Meta-Analysis on Invasive Versus Conservative Strategy in Patients Older Than Seventy Years With Non-ST Elevation Myocardial Infarction

Management of non-ST elevation myocardial infarction (NSTEMI) has evolved over the years, but most published data are from younger patients. Data on the NSTEMI management in older patients remain limited. We performed a meta-analysis of randomized controlled trials to evaluate the long-term outcomes of invasive versus conservative strategies in older patients (>70 years old) with NSTEMI. Of 1,550 reports searched, 4 randomized controlled trials (1,126 patients) were included in the analysis, with a median follow-up of 1.25 years (range: 1 to 2.5 years). The median age of included patients was 83.6 (interquartile range: 2.8 years). The invasive strategy was associated with significantly lower risk of major adverse cardiac and cerebrovascular event (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.91, I² = 54%; 3 trials] and unplanned revascularization (OR 0.31, 95% CI 0.15 to 0.64, I² = 1.7%; 3 trials] than was the conservative strategy. There was no difference in all-cause mortality (OR 0.88, 95% CI 0.65 to 1.18, I² = 0%; 4 trials], myocardial infarction (OR 0.70, 95% CI 0.42 to 1.19, I² = 54.7%; 4 trials], or bleeding (OR 0.87, 95% CI 0.39 to 1.93, I² = 0%; 3 trials] between the strategies. In conclusion, the use of initial invasive strategy in older patients presenting with NSTEMI was associated with a significantly lower risk of major adverse cardiac and cerebrovascular event and unplanned revascularization than that of the initial conservative strategy without increased bleeding.

Utility of Coronary Artery Calcium Scores in Predicting Risk of Subclinical Cardiovascular Atherosclerotic Disease: An Analysis of Limitations to its Adoption With Policy Recommendations

This survey-based analysis aims to highlight key limitations to a wider adoption of coronary artery calcium (CAC) scoring as a means of screening asymptomatic individuals for atherosclerotic cardiovascular disease. The need for a screening tool that adds objective anatomical information to historically established risk scores in the aforementioned population has been met by this imaging modality. Despite that, there has been a hesitance towards frequent usage of these scans. Within the pre-set sampling frame of the University of Toledo, a convenience sampling technique was used to reach out to 60 health care providers. The resultant responses were analyzed and discussed. In addition to identifying patients who need to be worked up further, CAC scans can also help re-stratify patients within-risk groups and inform decision-making regarding the use of lipid-lowering therapies. The public health impact of a greater but appropriate utilization of this diagnostic tool will be impactful. This analysis seeks to better understand real-life obstacles to a wider adoption of these scans and attempts to lay out policy recommendations to address these issues.

Recurrent Bacteremia with Corynebacterium Striatum After Prosthetic Valve Replacement: A Case Report

Infective endocarditis is typically caused by Staphylococcus aureus (S. aureus), coagulase-negative staphylococci and streptococci but infection with Corynebacterium striatum (C. striatum) is also becoming prominent. We present the case of a 65-year-old female with a recent history of the coronary artery bypass graft with bioprosthetic aortic valve replacement. The surgery was complicated by sternal wound dehiscence with methicillin-sensitive S. aureus (MSSA) for which she was treated for six weeks with intravenous antibiotics. Two months later, she was found to have C. striatum which was treated. A transesophageal echocardiogram was done as well which did not show any vegetation. She presented to the hospital with vomiting, cough, fever, and shortness of breath. She had pyuria on urinalysis and was started on empiric antibiotics after taking blood cultures. She decompensated soon after admission and was transferred to the intensive care unit where she had a pulseless ventricular tachycardia and was resuscitated but required vasopressor support. The blood cultures from admission started growing C. striatum again. Daptomycin was added to the empiric antibiotics and supportive care was continued, but the family decided to make her 'do not resuscitate - comfort care only'. The support was withdrawn and she passed away.