Wellens’ Syndrome from COVID-19 Infection Assessed by Enhanced Transthoracic Coronary Echo Doppler: A Case Report

Wellens’ syndrome (WS) is a preinfarction state caused by a sub-occlusion of the proximal left anterior descending coronary artery (LAD). In this case report, for the first time, we describe how this syndrome can be caused by COVID-19 infection and, most importantly, that it can be assessed bedside by enhanced transthoracic coronary echo Doppler (E-Doppler TTE). This seasoned technique allows blood flow Doppler to be recorded in the coronaries and at the stenosis site but has never been tested in an acute setting. Two weeks after clinical recovery from bronchitis allegedly caused by COVID-19 infection on the basis of epidemiologic criteria (no swab performed during the acute phase but only during recovery, at which time it was negative), our patient developed typical angina for the first time, mainly during effort but also at rest. He was admitted to our tertiary center, where pharyngeal swabs tested positive for COVID-19. A typical EKG finding supporting WS prompted an assessment of the left main coronary artery (LMCA) and the whole LAD blood flow velocity by E-Doppler TTE. Localized high velocity (transtenotic velocity) (100 cm/s) was recorded in the proximal LAD, with the reference velocity being 20 cm/s. This indicated severe stenosis with 90% area narrowing according to the continuity equation, as confirmed by coronary angiography. During follow-up after successful stenting, E-Doppler TTE showed a decrease in the transtenotic acceleration, confirming stent patency and a normal coronary flow reserve (3.2) and illustrating a normal microcirculatory function. Conclusion: COVID infection can trigger a coronary syndrome like WS. E-Doppler TTE, an ionizing radiation-free method, allows safe and rapid bedside management of the syndrome. This new strategy can be pivotal in distinguishing true WS from pseudo-WS. In cases of pseudo-WS, coronary angiography can be avoided. If E-Doppler TTE confirms the stenosis and PCI (percutaneous coronary intervention) is performed, the same method can allow assessment over time of the precise residual stenosis after stenting and verify the microvasculature status by evaluating coronary flow reserve.

Efficacy of high-dose atorvastatin or rosuvastatin loading in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials with GRADE qualification of available evidence

PURPOSE

We aimed to summarize current evidence regarding the impact of a high-dose statin loading before percutaneous coronary intervention (PCI) on short-term outcomes in patients presenting with the acute coronary syndrome (ACS).

METHODS

This meta-analysis was based on a search of the MEDLINE, Cochrane Central Register of Controlled Trials, Ovid Journals, and SCOPUS for randomized controlled trials that compared high-dose atorvastatin or rosuvastatin with no or low-dose statin administered before planned PCI in statin-naive patients with ACS. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and all-cause mortality at 30 days. Prespecified subanalyses were performed with respect to statin and ACS type.

RESULTS

A total of eleven trials enrolling 6291 patients were included, of which 75.4% received PCI. High-dose statin loading was associated with an overall 43% relative risk (RR) reduction in MACCE at 30 days (RR 0.57, 95% CI 0.41-0.77) in whole ACS population. This effect was primarily driven by the 39% reduction in the occurrence of MI (RR 0.61, 95% CI 0.46-0.80). No significant effect on all-cause mortality reduction was observed (RR 0.92, 95% CI 0.67-1.26). In the setting of ST-elevation myocardial infarction (STEMI), atorvastatin loading was associated with a 33% reduction in MACCE (RR 0.67, 95% CI 0.48-0.94), while in non-ST-elevation myocardial infarction ACS (NSTE-ACS), rosuvastatin loading was associated with 52% reduction in MACCE at 30 days (RR 0.48, 95% CI 0.34-0.66). The level of evidence as qualified with GRADE was low to high, depending on the outcome.

CONCLUSION

A high-dose loading of statins before PCI in patients with ACS reduces MACCE and reduces the risk of MI with no impact on mortality at 30 days. Atorvastatin reduces MACCE in STEMI while rosuvastatin reduces MACCE in NSTE-ACS at 30 days.

Comparison of Atorvastatin and Rosuvastatin in Reduction of Inflammatory Markers in Acute Coronary Syndrome

Introduction: Patients suffering from acute coronary syndrome (ACS) are found to have elevated levels of inflammatory markers such as high sensitivity C-reactive protein (hsCRP) and erythrocyte sedimentation rate (ESR) in their blood. These elevated inflammatory markers can lead to complications in ACS. Statins such as atorvastatin and rosuvastatin are known to reduce inflammatory markers. Our aim is to compare the efficacy of atorvastatin and rosuvastatin in reducing inflammatory markers.

Methods: This prospective, open-label, randomized trial was conducted in the cardiovascular department of tertiary care in a rural area of Pakistan. There were 128 patients diagnosed with ACS who were enrolled in the study. They were randomized into two groups, i.e. group A in which patients received 40 mg rosuvastatin daily and group B in which patients received 20 mg atorvastatin daily. hsCRP and ESR were recorded for all the patients at baseline (before starting therapy) and then again after four weeks. The results were compared between both groups.

Result: Out of 128 patients, 113 (88.2%) patients completed the study. According to this study, at the end of four weeks, rosuvastatin reduced hsCRP (p value: < 0.0001) and ESR (p value: 0.015) values significantly more when compared with atorvastatin.

Conclusion: In this study, rosuvastatin was significantly superior to atorvastatin in reducing inflammatory markers such as ESR and hsCRP in patients suffering from ACS. Cardiologists should consider using rosuvastatin rather than atorvastatin in management of patients suffering from ACS with elevated inflammatory biomarkers. 

Survival benefit from recent changes in management of men and women with ST-segment elevation myocardial infarction treated with percutaneous coronary interventions

BACKGROUND

Nowadays, the majority of patients with myocardial infarction with ST-segment elevation (STEMI) are treated with primary percutaneous coronary interventions (PCI). In recent years, there have been ongoing improvements in PCI techniques, devices and concomitant pharmacotherapy. However, reports on further mortality reduction among PCI-treated STEMI patients remain inconclusive. The aim of this study was to compare changes in management and mortality in PCI-treated STEMI patients between 2005 and 2011 in a real-life setting.

METHODS

Data on 79,522 PCI-treated patients with STEMI from Polish Registry of Acute Coronary Syndromes (PL-ACS) admitted to Polish hospitals between 2005 and 2011 were analyzed. First, temporal trends of in-hospital management in men and women were presented. In the next step, patients from 2005 and 2011 were nearest neighbor matched on their propensity scores to compare in-hospital, 30-day and 1-year mortality rates and in-hospital management strategies and complications.

RESULTS

Some significant changes were noted in hospital management including shortening of median times from admission to PCI, increased use of drug-eluting stents, potent antiplatelet agents but also less frequent use of statin, beta-blockers and angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. There was a strong tendency toward preforming additional PCI of non-infarct related arteries, especially in women. After propensity score adjustment there were significant changes in inhospital but not in 30-day or 1-year mortality rates between 2005 and 2011. The results were similar in men and women.

CONCLUSIONS

There were apparent changes in management and significant in-hospital mortality reductions in PCI-treated STEMI patients between 2005 and 2011. However, it did not result in 30-day or 1-year survival benefit at a population level. There may be room for improvement in the use of guideline-recommended pharmacotherapy.

Atheroprotective effects of statins in patients with unstable angina by regulating the blood-borne microRNA network

Experimental studies have demonstrated several effects of statins in acute coronary syndrome (ACS) that may extend their clinical benefit beyond the lipid profile modification itself. However, the precise underlying mechanism remains to be elucidated. microRNAs (miRNAs) serve significant roles in the pathophysiology of atherosclerotic plaque progression. The present study investigated the protective role of statins in patients with unstable angina (UA) by regulating the circulating miRNA network. miRNA array results demonstrated that there were 21 differentially expressed miRNAs in non-statin-treated patients with UA (n=8) compared with non-coronary artery disease controls (n=8), and 33 differentially expressed miRNAs in statin-treated patients with UA (n=8) compared with non-statin patients. TargetScan and miRanda programs were used to predict miRNAs target genes. miRNAs target genes in vascular endothelial cells and monocytes were clustered based on the CGAP SAGE library via the Database for Annotation, Visualization and Integrated Discovery (DAVID) platform, and miRNA target genes in platelets were clustered based on a UP tissue-specific library via the DAVID platform. The PANTHER database via DAVID platform was used to perform signaling pathway analysis. The miRNA-gene/pathway network was visualized by Cytoscape software. Bioinformatic analysis suggested that statin-induced miRNAs functions were primarily enriched in angiogenesis, integrin and platelet derived growth factor signaling pathways in UA patients. In endothelial cells and platelets, statin-induced miRNAs primarily targeted the integrin signaling pathway, and in monocytes primarily targeted cytoskeletal regulation by the Rho GTPase signaling pathway. These results revealed that statins may serve systematic protective roles in UA patients by influencing the circulating miRNA regulatory network. Further studies are required to verify the functions of statin-induced miRNAs in endothelial cells, platelets and monocytes.

Stimulating endogenous cardiac repair

The healthy adult heart has a low turnover of cardiac myocytes. The renewal capacity, however, is augmented after cardiac injury. Participants in cardiac regeneration include cardiac myocytes themselves, cardiac progenitor cells, and peripheral stem cells, particularly from the bone marrow compartment. Cardiac progenitor cells and bone marrow stem cells are augmented after cardiac injury, migrate to the myocardium, and support regeneration. Depletion studies of these populations have demonstrated their necessary role in cardiac repair. However, the potential of these cells to completely regenerate the heart is limited. Efforts are now being focused on ways to augment these natural pathways to improve cardiac healing, primarily after ischemic injury but in other cardiac pathologies as well. Cell and gene therapy or pharmacological interventions are proposed mechanisms. Cell therapy has demonstrated modest results and has passed into clinical trials. However, the beneficial effects of cell therapy have primarily been their ability to produce paracrine effects on the cardiac tissue and recruit endogenous stem cell populations as opposed to direct cardiac regeneration. Gene therapy efforts have focused on prolonging or reactivating natural signaling pathways. Positive results have been demonstrated to activate the endogenous stem cell populations and are currently being tested in clinical trials. A potential new avenue may be to refine pharmacological treatments that are currently in place in the clinic. Evidence is mounting that drugs such as statins or beta blockers may alter endogenous stem cell activity. Understanding the effects of these drugs on stem cell repair while keeping in mind their primary function may strike a balance in myocardial healing. To maximize endogenous cardiac regeneration, a combination of these approaches could ameliorate the overall repair process to incorporate the participation of multiple cellular players.

Hyperglycemia in acute coronary syndromes: from mechanisms to prognostic implications

Hyperglycemia is a frequent condition in patients with acute coronary syndromes (ACS). Hyperglycemia during ACS is caused by an inflammatory and adrenergic response to ischemic stress, when catecholamines are released and glycogenolysis induced. Although the involved pathophysiological mechanisms have not yet been fully elucidated, it is believed that hyperglycemia is associated with an increase in free fat acids (which induce cardiac arrhythmias), insulin resistance, chemical inactivation of nitric oxide and the production of oxygen reactive species (with consequent microvascular and endothelial dysfunction), a prothrombotic state, and vascular inflammation. It is also related to myocardial metabolic disorders, leading to thrombosis, extension of the damaged area, reduced collateral circulation, and ischemic preconditioning. In the last few years, several observational studies demonstrated that hyperglycemia in ACS is a powerful predictor of survival, increasing the risk of immediate and long-term complications in patients both with and without previously known diabetes mellitus. Glucose management strategies in ACS may improve outcomes in patients with hyperglycemia, perhaps by reducing inflammatory and clotting mediators, by improving endothelial function and fibrinolysis and by reducing infarct size. Recent clinical trials of insulin in ACS have resulted in varying levels of benefit, but the clinical benefit of an aggressive treatment with insulin is yet unproved.

Does treatment impact health outcomes for patients after acute coronary syndrome?

Background: Mortality rates for acute coronary syndrome (ACS) patients are still very high all over the world. Our study aimed to investigate the impact of ACS treatment on cardiovascular (CV) mortality eight years following ACS. Methods: A retrospective cohort study with a total of 613 patients was used. The data was collected from databases and medical records. An evidence-based treatment (EBT) algorithm was used based on the ESC guidelines. Logistic regression analysis and standardized odds ratios with 95% confidence interval (CI) were used for the risk assessment, with a p level < 0.05 considered as significant. Results: The median follow-up time in this study was 7.6 years. During follow-up 48.9% of the patients (n = 300) died from CV and 207 (69%) for a relevant reason. For monotherapy ACE inhibitors and β-blockers, and for fixed dose combined drugs ACE inhibitors and diuretics, were most frequently used. EBT was provided to 37.8% of patients. The EBT use (HR 0.541, CI 0.394–0.742, p < 0.001) during follow-up period was important for reducing CV mortality in ACS patients. Conclusions: The combined use of EBT significantly improved outcomes. The recurrent myocardial infarction and percutaneous coronary intervention patients were more frequent in EBT and it was beneficial for reducing CV mortality.

Impact of long-term statin pretreatment on myocardial damage in ST elevation myocardial infarction (from the AIDA STEMI CMR Substudy)

Nonrandomized studies suggested lower mortality rates with statin pretreatment in patients with acute ST elevation myocardial infarction (STEMI). However, clinical data are still inconclusive and the mechanisms of these presumed beneficial effects require further exploration. Cardiac magnetic resonance (CMR) imaging offers the possibility of studying a variety of markers of myocardial damage and reperfusion injury after myocardial infarction. The aim of this study was to assess a possible link of statin pretreatment with myocardial damage in acute STEMI. The multicenter Abciximab i.v. versus i.c. in ST-elevation Myocardial Infarction CMR substudy enrolled 795 consecutive patients with acute STEMI who underwent primary angioplasty within 12 hours of symptom onset. CMR studies assessing left ventricular ejection fraction, infarct size, microvascular obstruction, area at risk, and myocardial salvage index were performed in a median of 3 days after the clinical event. We performed a retrospective analysis to evaluate the impact of statin pretreatment on myocardial damage. Information on statin pretreatment was available in 791 of 795 patients (99%). Of these, 122 (15%) had long-term statin pretreatment. CMR results showed no significant differences in the area at risk, left ventricular ejection fraction, infarct size, microvascular obstruction, and myocardial salvage index between patients with and without statin pretreatment. Furthermore, no differences in short- and long-term outcomes could be observed. In conclusion, in this CMR study, statin pretreatment in patients with STEMI was not associated with lesser myocardial damage.

Improving lipid control following myocardial infarction

PURPOSE OF REVIEW

Following a myocardial infarction, lipid-lowering therapy is an established intervention to reduce the risk of recurrent cardiovascular events. Prior studies show a need to improve clinical practice in this area. Here, we review the latest research and perspectives on improving postmyocardial infarction lipid control.

RECENT FINDINGS

Dyslipidemia and myocardial infarction remain leading causes of global disability and premature mortality throughout the world. The processes of care in lipid control involve multiple patient-level, provider-level, and healthcare system-level factors. They can be challenging to coordinate. Recent studies show suboptimal use of early high-intensity statin therapy and overall lipid control following myocardial infarction. Encouragingly, lipid control has improved over the last decade. Implementation science has identified checklists as an effective tool. At the top of the checklist for reducing atherogenic lipids and recurrent event risk postmyocardial infarction is early high-intensity statin therapy. Smoking cessation and participation in cardiac rehabilitation are also priorities, as are lifestyle counseling, promotion of medication adherence, ongoing lipid surveillance, and medication management.

SUMMARY

Optimizing lipid control could further enhance clinical outcomes after myocardial infarction.

Meta-analysis of time-related benefits of statin therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Patients with acute coronary syndromes (ACSs) still experience high rates of recurrent coronary events, particularly, early in their presentation. Statins yield substantial cardiovascular benefits, but the optimal timing of their administration, before or after percutaneous coronary intervention (PCI), remains unclear. We aimed to perform a meta-analysis of randomized controlled trials of statin administration before or after PCI versus no statin or low-dose statin in patients with ACS. Primary end points were 30-day all-cause mortality and 30-day myocardial infarction (MI) stratified by pre- and post-PCI statin administration. Secondary end points were major adverse cardiac events (MACEs) or major adverse cardiac and cerebrovascular events (MACCEs). Long-term analysis beyond 30 days was also performed. Twenty randomized controlled trials enrolling 8,750 patients were included. At 30 days, the rate of MI was significantly lower in the statin group (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.53 to 0.84, p = 0.0007) with a trend toward reduced mortality (p = 0.06) and significant reductions in MACE and MACCE compared with no or low-dose statin. The 30-day incidence of MI was markedly lower when statins were administered before PCI (OR 0.38, 95% CI 0.24 to 0.59, p <0.0001) rather than after PCI (p = 0.28). The direction and magnitude of the estimates for before and after PCI versus no statin or low-dose statin were sustained at long term, not reaching statistical significance for MI (OR 0.81, 95% CI 0.65 to 1.01, p = 0.06) but with significant reductions in MACE (p = 0.0002). By meta-regression, earlier statin administration correlated significantly with lower risk of MI, MACE, and MACCE at 30 days. In conclusion, the present meta-analysis indicates a time-related impact of statin therapy on clinical outcomes of patients with ACS undergoing PCI: the earlier the administration before PCI, the greater the benefits.

Statin treatment before percutaneous cononary intervention

Treatment with 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) improves short-and-long term prognosis in high-risk patients with stable coronary artery disease and in those with acute coronary syndrome and their use is strongly recommended for secondary prevention. Moreover, recent data suggest that statin pre-treatment is associated with a better short- and long-term outcome in patients undergoing percutaneous coronary intervention. Current guidelines for coronary revascularization recommend the use of high-dose of statins before percutaneous coronary intervention to reduce the risk of periprocedural myocardial infarction in statin naïve patients (class IIa A) and in those on chronic statin therapy (class IIa B). However, the beneficial clinical effects elicited by statins in patients undergoing coronary angioplasty may arise not only from a cardiac protection against periprocedural myocardial injury but also from a renal protection against acute kidney injury caused by iodinated contrast media. Actually, statins exert multiple non-lipid lowering (pleiotropic) effects, including improved endothelial function, reduced inflammatory and immuno-modulatory processes, oxidative stress and platelet adhesion, that may contribute to both cardio- and nephro-protection even in the short-term.

Prior statin therapy is associated with milder course and better outcome in acute pancreatitis--a cohort study

BACKGROUND

Statin treatment was shown to be associated with improved outcomes in several inflammatory conditions. We wanted to evaluate the effects of statin therapy on the course and outcome of acute pancreatitis (AP).

METHODS

A prospective cohort study included patients with acute pancreatitis divided into two groups according to statin use prior to hospitalization. Age, sex, etiology of AP, Ranson's score, APACHE II score and maximal CRP were recorded. Outcome measures were hospital length of stay and mortality. Matching of patients for matched analyses was done using individual matching and propensity score matching using variables a priori associated with course and outcome of acute pancreatitis.

RESULTS

Inclusion criteria were met for 1062 patients of whom 92 were taking statins. Statin users were older and had higher body mass indexes. Severe disease was more common in the no-statin group than in statin group (20.6% vs. 8.7% respectively). All severity markers were also higher in the no-statin group. All cause mortality was not different, while cardiovascular mortality was higher in the statin group in the cohort analysis. After matching by either method, the severity of disease was greater for the patients without statins treatment. Pancreatitis related mortality was higher in the no-statin group after matching. Among patients who developed severe AP, statin users showed lower Ranson's and APACHE II scores and lower maximal CRP.

CONCLUSIONS

Prior statin treatment significantly reduces morbidity and mortality in acute pancreatitis. Further studies are needed to evaluate possible therapeutic use of statins in acute pancreatitis.