au niveau de la région 5’ du promoteur et rs1800321, localisé au niveau de l’exon 2, du gène OTC avec le risque de survenue d’infarctus du myocarde (IDM) et les valeurs de pressions artérielles systolique et diastolique.Population étudiée et Méthodes - Cette étude a été réalisée dans la population de l’étude ECTOR (Etude Cas Témoins sur l’Infarctus du myocarde en ORanie). La population étudiée est composée de deux groupes : 68 cas ayant survécu à un Infarctus Du Myocarde (IDM) et 67 sujets témoins ne souffrant d’aucune maladie apparente. La caractérisation génétique des deux polymorphismes a été réalisée par la technique PCR (Polymerase Chain Reaction) suivie d’une digestion enzymatique.Résultats - Les polymorphismes rs5963409 et rs1800321 ne sont pas associés ni à l’IDM ni aux variations des valeurs de pressions artérielles systolique et diastolique.Cependant, nous avons observé une interaction significative entre le polymorphisme rs5963409 et l’Indice de Masse Corporelle (IMC) sur le risque de survenue d’IDM.Conclusion - Nos résultats indiquent queles deux polymorphismes du gène de l’OTC ne sont pas associés à l’IDM dans la population Ouest-Algérienne.

Introduction : Malgré l'efficacité des mesures de prévention cardiovasculaire (CV), le contrôle des facteurs de risque (FR) CV reste insuffisant chez les patients à très haut risque. Objectif : Evaluer la prévalence de l'atteinte des cibles thérapeutiques recommandées pour les FRCV majeurs et modifiables 12 mois après un infarctus du myocarde (IDM). Méthodes : Du 1er janvier au 30 avril 2023, nous avons colligé des patients consécutifs ayant eu un IDM de type 1 et ayant totalisé 12 mois de suivi. Le critère de jugement primaire (CJP) était le taux d’atteinte de toutes les cibles thérapeutiques recommandées pour le diabète, l’hypertension artérielle (HTA), le LDL-C et le tabagisme. Les cibles thérapeutiques ont été définies conformément aux recommandations de la Société Européenne de Cardiologie de 2021. Résultats : 107 patients, d'âge moyen 58,8±8,8 ans, 74,8% de sexe masculin, ont été inclus. 42 (39,3%) avaient une HTA, 50 (46,7%) étaient diabétiques, 77 (72,0%) étaient fumeurs et huit (7,5%) avaient une hypercholestérolémie. À 12 mois, le CJP était atteint chez 20 (18,7%) patients. 55 (71,4%) des 77 patients fumeurs étaient sevrés. La pression artérielle était à la cible chez 26 (61,9%) patients parmi les hypertendus. Chez les patients diabétiques, l'objectif d'HbA1c était atteint chez 23 (46,0%) d'entre eux. 32 patients (29,9%) ont atteint l'objectif de LDL-C <0,55 g/l. Conclusions : La prévention secondaire des maladies CV était suboptimale. Moins du cinquième des patients ont atteint l'objectif thérapeutique pour les FRCV modifiables. Il est nécessaire d'améliorer la prise en charge après IDM.

<p><strong>ABSTRACT</strong></p><p><strong>Background:</strong> Influenza is a common respiratory infection that may cause complications, including cardiovascular events. Influenza illness has been shown to double the risk of myocardial infarction, with the highest risk among patients with established cardiovascular disease. Vaccination against influenza has been associated with reductions in myocardial infarction, cerebrovascular disease, and death.</p><p><strong>Objective:</strong> To evaluate the evidence for influenza vaccination as a strategy to reduce cardiovascular events specifically in patients with established cardiovascular disease.</p><p><strong>Data Sources and Study Selection:</strong> MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched with the terms “influenza vaccine” and “cardiovascular disease”. Included in this review were randomized controlled trials (RCTs), nonrandomized studies, and meta-analyses that compared influenza vaccination against control in patients with established cardiovascular disease and that reported clinically meaningful cardiovascular outcomes (defined as cardiovascular death, myocardial infarction, and stroke).</p><p><strong>Data Extraction and Synthesis:</strong> The search yielded 10 studies (3 nonrandomized studies, 5 RCTs, and 2 meta-analyses). The nonrandomized studies and the RCTs had inconsistent results with respect to cardio - vascular death and adverse cardiovascular events. The 2 meta-analyses, which included the same 4 RCTs involving patients with established cardiovascular disease, showed that the influenza vaccine reduced cardiovascu lar death by about 50% relative to control. Vaccination also reduced major cardiovascular events by about 43%; the reduction was greater (54%) in the subgroup of patients with recent (≤ 1 year) acute coronary syndrome. However, these data are potentially confounded by small sample sizes, low event rates, and variable outcome reporting. There was also high clinical heterogeneity among the studies, which may not reflect contemporary practice.</p><p><strong>Conclusions:</strong> Given the limitations of these data, it is unclear whether the cardiovascular benefit with influenza vaccination in patients with cardiovascular disease is a true effect. Nevertheless, because of the potential benefit and the low risk of adverse events, the annual influenza vaccine should be recommended for all patients with established cardiovascular disease.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte :</strong> La grippe est une infection courante des voies respiratoires qui peut causer des complications, notamment des événements cardiovasculaires. On a montré que la grippe double les risques d’infarctus du myocarde. De plus, les patients atteints d’une maladie cardiovasculaire sont les plus menacés. La vaccination contre la grippe a été associée à une réduction des cas d’infarctus du myocarde, de maladie cérébrovasculaire et de décès.</p><p><strong>Objectif :</strong> Évaluer les données probantes montrant que la vaccination contre la grippe permet de réduire le nombre d’événements cardiovasculaires chez les patients déjà atteints d’une maladie cardiovasculaire.</p><p><strong>Sources des données et sélection des études :</strong> Les bases de données MEDLINE et Embase et le Registre central Cochrane des essais aléatoires ont été interrogés en utilisant les termes « vaccin antigrippal » et « maladie cardiovasculaire ». Les études retenues pour la présente revue de la littérature devaient être des essais cliniques à répartition aléatoire, des essais cliniques non aléatoires ou des méta-analyses. De plus, elles devaient comparer les résultats de patients vaccinés contre la grippe et atteints d’une maladie cardiaque à ceux d’un groupe témoin qui étaient aussi atteints d’une maladie cardiaque. Enfin, elles devaient signaler des résultats cardiovasculaires cliniquement significatifs (définis comme un décès d’origine cardiovasculaire, un infarctus du myocarde ou un accident vasculaire cérébral).</p><p><strong>Extraction et synthèse des données :</strong> Dix études répondaient aux critères de recherche (trois essais cliniques non aléatoires, cinq essais cliniques à répartition aléatoire et deux méta-analyses). Les essais cliniques non aléatoires et les essais cliniques à répartition aléatoire présentaient des résultats variables en ce qui touche aux décès d’origine cardiovasculaire et aux événements cardiovasculaires indésirables. Les deux méta-analyses, qui avaient en commun quatre essais cliniques à répartition aléatoire concernant des patients atteints d’une maladie cardiovasculaire, montraient que le vaccin contre la grippe permettait de réduire le nombre de décès d’origine cardiovasculaire d’environ 50 % comparativement au groupe témoin. La vaccination a aussi réduit le nombre d’événements cardiovasculaires graves d’environ 43 %; le pourcentage était plus important (54 %) dans le sous-groupe de patients ayant récemment (à l’intérieur d’un an) souffert d’un syndrome coronarien aigu. Cependant, ces résultats sont potentiellement faussés par la petite taille des échantillons, les faibles taux d’événements et la variabilité avec laquelle on signale les résultats. Il y avait aussi une forte hétérogénéité clinique entre les études, ce qui pourrait ne pas être représentatif de la pratique actuelle.</p><p><strong>Conclusions</strong> : En raison des limites de ces données, on ignore si le vaccin antigrippal offre réellement des effets cardiovasculaires bénéfiques pour les patients atteints d’une maladie cardiovasculaire. Néanmoins, compte tenu des avantages potentiels et du faible risque d’événements indésirables, le vaccin annuel contre la grippe doit être recommandé pour tous les patients atteints d’une maladie cardiovasculaire.</p>

Abstract Background The Programmed cell death protein 1 (PD1) immune checkpoint is densely expressed on cardiac endothelial cells. The increasing clinical application of immune checkpoint inhibitor therapy targeting PD1 for the treatment of advanced malignancies has revealed profound cardiovascular side effects that have recently paralleled in a preclinical model. However, the effects of PD1 deficiency during baseline conditions and myocardial injury are so far unknown. Purpose This study aims to assess the impact of PD1 deficiency on myocardia immunity, and to evaluate the relevance of PD1 signalling in cardiac disease. Methods C57BL/6J wild-type mice and C57BL/6J Pdcd1−/− mice were purchased and bred at the animal facility. In-vivo ischaemia/reperfusion (I/R) injury was applied to assess the response in cardiac injury. In brief, mice were anesthetised followed by lateral thoracotomy and ligation of the left coronary artery for 45 min. For flow cytometry, hearts were removed and subjected to an enzymatic digestion. Single cell solutions were stained with different antibody panels to assess cardiac immune cells and the expression of programmed cell death protein 1 ligand 1 (PDL1). Western blot was conducted after homogenization of snap-frozen heart tissue using specific primary and corresponding secondary antibodies. Immunofluorescence and conventional haematoxylin and eosin stain from 4 μm sections were used to visualize the distribution of PDL1 in cardiac tissue. Results While no overt cardiac phenotype was observed in Pdcd1−/− mice, a profound upregulation of pro-inflammatory cytokines was determined during baseline conditions, including interleukin (IL) 1α IL4, and extracellular-signal regulated kinase (ERK) 1/2. NADPH oxidase 1 (NOX1) which is involved in production of reactive oxygen species and endothelial injury response was downregulated in Pdcd1−/− mice. Following I/R injury, a significant decline in endothelial PDL1 expression was observed, which was attributed to changes in the area at risk, as shown by immunofluorescence staining. The infarct size following in-vivo I/R injury was not altered upon PD1-deficiency as determined by TTC staining. However, flow cytometry determined increased cell numbers of distinct leukocyte subsets during reperfusion-related inflammation. Conclusion Deficiency of PD1/PDL1 signalling shows distinct inflammatory changes in cardiac tissue at baseline and I/R injury. The results indicate that relevant PD1-related detrimental effects are not limited to complications from cancer therapy but can be expected in various forms of cardiovascular disease, hence requiring further investigations. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany

Background: The optimal antithrombotic regimen for patients with coexistent atrial fibrillation (AF) and coronary artery disease (CAD) requiring percutaneous coronary intervention (PCI) remains controversial.Methods: We performed a chart review of 2,645 consecutive patients with non-ST elevation or ST elevation myocardial infarction at a regional cardiac centre, to examine the clinical characteristics and discharge antithrombotic medications of patients with coexistent AF (known or new onset AF with CHADS2 ≥1), treated with PCI.Results: Among 2,645 patients, 94 eligible patients were analyzed and 30 (32%) were prescribed triple therapy (TT) at hospital discharge. CHADS2 score was the major predictor of the decision to prescribe TT (P =0.002).Conclusion: Approximately one-third of the patients with AF undergoing PCI were prescribed TT at hospital discharge. Clinicians are generally following national guidelines and internationally-developed consensus statements, and focus on stroke risk despite the risks of bleeding and insufficient evidence supporting the benefits of TT. RésuméContexte : Le régime optimal antithrombotique pour les patients atteints à la fois de fibrillation atriale (FA) et d’une coronaropathie nécessitant une angioplastie coronarienne percutanée (ACP) demeure controversé.Méthodologie: Dans un centre régional de cardiologie, nous avons examiné les dossiers médicaux de 2645 patients ayant subi un infarctus du myocarde avec ou sans sus‑décalage du segment ST. Le but consistait à analyser les caractéristiques cliniques des patients présentant une FA concomitante (ancienne ou nouvelle, avec un indice CHADS2 ≥ 1) traitée par ACP, et les médicaments antithrombotiques prescrits au moment de leur sortie de l’hôpital.Résultats: Parmi les 2645 dossiers, 94 patients admissibles ont été analysés. Trente (32 %) s’étaient vus prescrire une trithérapie (TT) à leur sortie de l’hôpital. L’indice CHADS2 était le principal indicateur prévisionnel pris en compte dans la décision de prescrire la TT (P = 0,002).Conclusion : Environ un tiers des patients atteints de FA et ayant subi une ACP se sont vus prescrire une TT à leur sortie de l’hôpital. En général, les cliniciens suivent les directives nationales et les protocoles consensuels élaborés à l’international et se concentrent sur le risque d’ictus, malgré les risques de saignements et le manque de données probantes soutenant les avantages d’une TT.BACKGROUNDDual antiplatelet therapy (DAPT) including Aspirin and a P2Y12 receptor antagonist is recommended for patients who undergo percutaneous coronary intervention (PCI) with stent implantation.1,2 DAPT is superior to oral anticoagulants (OAC) in preventing stent thrombosis, 3while OAC is superior to DAPT in reducing stroke in patients with atrial fibrillation (AF).4,5 It is estimated that 5–8% of patients sustaining an acute coronary syndrome (ACS) have concomitant AF.6,7 The optimal antithrombotic regimen for patients with coexistent AF and coronary artery disease (CAD) requiring PCI remains controversial. In patients with AF and CHADS2 stroke risk score ≥1, consensus statements suggest that triple therapy (TT), defined as a combination of DAPT + OAC, be utilized in patients undergoing PCI with ACS.8,9 However, there is data indicating no improved efficacy of treatment with TT compared with DAPT alone, while exposing patients to increased bleeding risk.7,10,11 Major bleeding has been proven to be independently associated with death in patients following an ACS.12 Therefore, balancing the thromboembolic and bleeding risk is critical in patients with a recent ACS.Large randomized trials have indicated that compared with warfarin, novel oral anticoagulants (NOAC’s) are at least as effective as, and are associated with reduced rates of major, fatal and intracranial bleeding in patients with non-valvular AF.13 Due to the favourable safety profile, NOACs are being evaluated against warfarin in patients with AF undergoing PCI. Three of these trials are ongoing (RE-DUAL PCI, AUGUSTUS, ENTRUST-AF-PCI),14–16 and the fourth is the recently published PIONEER AF-PCI trial, which showed that reduced-dose rivaroxaban combined with clopidogrel lowered the risk of bleeding compared with TT with warfarin.17Despite the emergence of these recent data, the highest risk patients remain excluded from large randomized trials, and thus sound clinical judgment will remain the cornerstone in caring for these patients. In the current study, we aim to describe the local practice patterns of clinicians making treatment decisions for patients with new or existing AF, who present with an ACS and undergo PCI.METHODSA retrospective and prospective chart review was performed on 2,645 consecutive patients presenting with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial elevation (NSTEMI) to 3 academic hospitals affiliated with McMaster University and 8 community hospitals located in Local Health Integrated Network (LHIN) 4, Ontario, Canada from January to December 2014. Of those, 1,458 patients had undergone PCI with stent implantation; and, 124 patients were identified to have concomitant AF (Figure 1). Inclusion criteria for our study were: admission to hospital for either STEMI or NSTEMI, known or new onset AF with CHADS2 ≥ 1, coronary angiography demonstrating at least one epicardial coronary artery with a ≥70% stenosis, and successful PCI with stent implantation. Patients who expired before discharge were excluded from the analysis. Clinical and demographic characteristics of patients were summarized. DAPT and TT groups were identified by reviewing medication records from discharge summaries or copies of discharge prescriptions. DAPT was defined as Aspirin plus clopidogrel (75 mg once daily) or ticagrelor (90 mg twice daily), while TT was defined as DAPT plus an OAC; including either warfarin or novel oral anticoagulants (NOAC). We analyzed the CHADS2 and ATRIA (Anticoagulation and Risk factors in Atrial fibrillation) scores according to treatment groups.18,19 Statistical analysis was performed using SAS/STAT version 9.3 (SAS Institute Inc., Cary, NC). Categorical data was compared using Chi-square testing. Continuous data comparison was performed applying the Wilcoxon test and Cochran-Armitage test for trends. A binary logistic regression model was developed to identify the clinical predictors of discharge groups based on their CHADS 2 and ATRIA scores (Figure 2 and Figure 3). The cut-off for statistical significance was a P-value of <0.05.Figure 1. Flow chart of study cohort. Figure 2. Use of triple therapy versus dual antiplatelet therapy at the time of discharge in different stroke risk groups predicted by their CHADS2 score. Figure 3. Use of triple therapy versus dual antiplatelet therapy at the time of discharge in different bleeding risk groups predicted by their ATRIA score. RESULTSDemographic and clinical characteristics of patients are described in Table 1. Ninety four out of 124 patients with ACS and a prior or new diagnosis of AF were included in the final analysis. The mean (s.d.) age was 74 years (10 years) and 55.3% were male. In our cohort, 59.6% of patients sustained a STEMI and 54.3% had single vessel CAD. Overall, 32% (n = 30) of patients were discharged on TT of whom 55.6% were prescribed a combination of DAPT and a NOAC while the remaining patients were prescribed conventional TT (DAPT+warfarin) (Table 2). The median CHADS2 score in the DAPT and TT groups were 2 and 3, respectively (P = 0.001). The median ATRIA bleeding risk in DAPT and TT groups were 3 and 4, respectively (P = 0.008). The P-value for trend of CHADS 2 and ATRIA scores were <0.0001 and 0.001, respectively. However, these 2 trends were not significantly different from one another (P = 0.26). In a logistic regression analysis with both CHADS 2 and ATRIA scores included in the model, the CHADS2 score was significantly different between both groups (P = 0.002), while the ATRIA score was not (P = 0.58). In patients who were prescribed TT, 36.6% had a history of stroke or TIA compared with 10.9% in the DAPT group (P = 0.005). Additionally, the patients who were discharged on TT were more likely to have been treated with an OAC prior to admission, compared with those in the DAPT group (70% vs 17.1%; P < 0.001). We observed that there was proportionally more use of a BMS in patients with AF (41.5% of the 94 patients) compared with BMS being used in the whole cohort (15% of the 1,458 patients).There was no statistically significant difference in the likelihood of being discharged on TT based on whether patients were hospitalized at a community or academic hospital (44% vs. 56%, P = 0.42). Academic hospitals had the availability of a thrombosis service and they provided a consultation on 18% of the patients analyzed at those hospitals. The thrombosis service was generally involved in the care of patients with higher CHADS2 scores,and the involvement of the thrombosis service was associated with a significantly increased use of TT (P = 0.002). DISCUSSIONOur results indicate that approximately one-third of patients were prescribed TT at hospital discharge, while the remaining patients received DAPT alone. No patients received a combination of single antiplatelet therapy and an OAC. Although both the CHADS2 and ATRIA scores were significantly higher in the TT group, the CHADS2 score more strongly predicted the use of TT in our local practice. Our results also showed that OAC use prior to admission increased the probability of TT use upon discharge. Furthermore, the current study reveals that in patients discharged on TT, a combination of Aspirin, a P2Y12 inhibitor and NOAC were prescribed more often than conventional TT with warfarin despite the lack of clear evidence about their safety profile. 20,21An analysis of the AVIATOR registry, which included patients with a similar mean CHADS2 score as in our study (2.7 in the AVIATOR registry vs. 2.3 in our cohort) reported that 41.2% of patients were prescribed TT at discharge,22 compared with 31.9% in our cohort. This indicates that some practice variability exists among clinicians when considering treatment with TT in patients with similar risk profiles. The AVIATOR registry data also demonstrated that patients who were discharged on TT had a higher risk of stroke defined by their CHADS2 score but in contrast to our results, their bleeding risk score was not higher than the DAPT group. Our results were, however, consistent with another retrospective study within a large registry, which reported greater use of OAC at discharge among patients with both higher stroke and bleeding risk. 23 This observation highlights the important point that many major predictors of stroke, such as advanced age, are also important risk factors for bleeding.TT in our local clinical practice was used more selectively and was predominantly for those patients with a high CHADS2 score (≥3). Our data also show that clinicians favoured use of TT even in patients with higher bleeding risk despite the lack of robust evidence.24Our study was designed to describe practice patterns only, and therefore, one limitation was the inability to report patient outcomes following hospital discharge. Secondly, given the observational and retrospective nature of our study and the relatively small study cohort we are only able to describe associations. Thirdly, there are unmeasured variables such as frailty, patients’ overall goals of care, and personal preferences that could contribute to the ultimate decision for a given antithrombotic regimen, which were not captured in our study. Fourthly, the type and dose of NOAC were not collected in our study. Our study was unique in assessing practice parameters such as discharge settings (academic versus community hospitals) and describing the effect of the involvement of a thrombosis service in making treatment decisions.The choice of the most favourable antithrombotic regimen in patients with AF and ACS undergoing PCI remains an area of clinical debate. There were no patients in our study cohort discharged on a combination of a P2Y 12 inhibitor and warfarin alone, a regimen evaluated in the previously published WOEST trial.25 This observation indicates either a knowledge gap or reluctance among clinicians in applying the results of the WOEST study. The results of the PIONEER AF-PCI trial suggest that a WOEST study type strategy of reduced-dose rivaroxaban with single antiplatelet therapy (clopidogrel) is an attractive alternative to warfarin because of the substantial reduction in major bleeding. This trial has been criticized because it was not powered for ischemic events, had an open-label design, and tested doses of rivaroxaban that had not been previously evaluated.26 However, PIONEER AF-PCI and ongoing trials in this area will hopefully strengthen the body of evidence and lead to more informed clinical decision making and improved patient care. Despite the growing evidence in this area, the uptake will remain slow among clinicians until emergence of further robust evidence and variability of practice will persist as partially reflected in the current study.DisclosureThere was no dedicated funding for this study.None of the authors have any disclosures relevant to this study.REFERENCES1. Tanguay JF, Bell AD, Ackman ML, et al. Focused 2012 Update of the Canadian Cardiovascular Society Guidelines for the Use of Antiplatelet Therapy. Can J Card 2013; 29(11):1334–34.2. Windecker S, Kolh P, Alfonso F, et al. European Society of Cardiology Working Group on Thrombosis. 2014 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2014;35(37):2541–619.3. Schomig A, Neumann FJ, Kastrati A, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary artery stents. N Engl J Med 1996;334:1084–9.4. Connolly S, Pogue J, Hart R, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006;367:1903–12.5. Verma A, Cairns JA, Mitchell LB, et al. 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Card 2014;30(10):1114–30.6. McManus DD, Huang W, Domakonda KV, et al. Trends in atrial fibrillation in patients hospitalized with an acute coronary syndrome. Am J Med 2012;125(11):1076–84.7. Chen CF, Chen B, Zhu J, et al. Antithrombotic therapy after percutaneous coronary intervention in patients requiring oral anticoagulant treatment. Herz 2015;40(8):1070–83.8. Faxon DP, Eikelboom JW, Berger PB, et al. Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting: A North-American perspective. Thromb Haemost 2011;106:572–84.9. Lip GY, Windecker S, Huber K, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association(EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 2014;35:3155–79.10. Hess CH, Peterson ED, Peng SA, et al. Use and outcomes of triple therapy among older patients with acute myocardial infarction and atrial fibrillation. J Am Coll Cardiol 2015;66:616–27.11. Lamberts M, Olesen JB, Ruwald MH, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation 2012;126(10):1185–93.12. Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006;114(8):774–82.13. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.14. ClinicalTrials.gov. Evaluation of Dual Therapy with Dabigatran vs. Triple Therapy with Warfarin in Patients with AF That Undergo a PCI with Stenting (REDUAL-PCI). Lancet. 2014 Mar 15;383(9921):955–62. doi: 10.1016/S0140-6736(13)62343-0. Epub 2013 Dec 4. Available at: https://clinicaltrials.gov/ct2/show/NCT02164864 .15. ClinicalTrials.gov. A Study of apixaban in patients with atrial fibrillation, not caused by a heart valve problem, who are at risk for thrombosis (blood clots) due to having had a recent coronary event, such as a heart attack or a procedure to open the vessels of the heart. Available at: https://clinicaltrials.gov/ct2/show/NCT02415400 16. ClinicalTrials.gov. Edoxaban Treatment Versus Vitamin K Antagonist in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention (ENTRUST-AF-PCI). Available at: https://clinicaltrials.gov/ct2/show/NCT02866175 17. Gibson CM, Mehran R, Bode C, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 2016;375:2423–3418. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001;285:2864–70.19. Fang MF, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated hemorrhage, the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation Study). J Am Coll Cardiol 2011;58(4):395–401.20. Tsu LV, Dager WE. Safety of new oral anticoagulants with dual antiplatelet therapy in patients with acute coronary syndromes. Ann Pharmacother 2013;47(4):573–7.21. Oldgren J, Wallentin L, Alexander JH, et al. New oral anticoagulants in addition to single or dual antiplatelet therapy after an acute coronary syndrome:a systematic review and meta-analysis. Eur Heart J 2013;34(22): 1670–80.22. Mennuni MG, Halperin JL, Bansilal S, et al. Balancing the risk of bleeding and stroke in patients with atrial fibrillation after percutaneous coronary intervention (from the AVIATOR Registry). Am J Cardiol 2015;116:37–42.23. Lopes RD, Li L, Granger CB, et al. Atrial fibrillation and acute myocardial infarction: antithrombotic therapy and outcomes. Am J Med 2012; 125:897–905.24. Skanes A, Healey JS, Cairns JA, et al. Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control. Can J Cardiol. 2012 May;28(3):396.25. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomized, controlled trial. Lancet 2013;381:1107–15.26. Jolly SS, Natarajan MK. Atrial fibrillation and PCI — do we still need aspirin? N Engl J Med 2016; 375:2490–92.

An intramyocardial dissecting hematoma is a rare mechanical complication after an acute myocardial infarction that carries a high mortality rate. Because intramyocardial dissecting hematomas are associated with multiple cardiac complications, cardiac imaging is an integral component to guiding therapy. We present a case of an intramyocardial dissecting hematoma treated conservatively. Here we explore the role of surgery in patients with intramyocardial dissecting hematomas as well as issues of optimal medical management including the decision to anticoagulate. In conclusion, this report offers a unique commentary on a rare case of an intramyocardial dissecting hematoma.RésuméUn hématome disséquant intramyocardique est une rare complication mécanique après un infarctus aigu du myocarde qui comporte un taux élevé de mortalité. Parce que les hématomes dissection intramyocardique associés à de multiples complications cardiaques, l’imagerie cardiaque est une composante intégrale de guider le traitement. Nous présentons un cas d’hématome disséquant intramyocardique traités conservativement. Ici, nous examinons le rôle de la chirurgie chez les patients souffrant d’hématomes dissection intramyocardique ainsi que des questions de gestion médicale optimale y compris la décision d’anticoagulate. En conclusion, ce rapport offre un unique commentaire sur un cas rare d’un hématome disséquant intramyocardique.A dissecting intramyocardial hematoma is a rare mechanical complication after an acute myocardial infarction (AMI) that carries a high mortality rate. The pathophysiology of a dissecting intramyocardial hematoma involves hemorrhagic dissection through an area of necrotic tissue between the spiral myocardial fibres of the ventricle.1 Although most intramyocardial dissections occur in the left ventricle, the dissection plane can progress to lower pressure areas and involve the right ventricle as myocardial fibres are shared.1 Intramyocardial dissections are most commonly seen as a complication of an acute AMI, but have also been described following blunt chest trauma, and rarely, from cardiac echinococcus infections.2 Because intramyocardial hematomas are associated with multiple cardiac complications such as ventricular rupture, biventricular dysfunction, and thrombus formation, cardiac imaging is an integral component to guiding therapy. We present a case of intramyocardial dissection treated with conservative management.CaseA 58-year-old male presented to the emergency department with a one-day history of shortness of breath occurring at rest. Further history revealed progressive dyspnea with exertion over the prior two months and intermittent chest tightness. He denied symptoms of typical angina. His medical history was significant for hypertension, hypercholesterolemia, and peripheral vascular disease with remote aorto-bifemoral bypass surgery. He had a 20-pack year history of smoking. His only medication on presentation was low-dose aspirin.On examination, his vital signs were as follows: temperature of 36.6°C, heart rate of 98 BPM, blood pressure of 131/105 mmHg, respiratory rate of 20, and an oxygen saturation of 99% on room air. His precordial examination was normal and there was no evidence of volume overload. Initial laboratory investigations showed a mildly elevated high-sensitivity troponin I which peaked at 39 ng/L. Chest radiography showed mild vascular redistribution but no evidence of overt heart failure. ECG showed sinus rhythm with poor R-wave progression but no ST-segment deviation or Q-waves to suggest a prior MI. The patient was subsequently admitted to hospital for further work-up of his shortness of breath.A transthoracic echocardiogram was performed which showed a dissecting intramyocardial hematoma from the mid segment of the left ventricular septum extending to the apex of the left ventricle (Figure 1 and Supplemental Videos 1 and2). The hematoma occupied approximately 50% of the left ventricular cavity, and the estimated left ventricular ejection fraction was 25–30%. The hematoma did not appear to receive any flow from the cavity of the left ventricle itself. There was no left ventricular thrombus identified. All other segments of the ventricle were either hypokinetic or akinetic and thinned. Surgical options were explored, but it was determined that the patient would be at excessive risk for morbidity and mortality with surgical resection of the hematoma due to the extent of left ventricular involvement. The patient was started on medical treatment for congestive heart failure. Due to the concern for myocardial rupture, no anticoagulation or anti-platelet therapies were given. Cardiac catheterization was not performed as there was no good option for revascularization.Six days later, cardiac magnetic resonance imaging (MRI) was performed to reassess the hematoma. The MRI identified a well-defined heterogeneity within the left ventricular mid to apical cavity extending into the apex, raising concern for an intramural dissecting hemorrhage of the myocardium or intracavitary thrombus (Supplemental Video 3). There was also late enhancement of the left ventricular septal and apical segments extending into the right ventricle, indicating an extensive left anterior descending artery territory AMI (Figure 2). Although it was unclear whether the thrombus was contained within the myocardium, anticoagulation was not pursued because of the concern that it would impair healing of, or potentially worsen, the hematoma. A repeat echocardiogram was performed two months after initial presentation, which showed an ejection fraction of 20–25%, a new large apical thrombus, and complete thrombosis of the intramyocardial dissection (Figure 3 and Video4). This was confirmed by cardiac MRI (Figure 4). The patient was subsequently started on warfarin therapy.Figure 1: Two-dimensional echocardiogram from four-chamber view showing the somewhat mobile intramyocardial dissecting hematoma occupying the distal one third of the LV cavity (arrow).Figure 2: Post-gadolinium enhanced cardiac MRI showing an extensive antero- septal and apical transmural MI (yellow arrow) extending into the apical part of the RV and the non-enhancing intramyocardial dissecting hematoma (red arrow). Figure 3: Two-dimensional echocardiogram from four-chamber view at follow-up showing a large wall-adherent apical thrombus (arrow).Figure 4: Post-gadolinium enhanced cardiac MRI confirming structure seen on echocardiogram was a showing a large, non-enhancing and wall-adherent apical thombus (arrow).DiscussionThis case describes a left ventricular dissecting intramyocardial hematoma which was likely the result of a late presenting AMI. Although coronary angiography was not performed to identify the culprit lesion, based on non-invasive imaging we suspect that the myocardial dissection originated in the left ventricle following an extensive antero-septal AMI.1,3 While the mild troponin elevation and lack of overt ischemic signs on electrocardiogram challenge this assertion, the severe regional hypokinesis and signs of ventricular thinning and remodelling on echocardiogram and MRI suggested infarcted tissue, likely in the LAD territory.There is limited data available on the appropriate management of dissecting intramyocardial hematomas following AMI. This is mainly due to their relative infrequency, with the literature limited to case reports and case series. Acute surgical options include application of pericardial patches or other prosthetic material (such as gore-tex or teflon felt), accompanied by excision of necrotic tissue, and coronary artery bypass grafting.1A case review in 1993 examined survival rates in 16 patients with intramyocardial hematomas treated either surgically or medically. This case review observed that only 10% of patients treated conservatively survived past 30 days in contrast to all patients treated surgically.1 While this may suggest that surgical management offers a better prognosis, the finding may have also been due to patients undergoing surgery being at lower risk (due to anatomic factors related to the hematoma or patient comorbidities) compared to those treated conservatively. Conversely, Vargas-Barron et al., examined 15 patients with intramyocardial dissections with a 12-month follow-up period, with 9 patients presenting with an apical free-wall dissection and 6 patients with dissections extending into the septum and/ or right ventricle.4 In the first group, all patients were treated conservatively with all patients surviving to follow up at one year, although 4 patients had worsening heart failure.4 In the second group, 80% of those treated surgically died, compared to 50% who underwent coronary angioplasty and 100% of those conservatively managed.4 This study suggests that conservative management may be a reasonable option in patients with less complicated hematomas, while those with more complicated features are at a high mortality risk irrespective of the course of treatment. While our patient likely fit into the latter group with a more extensive dissection, the primary reason for surgical exclusion was the extent of the hematoma without well-perfused residual tissue to surgically remodel the ventricle.Patients who are conservatively managed for an intramyocardial hematoma are at high risk for further major adverse events and require close follow-up. Concomitant heart failure secondary to MI can lead to left ventricular dysfunction and significant comorbidities, and treatment with proven heart failure medications is essential. Patients with a reduced ejection fraction are also at increased risk of apical thrombus formation.In patients with a myocardial dissection, the decision to anticoagulate must carefully balance the increased risk of stroke and possibility of dissection extension, a potentially devastating consequence. Studies investigating ventricular remodelling after an AMI suggest substantial remodelling, infarct thinning, and reduction of infarct extent typically occur within the first month of healing.5 Thus, deferring any anticoagulation for at least4 weeks may be prudent to allow for healing of the hematoma, as long as no clear indications (e.g., left ventricular thrombus) arise.In our patient, a follow-up echocardiogram performed after two months revealed a large apical thrombus, and anticoagulation was initiated at that point in time.Little is known about the long-term survival of conservatively treated dissecting intramyocardial hematomas. In a study of 8 patients with intramyocardial dissecting hematomas treated with medical management, six were alive at a mean follow up of 12 months.4 One case report has identified a case of a medically treated intramyocardial dissection with event free follow up extending to 40 months.6 Cases of prolonged survival seem to be related to a decrease in size or complete resolution of the hematoma, as was seen in our patient, underscoring the need for serial cardiac imaging both to determine prognosis and to guide therapeutic decisions.7 With improvement or resolution of the hematoma, the primary risks of morbidity and mortality will likely be related to heart failure as well as arrhythmias from scarring; long-term prognosis will depend on optimal heart failure management (e.g., evidence based heart failure medications and evaluating for implantable cardioverter defibrillator [ICD] and cardiac resynchronization therapy [CRT] placement). Finally, in appropriate patients, cardiac transplantation may be considered as a treatment option.References1. Pliam M, Sternlieb J. Intramyocardial dissecting hematoma: An unusual form of subacute cardiac rupture. J Cardiac Surg 1993;8(6):628–37.2. Sari I, Davutoglu V, Kucukdurmaz Z. Intramyocardial dissection after subacute anterior wall myocardial infarction: An unusual form ofmyocardial rupture with subsequent spontaneous healing. Echocardiography2007;25(2):228–30.3. Tighe D, Paul J, Maniet A, et al. Survival in infarct related intramyocardial dissection: Importance of early echocardiography and prompt surgery. Echocardiography 1997;14(4):403–8.4. Vargas-Barrón J, Roldán F, Romero-Cárdenas Á, et al. Dissecting intramyocardial hematoma: Clinical presentation, pathophysiology, outcomes and delineation by echocardiography. Echocardiography 2009;26(3):254–61.5. Hillenbrand H, Sandstede J, Störk S, et al. Remodeling of the infarct territory in the time course of infarct healing in humans. Magnetic Reson Mat Phys Biol Med 2011;24(5):277–84.6. Drozdz J, Kasprzak J, Krzeminska-Pakula M. Spontaneous closure (thrombosis) of the intramyocardial dissection: 40-month follow-up. J Am Soc Echocardio 2002;15(9):1023–24.7. Vargas-Barrón J, Romero-Cárdenas A, Roldán F, et al. Long-term follow-up of intramyocardial dissecting hematomas complicating acute myocardial infarction. J Am Soc Echocardio 2005;18(12):1422.e1–1422.e6.