Myocardial infarction with nonobstructive coronary arteries: a single-center retrospective study by sex and race

BACKGROUND

In myocardial infarction with nonobstructive coronary arteries (MINOCA), there are limited patient-level data on outcomes by sex and race.

OBJECTIVE

The aim of this study was to assess baseline demographics and 3-year outcomes by sex and race for MINOCA patients.

METHODS

Patients admitted to a single center with acute myocardial infarction (MI) between 1 January 2012 and 31 December 2018, were identified by chart and angiographic review. The primary outcome was nonfatal MI with secondary outcomes including nonfatal cerebrovascular accident (CVA), chest pain readmission, and repeat coronary angiography.

RESULTS

During the study period, 304 patients were admitted with MINOCA. The cohort was predominantly female (66.4%), and women were significantly older (64.6 vs. 59.2). One-sixth of the total population were Black patients, and nearly half of Black patients (47.2%) were male. Prior CVA (19.7%) and comorbid anxiety, depression, or post-traumatic stress disorder (41.1%) were common. Rates of nonfatal MI were 6.3% without difference by sex or race. For secondary outcomes, rates of CVA were 1.7%, chest pain readmission was 22.4%, and repeat angiography was 8.9%. Men were significantly more likely to have repeat angiography (13.7 vs. 6.4%), and Black patients were more likely to be readmitted for angina (34.0 vs. 19.1%). Over one-quarter of patients underwent repeat stress testing, with 8.9% ultimately undergoing repeat angiograms and low numbers (0.7%) undergoing revascularization. Men were more likely to be referred for a repeat angiogram (13.7 vs. 6.4%, P = 0.035). In multivariate analysis, Black race [odds ratio (OR), 2.31; 95% confidence interval (CI), 1.06-5.03] was associated with an increased risk of readmission for angina, while female sex was associated with decreased odds of repeat angiography (OR, 0.36; 95% CI, 0.14-0.90) and current smoking was associated with increased odds of repeat angiography (OR, 4.07; 95% CI, 1.02-16.29)] along with hyperlipidemia (OR, 4.65; 95% CI, 1.22-17.7).

CONCLUSION

White women presented more frequently with MINOCA than White men, however, Black men are equally as affected as Black women. Rates of nonfatal MI were low without statistical differences by sex or race.

Percutaneous coronary intervention can be safely performed with left ventricular thrombus without increasing stroke risk: A 5-year retrospective review using real-world data

INTRODUCTION

Left ventricular thrombus (LVT) increases the risk of ischemic stroke. However, it remains uncertain if the percutaneous coronary intervention (PCI) in the confirmed LVT setting further augments the stroke risk. Therefore, in this study, we evaluated the risk of stroke among patients with LVT undergoing CAG +/- PCI.

METHODS

This retrospective observational cohort study included all the patients encountered with LVT from 1st of April 2015, to 31st of March 2020. The study population was divided into two groups: Longobardo et al. (2018) [1] patients with LVT who underwent CAG +/- PCI; Solheim et al. (2010) [2] patients with LVT who did not undergo CAG +/- PCI. The primary outcome evaluated was stroke during the index admission, and the secondary outcomes included in-hospital mortality, all-cause mortality, and stroke at 12 months post-discharge. Logistic regression was used to determine the risk of stroke associated with PCI among patients with LVT, and a p-value<0.05 indicated statistical significance.

RESULTS

Of the 210 patients included, 119 underwent CAG +/- PCI, while 91 patients did not undergo CAG +/- PCI. Most of the patients were Asian (67%), male (96%), with a mean age of 56 years. Ischemic cardiomyopathy was the primary etiology of LVT in both groups (96% in the CAG +/- PCI group and 80% in non CAG +/- PCI group). During the index admission, stroke among patients with LVT did not differ between the CAG +/- PCI and non CAG +/- PCI groups (5% versus 3.3%; odds ratio (OR) 1.6, 95% confidence interval (CI) 0.34-6.4, p = 0.539; adjusted OR 0.9, 95% CI 0.09-10.6, p = 0.968). Similarly, in-hospital mortality, all-cause mortality, and stroke at 12 months did not differ between the study groups.

CONCLUSION

Performing CAG +/- PCI among patients with LVT was not associated with an increased risk of stroke during admission or within 12 months in comparison to patients who did not undergo CAG +/- PCI, which may reassure cardiologists to perform CAG +/- PCI among patients with LVT safely.

Coronary Angiography Complicated by Acute Ischaemic Stroke and the Use of Thrombolysis: a Cardiology Perspective and Narrative Review of Current Literature

PURPOSE OF REVIEW

Coronary angiography-associated acute ischaemic stroke (CAAIS) is an uncommon event but is associated with significant mortality and morbidity. The incidence of CAAIS has increased with a rise in the volume of coronary angiography (CA) and percutaneous coronary intervention (PCI) performed. Intravenous thrombolysis (IVT) is utilized in the general management of acute ischaemic stroke; however, it is associated with a higher risk of intracranial hemorrhage (ICH). As CA or PCI is performed more often in an aging population or high-risk patients that also carry an increased risk of ICH, it is vital to minimize additional complications from the treatment of CAAIS. This article aims to review the pathophysiological mechanisms for CAAIS, clarify the current evidence regarding IVT use in this setting, and thus assist cardiologists in the management of CAAIS.

RECENT FINDINGS

The pathophysiology for CAAIS may be different from acute ischaemic stroke in the general population. Embolic phenomena from dislodgement of calcium or other debris during manipulation of instrumentation during CA or PCI are likely mechanisms. This may contribute to altered thrombus composition, which affects the efficacy of IVT as suggested in recent studies. Furthermore, IVT in the management of CAAIS has not been evaluated specifically. The utilization of IVT should be carefully considered in CAAIS given a paucity of evidence demonstrating safety and efficacy in this setting. A multidisciplinary pathway that emphasizes the involvement of cardiologists in the treatment decision-making process would aid in thoughtful risk-benefit evaluation for IVT use in CAAIS and reduce adverse patient outcomes. Future studies to assess the impact of this pathway on CAAIS outcomes would be beneficial.

Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis

AIM

Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis.

RESULTS

The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%).

CONCLUSIONS

There was no significant difference in stroke outcomes between the TR approach and the TF approach.

Adverse Impact of Peri-Procedural Stroke in Patients Who Underwent Percutaneous Coronary Intervention

Peri-procedural stroke (PPS) is an important complication in patients who underwent percutaneous coronary intervention (PCI). The extent to which PPS impacts mortality and outcomes remains to be defined. Consecutive patients who underwent PCI enrolled in the Victorian Cardiac Outcomes Registry (2014 to 2018) were categorized into PPS and no PPS groups. The primary outcome was 30-day major adverse cardiovascular events (MACEs) (composite of mortality, myocardial infarction, stent thrombosis, and unplanned revascularization). Of 50,300 patients, PPS occurred in 0.26% patients (n = 133) (71% ischemic, and 29% hemorrhagic etiology). Patients who developed PPS were older (69 vs 66 years) compared with patients with no PPS, and more likely to have pre-existing heart failure (59% vs 29%), chronic kidney disease (33% vs 20%), and previous cerebrovascular disease (13% vs 3.6%), p <0.01. Among those with PPS, there was a higher frequency of presentation with ST-elevation myocardial infarction (49% vs 18%) and out-of-hospital cardiac arrest (14% vs 2.2%), PCI by way of femoral access (59% vs 46%), and adjunctive thrombus aspiration (12% vs 3.6%), all p = <0.001. PPS was associated with incident 30-day MACE (odds ratio [OR] 2.97, 95% confidence intervals [CIs] 1.86 to 4.74, p <0.001) after multivariable adjustment. Utilizing inverse probability of treatment weighting analysis, PPS remained predictive of 30-day MACE (OR 1.91, 95% CI 1.31 to 2.80, p = 0.001) driven by higher 30-day mortality (OR 2.0, 95% CI 1.35 to 2.96, p = 0.001). In conclusion, in this large, multi-center registry, the incidence of PPS was low; however, its clinical sequelae were significant, with a twofold increased risk of 30-day MACE and all-cause death.

Relation of Extracardiac Vascular Disease and Outcomes in Patients With Diabetes (1.1 Million) Hospitalized for Acute Myocardial Infarction

The association between vascular disease and outcomes of patients with acute myocardial infarction (AMI) has not been well-defined in the diabetes mellitus (DM) population. All patients with DM presenting with AMI between October 2015 and December 2018 in the National Inpatient Sample database were stratified by number and site of extracardiac vascular comorbidity (cerebrovascular [CVD], renovascular, neural, retinal and peripheral [PAD] diseases). Multivariable logistic regression was used to determine the adjusted odds ratios (aORs) of in-hospital adverse outcomes and procedures. Of 1,116,670 patients with DM who were hospitalized for AMI, 366,165 had ≥1 extracardiac vascular comorbidity (32.8%). Patients with vascular disease had an increased aOR for mortality (aOR 1.05, 95% confidence interval [CI] 1.04 to 1.07), major adverse cardiovascular and cerebrovascular events (MACCEs) (aOR 1.19, 95% CI 1.18 to 1.21), stroke (aOR 1.72, 95% CI 1.68 to 1.76), and major bleeding (aOR 1.11, 95% CI 1.09 to 1.13) and had lower odds of receiving coronary angiography (CA) (aOR 0.90, 95% CI 0.90 to 0.91) and percutaneous coronary intervention (PCI) (aOR 0.82, 95% CI 0.82 to 0.83) than patients without extracardiac vascular disease. Patients with PAD had the highest odds of mortality (aOR 1.29, 95% CI 1.27 to 1.32), whereas patients with CVD had the greatest odds of MACCEs, stroke, and major bleeding (aOR 1.82, 95% CI 1.78 to 1.87, aOR 4.25, 95% CI 4.10 to 4.40, and aOR 1.51, 95% CI 1.45 to 1.57, respectively). Patients with DM presenting with AMI and concomitant extracardiac vascular disease were more likely to develop clinical outcomes and less likely to undergo CA or PCI. Patients with PAD had the highest risk of mortality, whereas patients with CVD had the greatest risk of MACCEs, stroke, and major bleeding.

Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications

INTRODUCTION

Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC.

METHODS

We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality.

RESULTS

The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity.

CONCLUSIONS

Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.

Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications

INTRODUCTION

Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC.

METHODS

We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality.

RESULTS

The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity.

CONCLUSIONS

Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.

A Rare Neurological Presentation Post-Cardiac Catheterization

Unilateral Isolated oculomotor nerve palsy is a rare neurological complication after cardiac catheterization. Concomitant thalamus and midbrain infarction secondary to embolic events involving the artery of Percheron after cardiac catheterization have been reported in the literature. However, isolated midbrain infarction is a rare neurological deficit. Here, we present the case of a patient who presented with mild left-sided ptosis, binocular diplopia, and partially impaired left eye adduction two hours after cardiac catheterization. Brain magnetic resonance imaging revealed a focal area of restricted diffusion within the midbrain tegmentum, confirming this rare brainstem stroke.

Revascularization or optimal medical therapy for stable ischemic heart disease: A Bayesian meta-analysis of contemporary trials

BACKGROUND

The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.

AIMS

To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.

METHODS

PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms.

RESULTS

Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0.

CONCLUSIONS

Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.

PROSPERO

The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].

In-Hospital acute ischemic stroke following ST-elevation myocardial infarction

BACKGROUND

In-hospital ischemic stroke following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale in the United States.

METHODS

We used 2003 to 2014 Nationwide Inpatient Sample data to identify adults with a principal diagnosis of STEMI. Patients were divided into two groups defined by presence or absence of ischemic stroke. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models identified factors associated with ischemic stroke, national trend of in-hospital stroke incidence and in-hospital mortality.

RESULTS

Of 1,842,529 STEMI patients hospitalized from 2003 to 2014, 22,268 (1.2%) developed acute in-hospital ischemic stroke. Those with acute strokes were older (age ≥ 65 years: 70% vs 46%), more likely female (51% vs 33%), and had higher rates of atrial fibrillation (28.9% vs 12.2%) and heart failure (40.5% vs 21.1%). Age and gender adjusted incidence of in-hospital ischemic stroke following STEMI remained stable; 1.4% in 2003 and 1.5% in 2014 (P trend = 0.50). However, age and gender adjusted in-hospital mortality declined in STEMI patients with and without in-hospital ischemic stroke [AOR 0.97 (0.95-0.99) P trend = 0.03, and AOR 0.98 (0.98-0.99) P trend < 0.001, respectively]. Patients with ischemic strokes had higher in-hospital mortality (25.7% Vs 7.2%, p < 0.001), [AOR 2.11, 95% CI (1.92-2.32)].

CONCLUSION

In the United States, the incidence of acute in-hospital stroke remained stable from 2003 to 2014 following STEMI with significant decrease of in-hospital mortality trends. Despite slight improvement in mortality trends, in-hospital mortality rates remained elevated calling for interventions to optimize health care delivery.

Contrast Extravasation Mimicking Subarachnoid Hemorrhage After Cardiac Catheterization

Neurological complications after coronary angiography are rare but associated with significant mortality and morbidity. These include ischemic and hemorrhagic strokes, and transient ischemic attacks. Rarely, contrast media can cross the blood brain barrier causing transient neurological symptoms including confusion and seizures. On imaging, it can mimic a subarachnoid hemorrhage (SAH). Blood can be differentiated from contrast media using MRI. We present a patient who developed confusion after undergoing cardiac angiography and the initial CT of the brain showed SAH. However, MRI of the brain did not reveal any hemorrhage indicating contrast staining.

Incidence and risk factors for stroke following percutaneous coronary intervention

BACKGROUND

Stroke rates and risk factors may change as percutaneous coronary intervention practice evolves and no data are available comparing stroke incidence after percutaneous coronary intervention to the general population.

AIMS

This study aimed to identify the incidence and risk factors for inpatient and subsequent stroke following percutaneous coronary intervention with comparison to age-matched controls.

METHODS

Data were prospectively collected from 22,618 patients undergoing percutaneous coronary intervention in the Melbourne Interventional Group registry (2005-2015). The cohort was compared to the North-East Melbourne Stroke Incidence Study population-based cohort (1997-1999) and predefined variables assessed for association with inpatient or outpatient stroke.

RESULTS

Inpatient stroke occurred in 0.33% (65.3% ischemic, 28.0% haemorrhagic, and 6.7% cause unknown), while outpatient stroke occurred in 0.55%. Inpatient and outpatient stroke were associated with higher rates of in-hospital major adverse cardiovascular outcomes (p < 0.0001) and mortality (p < 0.0001), as well as 12-month mortality (p < 0.0001). Factors independently associated with inpatient stroke were renal impairment, ST-elevation myocardial infarction, previous stroke, left ventricular ejection fraction 30-45%, and female sex, while those associated with outpatient stroke were previous stroke, chronic lung disease, previous myocardial infarction, rheumatoid arthritis, female sex, and older age. Compared to the age-standardized population-based cohort, stroke rates in the 12 months following discharge were higher for percutaneous coronary intervention patients <65 years old, but lower for percutaneous coronary intervention patients ≥65 years old.

CONCLUSIONS

Risk of inpatient stroke following percutaneous coronary intervention appears to be largely associated with clinical status at presentation, while outpatient stroke relates more to age and chronic disease. Compared to the general population, outpatient stroke rates following percutaneous coronary intervention are higher for younger, but not older, patients.

Are cerebral ischaemic complications more likely to occur in elderly patients undergoing transradial non-coronary intervention: A single-centre retrospective review

INTRODUCTION

Transradial artery access (TRA) is an established technique employed by interventional cardiologists for diagnostic and therapeutic coronary interventions. The use of TRA has gained increasing traction amongst interventional radiologists in recent years. In transradial, non-coronary interventions, the aorta has to be traversed. With increasing age, atherosclerotic changes in the aorta posed a theoretical risk of catheter-related emboli. Currently, there is limited literature available on the cerebral ischaemic complication rates in transradial non-coronary interventions.

METHODS

Between November 2015 and December 2017, 150 transradial non-coronary interventions were performed on 95 patients. Intra-procedural, in-hospital, 30-day and 6-month complications (ischaemic stroke, transient ischaemic attack and death, and minor complications, such as puncture site haematoma, pseudoaneurysm, thrombosis, dissection and perforation) were compared between the two age groups (≤65 and >65 years old).

RESULTS

The patients were predominantly male (87.0%) with age ≤65 (N = 69; 46.0%) and age >65 (N = 81; 54.0%). There were no ischaemic strokes at all time points in both groups, except for one case of ischaemic stroke at 6 months in the age ≤65 group(1.4% vs. 0.0%; P = 0.462). On multivariable analysis, age >65 was associated with lower in-hospital death rates (OR 0.251; 95% CI 0.013-3.09), at 30 days (OR 0.608; 95% CI 0.77-4.805) and at 6 months (OR 0.514; 95% CI 0.169-1.558) with no deaths intra-procedurally in both groups. Minor complications include puncture site grade I haematoma formation (2.9% vs. 2.5%; P = 0.999) and pseudoaneurysm (2.9% vs. 0.0%; P = 0.210). In our study, the overall major and minor complications rates are low and no statistically significant difference exists between the two groups.

CONCLUSION

Transradial non-coronary interventions are safe in elderly patients, who are likely to have more atherosclerotic disease of the aorta. Of note, no complication of ischaemic strokes within 30 days of the procedure is documented in all patients.

Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation

BACKGROUND

Use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients to treat refractory cardiogenic shock has increased in recent years, and ischemic stroke is the most frequent VA-ECMO-induced cerebrovascular complication. No adult case of mechanical thrombectomy (MT) has been reported.

METHODS

Retrospective observational study of hospital medical records of patients who received circulatory support with VA-ECMO with acute ischemic stroke treated with MT, from 2006 to 2018.

RESULTS

Two adult patients on VA-ECMO with acute ischemic stroke treated with MT were found. Both cases were successfully treated.

CONCLUSION

These cases illustrate the feasibility of performing MT in adult patients on ECMO.

Screening coronary angiography in patients with long-standing diabetes mellitus undergoing kidney transplant evaluation

BACKGROUND

The utility of coronary angiography in patients with diabetes mellitus undergoing kidney transplant evaluation is unclear. Predictors of critical angiography lesions in these patients will aid in appropriate use of angiography.

METHODS

Single-center study of 80 patients with ≥15 years of diabetes mellitus who underwent a screening coronary angiography despite a negative cardiac stress test. Risk factors for needing coronary intervention (CI) (percutaneous or bypass grafting) were analyzed.

RESULTS

Eighteen patients (23%) had a ≥70% occlusion in one or more major coronary vessel(s), with right coronary artery being the most commonly involved (71%). Fifteen patients (19%) underwent coronary intervention: ten percutaneously and five with bypass surgery. Risk factors for needing CI were not being on statin (OR 3.54, P = 0.047) and history of stroke or peripheral vascular disease (PVD; OR 3.5, P = 0.034). A model that included statin use, stroke/PVD history, and glycosylated hemoglobin had a receiver operating characteristic curve area under the curve of 0.8 to predict CI.

CONCLUSION

Despite a negative stress test, the prevalence of critical coronary lesions was high among kidney transplant candidates with long-standing diabetes. Risk factors for needing coronary intervention were absence of statin use and a history of stroke or peripheral vascular disease.

Comparison of Frequency of Ischemic Stroke in Patients With Versus Without Coronary Heart Disease and Without Atrial Fibrillation

Recent trials of antithrombotic therapy in patients with coronary artery disease (CAD) have demonstrated substantial reductions in ischemic stroke. Our aim was to examine ischemic stroke risk in patients with CAD and to identify those at highest risk. We examined ischemic stroke risk in patients without atrial fibrillation who underwent coronary angiography between 2004 and 2012. Patients were stratified according to presence or absence of CAD and further stratified by extent of CAD (0 vessel disease [VD], 1 VD, 2 VD, 3 VD, and diffuse VD). End points were composites of ischemic stroke, transient ischemic attack (TIA), and systemic embolism, as well as major adverse cardiovascular and cerebrovascular events (MACCE) defined as cardiac death, myocardial infarction, plus ischemic stroke, TIA, and systemic embolism. Adjusted incidence rate ratios (IRRs) were estimated. A total of 68,829 patients were included, 25,032 had 0 VD, 4,736 had diffuse VD, 18,471 had 1 VD, 10,588 had 2 VD, and 10,002 had 3 VD. Median follow-up was 4.0 years. CAD extent was associated with an increased risk of stroke, TIA, and systemic embolism (1 VD: adjusted IRR 1.02, 95% confidence interval [CI] 0.90 to 1.16; diffuse VD: adjusted IRR 1.22, 95% CI 1.02 to 1.47; 2 VD: adjusted IRR 1.28, 95% CI 1.12 to 1.45; 3 VD: adjusted IRR 1.37, 95% CI 1.20 to 1.55) compared with patients with 0 VD. Presence and extent of CAD were also associated with MACCE. In conclusion, CAD is associated with an increased risk of stroke, TIA, and systemic embolism and MACCE in patients without atrial fibrillation, and patients with coronary multi-VD are at highest risk and may be candidates for treatment strategies aiming at reducing ischemic stroke incidence.

Brain embolization of a healthy artery fragment as a complication of a cardiac catheterization

Ischemic stroke is the most common neurological complication of cardiac catheterization resulting in a high morbidity and mortality. We present a 44-year-old man admitted for vasospastic angina that suffered a right middle cerebral artery (MCA) occlusion after a cardiac catheterization. Mechanical thrombectomy was indicated and complete arterial recanalization was achieved. The material obtained showed a fragment of a healthy artery. Partial radial endarterectomy and cerebral embolization may be a rare complication of cardiac catheterization.

Contrast induced spinal myoclonus after percutaneous coronary intervention

We present a case of a 77-year-old man diagnosed with contrast-induced spinal myoclonus following primary percutaneous coronary intervention. After being admitted with a diagnosis of anteroseptal myocardial infarction, he underwent primary percutaneous coronary intervention to the left anterior descending artery and was prescribed aspirin, clopidogrel, and intravenous heparin. The following day he developed non-intentional irregular jerky movements confined to the truncal area. In view of rhythmic jerking confined to muscles innervated by a restricted segment of the spinal cord, resistance to supra-spinal influences and voluntary action, and no preceding electroencephalography activity in the contralateral sensorimotor cortex, a diagnosis of spinal myoclonus was made. Spinal myoclonus is a rare entity in which myoclonic movements occur in muscles originating from few (segmental), or many adjacent spinal motor roots (propriospinal). Structural lesions are found in the majority of cases but the actual pathophysiology is still unknown. Contrast-induced spinal myoclonus is an even rarer phenomenon with few published reports. We describe postulated mechanisms and the management of this phenomenon. <Learning objective: Myoclonus is a jerky movement due to abrupt involuntary contractions involving agonist and antagonist muscles. Spinal myoclonus is a rare disorder where myoclonic movements occur in muscles originating from spinal motor roots. The cause is usually a structural lesion, but in rare cases it can be induced by contrast. A video of this rare phenomenon is available with this article and the proposed pathophysiological mechanisms and treatment are discussed.>.

Fluctuating drowsiness following cardiac catheterisation: artery of Percheron ischaemic stroke causing bilateral thalamic infarcts

An 81-year-old man underwent cardiac catheterisation to investigate breathlessness and left ventricular impairment of unknown cause. He had unobstructed coronary arteries. Immediately following the procedure, he became suddenly unresponsive with vertical gaze palsy, anisocoria and bilateral upgoing plantar responses. He made a rapid recovery to his premorbid state 25 min later with no residual focal neurological signs. He then had multiple unresponsive episodes, interspaced with complete resolution of symptoms and neurological signs. MRI of the brain identified bilateral medial thalamic infarcts and midbrain infarcts, consistent with an artery of Percheron territory infarction. By the time the diagnosis was reached, the thrombolysis window had elapsed. The unresponsive episodes diminished with time and the patient was discharged to inpatient rehabilitation. At 6-month review after the episode, the patient has a degree of progressive cognitive impairment.

Percutaneous Coronary Intervention as a Trigger for Stroke

Percutaneous coronary intervention (PCI) is a plausible triggering factor for stroke, yet the magnitude of this excess risk remains unclear. This study aimed to quantify the transient change in risk of stroke for up to 12 weeks after PCI. We applied the case-crossover method, using data from the Norwegian Patient Register on all hospitalizations in Norway in the period of 2008 to 2014. The relative risk (RR) of ischemic stroke was highest during the first 2 days after PCI (RR 17.5, 95% confidence interval [CI] 4.2 to 72.8) and decreased gradually during the following weeks. The corresponding RR was 2.0 (95% CI 1.2 to 3.3) 4 to 8 weeks after PCI. The RR for women was more than twice as high as for men during the first 4 postprocedural weeks, RR 10.5 (95% CI 3.8 to 29.3) and 4.4 (95% CI 2.7 to 7.2), respectively. Our results were compatible with an increased RR of hemorrhagic stroke 4 to 8 weeks after PCI, but the events were few and the estimates were very imprecise, RR 3.0 (95% CI 0.8 to 11.1). The present study offers new knowledge about PCI as a trigger for stroke. Our estimates indicated a substantially increased risk of ischemic stroke during the first 2 days after PCI. The RR then decreased gradually but stayed elevated for 8 weeks. Increased awareness of this vulnerable period after PCI in clinicians and patients could contribute to earlier detection and treatment for patients suffering a postprocedural stroke.

Neurologic Complications in the Intensive Care Unit

Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Purpose—

To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.

Methods—

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

Results—

After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.