Ticagrelor could cause central sleep apnea after acute coronary syndrome in patients without left ventricular dysfunction or heart failure

Background

Although the prevalence of obstructive sleep apnea (OSA) syndrome is high in patients with acute coronary syndrome (ACS), little is known about central sleep apnea (CSA) in these patients, especially if they have no left ventricular dysfunction (indeed, it is well known that heart failure could be a confounding factor as it is an important cause of CSA). Furthermore, central apnea could be promoted by ticagrelor, a relatively new drug, already known to cause dyspnea (which could modify the apneic threshold) in some patients.

Purpose

To investigate the prevalence of central sleep apnea in patients without left ventricular dysfunction after ACS.

Methods

Monocentric prospective survey. All consecutive patients within 365 days after ACS were included if they had (1) left ventricular ejection fraction LVEF >45%, (2) no history of heart failure, (3) systolic arterial pulmonary artery pressure <45 mm Hg, and (4) no history of sleep apnea. After inclusion, patients underwent an overnight sleep study with a portable sleep monitor validated to differentiate central and obstructive apneas. Patients were then classified as “normal” patients if they had an AHI (apnea hypopnea index) <15, “CSA patients” if they had an AHI >15 with a majority of central sleep apneas and “OSA patients” if they had an AHI >15 with a majority of obstructive sleep apneas.

Results

Between January 2018 and January, 2020, we included 115 consecutive patients (age 56.1±10.5, male 84%, mean body mass index 28.4±4.5, LVEF: 56±4%). Sleep study was performed 68±62 days (7–350 days) after ACS on average. All of the patients were receiving a single or (mostly) dual antiplatelet therapy: aspirin (n=114: 99%, ticagrelor (n=80: 69.5%), clopidogrel (n=28: 24%), prasugrel (n=4: 3.5%).

Finally 80 patients were taking ticagrelor, while 35 were not.

A total of 49/115 patients (42.6%) had a clinically significant (moderate to severe) sleep disordered breathing, with an AHI>15: (CSA: n=27/115: 23.5%, OSA:n=22/115: 19%). Among them, 25/115 patients (22%) had a severe (AHI >30) sleep disordered breathing: CSA 12% OSA: 10%.

Among patients receiving ticagrelor, 24/80 (30%) had a CSA with an AHI >15, while, in patients not taking ticagrelor only 3/35 (8.5%) had CSA with an AHI >15 (p=0.04)

Conclusion

As expected, OSA is frequent after ACS, as in all types of coronary artery disease patients. High prevalence of CSA was less expected and seemed to be correlated with ticagrelor administration. This monocentric survey is a preliminary safety signal. Further studies are needed to investigate the exact incidence, the sustainability and the potential consequences of ticagrelor induced central sleep apnea.

Funding Acknowledgement

Type of funding source: None

[Sudden cardiac death in the youth. Is the new subcutaneous implantable cardioverter defibrillator S-ICD an alternative solution?]

Implantable cardioverter defibrillator (ICD) is well-recognized therapy to prevent sudden cardiac death. Classic ICD need the use of permanent endocavitary leads, which may cause serious troubles (lead dislodgement, ventricular perforation, lead infections, etc.). The subcutaneous implantable cardioverter defibrillator (S-ICD) is a new device provided by only a subcutaneous lead. It has been developed for the last five years and it is becoming at present a real alternative to classic ICD. We report a clinical case of a 34 y.o. woman who presented a sudden cardiac death and who benefited the implantation of this new technology. This paper deals with the potential indications, usefulness benefits, and problems of the S-ICD.

Aortic thrombus and multiple embolisms during a Mycoplasma pneumoniae infection

We report the case of a patient who presented with a thrombus of the aortic arch complicated with splenic, renal and peroneal artery embolisms, associated with transient lupus anticoagulant, during a Mycoplasma pneumoniae infection. The outcome was good under antibiotic and anticoagulant treatment. We also review the medical literature on M. pneumoniae-related thromboses.

[Rotational coronary angiography]

CONTEXT

Rotational angiography (RA) is a radiological technique that provides multiple views of a vessel for a single injection of contrast. Its significance in the field of coronary angiography is poorly known at present. This study aimed to compare the radiation dose as well as the volume of contrast used during RA compared to standard angiography (SA), and to evaluate its diagnostic precision.

METHOD

78 patients sent for diagnostic coronary angiography were explored using the radial approach. The patients were randomised between RA (3 acquisitions for the left coronary and 1 for the right coronary) or SA. Once a decision to undertake angioplasty had been made following the angiography (RA or SA), the initial study was complemented using the alternative technique (SA or RA) before the angioplasty procedure was performed at a later stage. The severity of the lesions as shown by RA and SA was compared by four experienced coronary angiography operators.

RESULTS

65 patients (mean age 61+/-10 years--mean BMI 26+/-4 Kg/m2) underwent complete RA+SA investigation. The total x-ray dose used during ciné-angiography, the dose received by the patient, and the volume of contrast were significantly reduced in the RA group compared to the SA group (-25%; -36%; -33% respectively). An evaluation of the severity of the stenoses was performed on 168 arterial segments. There was a significant correlation between the two techniques (R=0.95--p<0.001) and the intra-observer variability was non significant (3.7+/-6.8%--p=NS).

CONCLUSIONS

Rotational angiography allows the radiation dose and the volume of contrast to be reduced, while retaining a diagnostic precision similar to that of standard angiography.

Coronary heart disease and cardiovascular autonomic neuropathy in the elderly diabetic

Diabetes and old age come together to increase the frequency and severity of coronary heart disease. Often clinically nearly silent, symptoms frequently manifest dramatically, to such an extent that the question of screening should be raised, as in younger subjects. Preventing these manifestations relies on better management of the cardiovascular risk factors and obtaining good blood glucose control, but here progress remains necessary, which also requires adapting to the older patient's clinical and psychological condition. Cardiovascular autonomic neuropathy is a frequent degenerative complication in diabetics, particularly in the oldest subjects. The most severe types have serious clinical consequences, thus a higher mortality factor, but the mechanisms remain poorly understood. As for coronary heart disease, the therapeutic tools have expanded these last few years and should be thought out in relation to the geriatric evaluation, with the objective of improving these patients' quality of life. Therefore, a necessary distinction should be made between subjects who have aged successfully, whose management, ultimately, differs little from younger subjects, and frail elderly individuals for whom exploratory techniques and treatment should be adapted.

[Anaesthesia and amiodarone-associated hyperthyroidism]

Amiodarone can induce severe hyperthyroidism that justifies its withdrawal and initiation of antithyroid drugs. Impossibility to stop amiodarone, failure to control hyperthyroidism and unfavourable evolution can lead to thyroidectomy. Cardiac manifestations, persistence of hyperthyroidism and interactions between amiodarone and anaesthetic or haemodynamic drugs may contraindicate anaesthesia. We report nine consecutive cases of amiodarone-associated hyperthyroidism that prompted us to perform thyroidectomy under general anaesthesia. The features and anaesthetic data of patients were noted. The antithyroid medical treatment failed in all patients. After thyroidectomy, evolution was favourable in all nine cases, without any intra or postoperative complication, in spite of the extent of hyperthyroidism and the severity of the associated cardiac problems. Despite potential high risks, thyroidectomy for amiodarone-induced hyperthyroidism does not seem to increase morbidity or mortality and allows a quick return to euthyroidism and reintroduction of amiodarone.

[Input of coronary artery calcium score assessed by computed tomography in the screening of diabetic coronaropathy]

The poor prognosis of coronary artery disease along with the inaccuracy of available testing methods have favoured the development of new screening techniques. One such innovation involves measuring the coronary artery calcium score (CAC). Through computed tomography, this test quantifies the amount of calcium deposited in coronary arteries, itself a reflection of the degree of atherosclerosis. This investigation is a prospective study of 48 diabetic subjects comparing the performance of CAC score with the gold standard testing methods. The results of our study showed that, due to its high negative predictive value, 5 invasive tests were performed needlessly as these subjects had very low CAC scores. At this time, the CAC score is not recommended for every patient but rather on a case-by-case basis. However, it may soon emerge as the next step after the ECG in the evaluation of coronary artery disease. This would alleviate the need for more invasive tests in those patients for whom such investigations are deemed unnecessary. The CAC score, when matched for age, sex and other variables, could also serve as an indication for prescribing medications such as statins, along with other therapeutic interventions. Diabetologists, cardiologists and radiologists must work together in order to gain a better understanding of these new techniques. This may facilitate the emergence of a new approach to the treatment of coronary artery disease.

Procedural characteristics of primary coronary angioplasty in diabetic patients with acute anterior myocardial infarction

BACKGROUND

Mortality and morbidity rates are higher in diabetics compared to non-diabetics after acute myocardial infarction (AMI). Previous angiographic studies regarding primary angioplasty for the treatment of AMI found that angioplasty was similarly successful in diabetics and non-diabetics. However, it is noteworthy that patients of "real life" are often far from the population randomised in prospective protocols. The aim of this study was to examine the procedural characteristics of consecutive diabetic patients hospitalised for anterior AMI and treated with primary angioplasty as compared to non-diabetics.

METHOD

We analysed 28 consecutive diabetics and 74 non-diabetics who underwent primary angioplasty for anterior AMI (< 12 h from the onset of symptoms) during 15 consecutive months between 2000 and 2001 in our institution, depending on the presence or absence of diabetes.

RESULTS

Among analysed data, we found that in diabetics compared to non diabetics: (i) the delay before arrival in the cath-lab was significantly longer (5.5 +/- 2.7 vs 4.2 +/- 2.8 h); (ii) there was a less important collateral flow coming from the non-culprit arteries towards the culprit artery; (iii) there was a less important rate of recovery of a normal flow (TIMI 3) in the culprit artery after coronary angioplasty (67% vs 91%).

CONCLUSION

Our study demonstrates that several procedural characteristics could explain the poorer prognosis of AMI treated by primary angioplasty in the diabetic population. The longer delay found in diabetics before arrival in hospital could probably be improved.

[Importance of transesophageal echocardiography and computed tomography in the differential diagnosis of a case of papillary fibroelastoma revealed by a neurologic accident]

In the light of a new case revealed by a stroke, the authors confirm the importance of transesophagal echocardiography (TEE), and show that multislide computered tomography can be used as a new efficient tool for the diagnosis of cardiac papillary fibroelastoma (CPF). These benign tumours of endocardium are rare and case reports have been published sporadically. Stroke is an usual clinical complication and the most frequent symptom associated with CPF. Transesophageal echocardiography is the reference for diagnosis of CPF when transthoracic echocardiography is normal. When TEE is contraindicated or technically impossible, multislide computered tomography appears as an interesting alternate solution for diagnosis because of its fast acquisition and high spatial resolution. Symptomatology may be connected to either tumoral embolisation or cruoric emboli. Surgery is required for any symptomatic tumour.

Angiographic characteristics of coronary artery disease in diabetic patients compared with matched non-diabetic subjects

The aim of this study was to assess the extent and the severity of coronary artery disease (CAD) in diabetic patients. Angiographic findings were retrospectively analysed in 50 diabetic and in 50 non-diabetic patients, matched for age and sex, undergoing coronary angiography for evaluation of clinically CAD or silent ischaemia. Baseline characteristics did not show any increase of cardiovascular risk in diabetics compared to the non-diabetic group. Diabetic patients present less chest pain and more electric abnormalities, reflecting CAD specificity for diabetic patients. Angiograms of the coronary tree were divided into 13 segments and two experienced angiographers have developed a methodic analysis of selected coronary segment stenosis. The number of significant coronary artery stenosis (> or = 50%) per patient was higher in diabetic than in non-diabetic subjects (5.06+/-2.16 vs 2.40+/-1.97, p < 0.05). Diabetics had also more left main CAD (7/50 vs 1/50,p < 0.05). Though we did not find at any time statistical difference for multivessel, distal or diffuse CAD between the two groups, nevertheless there are more diffuse and distal lesions of the diabetic coronary artery trees. This debate is not closed, there is always controversy concerning whether the angiographic findings in diabetic or non-diabetic patients are different. But these results corroborate the hypothesis of a greater severity of angiographic proven CAD in diabetic than in non-diabetic patients, especially in the left main coronary artery.

[Postpericardiotomy syndrome; a rare complication of transcavitary cardiac pacing: apropos of a case]

The authors report a new case of the post-pericardiotomy syndrome occurring after implantation of a DDD pacemaker. This is a rare complication of the insertion of a screw atrial electrode, the iatrogenic potential of which has already been reported. The immediate outcome was favourable with anti-inflammatory therapy.