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Pepe M, Carulli E, Forleo C, Moscarelli M, Di Cillo O, Bortone AS, Nestola PL, Biondi-Zoccai G, Giordano A, Favale S. Inflammatory Bowel Disease and Acute Coronary Syndromes: From Pathogenesis to the Fine Line Between Bleeding and Ischemic Risk. Inflamm Bowel Dis 2021; 27:725-731. [PMID: 32592478 DOI: 10.1093/ibd/izaa160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 02/05/2023]
Abstract
Inflammatory bowel disease (IBD) is a pathological condition that first involves the gastrointestinal wall but can also trigger a systemic inflammatory state and thus extraintestinal manifestations. Systemic inflammation is probably secondary to the passage of bacterial products into the bloodstream because of altered intestinal permeability and the consequent release of proinflammatory mediators. Inflammation, through several diverse pathophysiological pathways, determines both a procoagulative state and systemic endothelial dysfunction, which are both deemed to be responsible for venous and arterial thromboembolic adverse events. The management of systemic thrombotic complications is particularly challenging in this category of patients, who also present a high bleeding risk; what is more, both bleeding and thrombotic risks peak during the active phases of the disease. The literature suggests that treating physicians have been, so far, more heavily influenced by concerns about bleeding than by the thrombotic risk. Despite the absence of data provided by large cohorts or randomized studies, the high risk of arterial and venous atherothrombosis in patients with IBD seems unquestionable. Moreover, several reports suggest that when arterial thromboembolism involves the coronary vessels, causing acute coronary syndromes, ischemic complications from antithrombotic drug undertreatment are frequent and severe. This review aims to shed light on the tricky balance between the ischemic and hemorrhagic risks of patients with IBD and to highlight how difficult it is for clinicians to define a tailored therapy based on a case-by-case, careful, and unprejudiced clinical evaluation.
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Affiliation(s)
- Martino Pepe
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Eugenio Carulli
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Cinzia Forleo
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital GVM Care and Research, Cotignola (RA), Italy
| | - Ottavio Di Cillo
- Chest Pain Unit, Cardiology Emergency, University of Bari, Bari, Italy
| | - Alessandro Santo Bortone
- Division of Heart Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Palma Luisa Nestola
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Napoli, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Stefano Favale
- Cardiovascular Diseases Section, Cardiothoracic Department, University of Bari, Bari, Italy
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Svendsen C, Pauley E, Falk K, Weickert T, Yeung M, Stouffer GA. Patients with Left Ventricular Thrombus Despite Normal Systolic Function. Am J Med Sci 2021; 362:198-206. [PMID: 34172202 DOI: 10.1016/j.amjms.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/19/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
Abstract
The formation of a thrombus in the left ventricle (LV) in patients with normal systolic function is very rare. We report a case and identified 31 other adult patients who had an LV thrombus with normal LV systolic function. The median (IQR) age of these patients was 43 [37,59] years with a slight male predominance (59%). The vast majority of patients presented with embolic complications (28; 88%) with 3 of the other patients presenting with a febrile illness. Most of the cases occurred in the setting of an identifiable medical condition that carries an increased risk of thrombosis including inflammatory diseases, malignancies or hypereosinophilia. Treatment generally included anticoagulation with or without surgical removal or systemic thrombolysis. Recurrence of LV thrombus and/or embolic events have been reported in patients with LV thrombus and normal LV systolic function suggesting that long term anticoagulation may be needed.
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Affiliation(s)
- Christopher Svendsen
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC, United States
| | - Eric Pauley
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Kristine Falk
- The McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, United States
| | - Thelsa Weickert
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Michael Yeung
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - George A Stouffer
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States; The McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, United States.
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Grewal HK, Bansal M, Garg A, Kasliwal RR, Bhan A, Gautam D. Left Ventricular Thrombus and Cardioembolic Stroke in a Patient with Ulcerative Colitis: A Case Report. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 9:67-70. [PMID: 33519347 PMCID: PMC7839577 DOI: 10.4103/sjmms.sjmms_525_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/16/2020] [Accepted: 08/20/2020] [Indexed: 12/02/2022]
Abstract
Left ventricular (LV) thrombi usually occur in the setting of global or regional LV systolic dysfunction and are extremely rare in the absence of LV wall motion abnormalities. We report here a case of a 23-year-old female who presented with cardioembolic stroke due to ulcerative colitis. To determine the cause of stroke, several investigations and evaluations were carried out, but the results were mostly normal or unremarkable. Transthoracic echocardiography revealed an oscillating pedunculated globular mass, which was eventually resected due to recurrent transient ischemic attacks. The histopathology of the excised mass revealed it to be an organized thrombus with acute and chronic inflammatory cells and fibroblasts. The uncommon etiology combined with the unusual appearance of the thrombus presented a major diagnostic and therapeutic dilemma for this exceedingly rare cause for intracardiac thrombus formation. Therefore, it would be useful to have a low threshold for screening patients with active inflammatory bowel disease for possible ventricular thrombosis before discharge, especially if other risk factors are present.
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Affiliation(s)
- Hardeep Kaur Grewal
- Department of Clinical and Preventive Cardiology, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Manish Bansal
- Department of Clinical and Preventive Cardiology, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Arun Garg
- Department of Neurology, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Ravi R Kasliwal
- Department of Clinical and Preventive Cardiology, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Anil Bhan
- Department of Cardiac Surgery, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Dheeraj Gautam
- Department of Laboratory Medicine, Pathology and Blood Bank, Medanta-The Medicity, Gurgaon, Haryana, India
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Shankar SH, Kumar P, Madhusudan KS. Arterial and venous thrombosis with right ventricular thrombus in Crohn's disease. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2019; 30:1070-1071. [PMID: 31854315 PMCID: PMC6924601 DOI: 10.5152/tjg.2019.19323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/27/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Sujay Halkur Shankar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prabhat Kumar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kumble S. Madhusudan
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Inflammatory bowel disease is closely associated with an increased risk for thrombotic events. Thrombosis mostly occurs in the extremities, lungs, and liver; but it can also occur in the ventricles of the heart. The primary goal of this article is to increase awareness of the risk for ventricular thrombosis in this patient population among healthcare professionals and, thus, appropriate prompt use of thromboprophylaxis therapy for these patients during acute flare-ups. Early diagnosis and intervention are critical for ventricular thrombosis to prevent systemic embolisation of the thrombus. Concisely, inflammatory bowel disease predisposes to the development of thrombi. A low threshold for the use of imaging studies to detect such thrombi is warranted.
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