Bleeding and Ischemic Risk Prediction in Patients With High Bleeding Risk (an EVOLVE Short DAPT Analysis)

The EVOLVE Short DAPT study demonstrated the safety of truncated dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) treated with SYNERGY stent(s) (Boston Scientific Company, Marlborough, Massachusetts). In this population, bleeding and ischemic risk prediction may further inform DAPT decisions. This post hoc analysis of the EVOLVE Short DAPT study identified predictors of ischemic and bleeding events up to 15 months using Cox proportional hazard models. The predicted probabilities of bleeding were calculated using the Breslow method. Of 2,009 enrolled patients, 96.9% of the patients met at least 1 HBR criteria. At 15 months, the cumulative incidences of bleeding and ischemic events were 6.3% and 6.0%, respectively. The risk of bleeding was increased in patients who received oral anticoagulants (hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.50 to 3.36, p <0.001) or had peripheral vascular disease (HR 1.61, 95% CI 1.01 to 2.56, p = 0.045). The risk of ischemic events was increased in patients with diabetes (HR 1.86, 95% CI 1.24 to 2.78, p <0.01) or congestive heart failure (HR 2.06, 95% CI 1.39 to 3.04, p <0.001). Renal insufficiency/failure was associated with both endpoints. There was a strong positive correlation between the predicted probability of ischemic and bleeding events (R = 0.77, p <0.001). In 617 patients with a predicted bleeding risk <4%, ischemic events predominated, and the ischemic and bleeding rates were higher in patients with a predicted bleeding risk ≥4%. Within an HBR cohort, specific characteristics identify patients at a higher risk for ischemic and separately, bleeding events. Increased bleeding risk is tied to increased ischemic risk. In conclusion, standardized risk models are needed to inform DAPT decisions in patients with a higher risk. Clinical Trial Registration: NCT02605447.

Primary Results of the EVOLVE Short DAPT Study: Evaluation of 3-Month Dual Antiplatelet Therapy in High Bleeding Risk Patients Treated With a Bioabsorbable Polymer-Coated Everolimus-Eluting Stent

[Figure: see text].

Incidental LAD stenosis identified on non-gated chest CTA

A 57-year-old male former smoker presented to the Emergency Department (ED) with blurry vision, headache, and generalized weakness. He was hypoxic on room air and ECG showed sinus tachycardia. A CT pulmonary angiogram was ordered in the ED and revealed no pulmonary embolism but incidentally noted a likely significant stenosis in the proximal LAD. Subsequent cardiac catheterization revealed a 90% stenotic lesion with percutaneous coronary intervention leading to symptom resolution. Unlike coronary CTA, CTPA is performed with non-ECG gated helical scanning and generates motion artifacts associated with myocardial contraction. However, the timing of vascular contrast opacification during CTPA often allows for at least partial evaluation of the coronary arteries, especially ostial and proximal segments. Physicians ordering and evaluating noncardiac-focused CT chest studies, particularly in the ED, should remain cognizant of the radiographic appearance of underlying CAD, particularly life-threatening incidental coronary pathologies to allow for timely management and intervention.

Wide-beam reconstruction half-time SPECT improves diagnostic certainty and preserves normalcy and accuracy: a quantitative perfusion analysis

BACKGROUND

Filtered back-projection (FBP) has been a standard in SPECT imaging. Newer iterative reconstruction algorithms have been shown to improve image quality and shorten acquisition time by taking into account statistical nature of raw data and using resolution recovery (RR). Wide-beam reconstruction (WBR) is an iterative algorithm with RR and adaptive noise control. We prospectively investigated outcome of WBR half-time SPECT on diagnostic certainty, accuracy and normalcy by quantitative perfusion analysis in comparison to full-time FBP images.

METHODS

434 patients underwent rest (201)Tl/stress (99m)Tc-sestamibi full-time (20 s/stop, FBP) followed by a half-time (10 s/stop, WBR) SPECT. 34 patients underwent an angiogram within 90 days of SPECT. Diagnostic certainty was based on summed stress scores (SSS, 5-point/17 segments): normal if SSS ≤ 1, equivocal if SSS = 2-3, and abnormal if SSS ≥ 4. Perfusion defects were normalized to a percent of total myocardium, and expressed as %LV = defect SSS/maximal SSS × 100% with maximal SSS of 28 for left anterior descending (LAD), and of 20 for right coronary (RCA) and left circumflex (LCX). Change in %LV (Δ%LV = %LV FBP - %LV WBR) was evaluated for diagnostically discordant versus concordant scans.

RESULTS

SSS and %LV demonstrated very good correlation. There were significantly fewer equivocal scans with WBR (38 vs 151 FBP, P < .0001). Most discordant scans were equivocal FBP SPECT becoming normal with WBR (123/151). Δ%LV(LAD) for discordant studies was greater for women (5.4% ± 4.2%, P < .001), while Δ%LV(RCA,LCX) (4.4% ± 5.1%, P < .001; 1.2% ± 5.0%, P = .04) were greater for men. Normalcy rate was 91.4% for FBP and WBR with more definitely normal WBR studies (84.5% vs 43.9% for FBP, P < .0001). There were no differences in sensitivity (FBP 84.2%, WBR 81.6%), specificity (FBP 54.6%, WBR 63.6%), and accuracy (FBP, WBR 77.6%).

CONCLUSION

Quantitative perfusion analysis suggests that adaptive noise control with WBR improves uniformity of myocardium comparing to FBP techniques, and results in improved diagnostic certainty while preserving normalcy and accuracy.

Coronary venous angioplasty and stenting for biventricular pacemaker left ventricular lead implantation

Biventricular pacing for the treatment of congestive heart failure is now one of the forefront therapies for symptomatic heart failure patients who are receiving maximal medical therapy. Recent advances in lead technology and delivery systems have improved the success rates of left ventricular (LV) lead implantation. A major difficulty in LV lead implantation, however, occurs in patients with coronary vein stenoses, insufficient coronary vein caliber, or significant variations in coronary venous anatomy, in terms of left ventricular lead implantation. We sought to examine whether cardiac vein angioplasty and/or stenting would allow for the proper placement of the LV lead in these patients.

Right-sided Myxomas

Primary tumors of the heart are rare with an incidence of 0.0017% to 0.19% in unselected patients at autopsy. Of those tumors, cardiac myxomas are the most commonly seen and account for about 50% of primary cardiac tumors. About 75% to 85% of myxomas originate in the left atrium, 15% to 20% in the right atrium, and only rare cases have been reported of myxomas originating in the left and right ventricles (5%). We present 3 cases in which right-sided myxomas were diagnosed echocardiographically and review the literature on primary cardiac myxomas.

Protein tyrosine kinase inhibitor, genistein, enhances apoptosis and cell cycle arrest in K562 cells treated with gamma-irradiation

Genistein, is a natural isoflavone compound with a potent activity against protein tyrosine kinases. The leukemic cell line, K562, is a bcr/abl (Philadelphia chromosome) positive cell line that is resistant to DNA-damaging agents, including gamma-irradiation. Treatment with genistein increased apoptosis and promoted G2-phase arrest in the non-apoptotic population of the gamma-irradiated K562 cells. Irradiated cells that survived 72 h after the irradiation had a normal distribution in cell cycle, whilst genistein treatment kept cells arrested in the G2-phase, decreased the S-phase fraction and suppressed DNA-synthesis. Taken together, our results show that genistein augments apoptotic cell death after gamma-irradiation in K562 cells and this result cannot be attributed to abrogation of the G2/M checkpoint.

Antineoplastic and cytogenetic effects of complexes of Pd (II) with 4N-substituted derivatives of 2-acetyl-pyridine-thiosemicarbazone

The effect of novel Pd(II) complexes with derivatives of 2-acetyl-pyridinethisemicarbazone, N4-ethyl (HAc4Et) and 3-hexamethyleneiminylthiosemicarbazone (HAchexim), on Sister Chromatid Exchange (SCE) rates and human lymphocyte proliferation kinetics was studied. Also, the effect of Pd(II) complexes on DNA synthesis of P388 and L1210 cell cultures and against Leukemia P388 was investigated. Among these compounds, the compound Bis(3-hexamethyleneiminyl-2-acetylpyridine-thisemicarbazonato++ +) palladium (II) was found to be distinctly effective against Leukemia P388, in inhibiting incorporation of 3H-thymidine into DNA and in inducing SCEs and cell division delays.

Comparative study of SCE induction and cytostatic effects by homo-azasteroidal esters of N,N-bis(2-chloroethyl)aminobenzoic acid in human lymphocytes

The effect of homo-azasteroidal esters of benzoic acid mustard isomers and the 4-methyl derivatives, which have steroidal lactams as a biological basis, on cytogenetic damage was studied. Twenty compounds were comparatively studied, on a molar basis, as regards their ability to induce sister-chromatid exchanges (SCEs) and cell division delays. A correlation between potency for SCE induction, effectiveness in cell division delay and previously established antitumor activity of these compounds was observed.

Comparative study on cytogenetic damage induced by homo-aza-steroidal esters in human lymphocytes

The effect of P[N,N-bis(2-chloroethyl)amino]phenylacetate esters of 3 beta-hydroxy-N-methyl-17 alpha-aza-D-homo-5 alpha-androstan-17-one (compound 3) and 3 beta-hydroxy-17 alpha-aza-D-homo-5 alpha-androstane (compound 2) on sister-chromatid exchange (SCE) frequencies and on human lymphocytes proliferation kinetics was studied. The results are compared with those of the P[N,N-bis(2-chloroethyl)amino]phenylacetate esters of 3 beta-hydroxy-17 alpha-aza-D-homo-5 alpha-androstan-17-one (compound 1). All compounds were found to be active in inducing markedly increased SCE rates and cell division delays. A correlation between potency for SCE induction, effectiveness in cell division delay and previously established antitumour activity of these compounds was observed.

Effects of tamoxifen and CV 205502 on the morphology and the evolution of the noncancerous mouse mammary gland

Tamoxifen (TAM, 0.01 mg/animal, three times a week) and the experimental prolactin-lowering CV 205502 (CV, 1 microgram/animal, daily) were administered prophylactically, alone or combined, to virgin C3H/Sy mice during the early period of promotion in this spontaneous mammary carcinogenesis system (end of 2nd-5th month of age), in order to study their influence on the morphology and evolution of the noncancerous mammary gland during therapy and after treatment cessation. During TAM administration the epithelial cells of the growing part of the gland exhibited myoepithelial- and, late in the treatment period, apoptotic-like features instead of the secretory ones expected, accompanied by intense basement membrane alterations, thickening of the surrounding connective tissue and arrested adipocyte maturation. These effects reversed progressively after drug withdrawal. The epithelial alterations were more intense and longer lasting in the TAM+CV-group, while growth arrest of the glands was observed in both groups parallel to the degree and the duration of these morphological changes. In these groups, tumor incidence was diminished, as expected, but the tumors that developed late after treatment cessation were of low histological differentiation. The above morphological observations show that TAM inhibits noncancerous mammary gland growth during the reproductive period by altering stromal and epithelial differentiation, effects that reverse progressively after treatment discontinuation and are potentiated by a prolactin-lowering agent in this animal study.

Comparative study on cytogenetic effects by diplatinum complexes of the ligands of naphthazarine and squaric acid in human lymphocytes

The effect of diplatinum complexes of the binucleating ligands of naphthazarine and squaric acid on Sister Chromatid Exchange (SCE) rates and human lymphocyte proliferation kinetics was studied. Squarodicisplatinum complex I, naphthazarindicisplatinum and squarodicisplatinum complex II induce cytotoxic effects as can be deduced from the resulted induction of SCEs and the produced cell division delays. Squarodicisplatinum complex I was found to be on a molar basis the most effective in causing markedly increased SCE rates and cell division delays. Cis-diaminodichloride platinum was found to be next in order of effectiveness with naphthazarindicisplatinum and squarodicisplatinum complex II following. Naphthazarine and SQA were found to be ineffective on induction of SCEs.

Induction of cytogenetic damage by modified steroidal derivatives of p-bis(2-chloroethyl)aminophenylacetic acid in human lymphocytes

The effect of modified steroids, containing alkylating agents, on SCE rates and on cell kinetics in cultured human lymphocytes was studied. The homo-aza-steroidal ester of p-bis(2-chloroethyl)aminophenylacetic acid (ASE) was found to be the most effective in causing markedly increased SCE rates and cell division delays. The androsterone ester of p-bis(2-chloroethyl)aminophenylacetic acid (AE-CAPA) was found to be next in order of effectiveness with the lactone ester (LE-CAPA), chlorambucil ester 3 beta-hydroxy-13a-amino-13,17-seco-5a-androstan-17-oic-13,17-lactam (CBC-HAAL) and chlorambucil (CBC) following. p-Bis(2-chloroethyl)aminophenylacetic acid (CAPA) had only a small effect and 3 beta-hydroxy-13a-amino-13,17-seco-5a-androstan-17-oic-13,17-lactam (HAAL) had no effect at all. A correlation between potency for SCE induction, effectiveness in cell division delay and previously established antitumor activity of these drugs was observed.

Potential antitumor agents: steroidal amidoesters with an alkylating moiety

17 beta-Acetamido-5-androsten-3 beta-ol-p-bis(2-chloroethyl) aminophenylacetate and 17 beta-acetamido-5 alpha-androstan-3 beta-ol-p-bis(2-chloroethyl)aminophenylacetate, amido steroidal alkylating agents, were investigated in L1210 and P388 leukemias, Ehrlich ascites tumor, and adenocarcinoma CA-755. Both substances were determined to increase the life span of the tumor-bearing animals and to cause several long-term survivors in adenocarcinoma CA-755.

Further studies on the antineoplastic activity of homo-aza-steroidal esters

The modified steroidal alkylating agents, 17 beta-hydroxy-3-aza-A-homo-4 alpha-androsten-4- one(p-[bis(2-chloroethyl)amino]phenyl)butyrate(1),3 alpha-hydroxy- 13,17-seco-5 alpha- butyrate(2),3 beta-hydroxy-13,17-seco-5-androsten-17-oic- 13,17-lactam(p-[bis-(2-chloroethyl)amino]phenyl)butyrate(3) and and (p-[bis(2-chloroethyl)amino]phenyl)butyric acid(4) have been tested against L1210, P388, Ehrlich ascites tumors (EAT), Lewis lung (LL) carcinoma and adenocarcinoma CA-755. Of four compounds evaluated in L1210 leukemia, none displayed antileukemic activity. Almost all of the four compounds were more or less active against P388 leukemia. Compound 2 possesses a slight antitumor activity in EAT, while only compound 1 appears to be active in LL carcinoma. The antitumor activity of the three modified steroidal esters on adenocarcinoma CA-755 seems to be interesting.

Studies on the effect of homo-aza-steroidal ester of p-bis (2-chloroethyl) amino phenyl acetic acid in Ehrlich ascites tumor cells

The effect of a homo-aza-steroidal ester (ASE) on the incorporation of radioactive precursor to DNA of Ehrlich ascites tumor (EAT) cells has been investigated. We found that treatment of cells with 80 micrograms/ml of ASE for 2 hours causes an inhibition of the incorporation of 3H-thymidine to DNA by 71%. This is partly because ASE affects the radioactive thymidine pool in the cell. The DNA from EAT cells after centrifugation in CsCl is shifted to higher densities when ASE is present throughout the experiment. This density shift was not observed when ASE was incubated only in the growth medium of the cells.

Interaction of homo-aza-steroidal ester of [p-[bis-(2-chloroethyl) amino]phenyl]acetic acid (ASE) with DNA of Ehrlich ascites tumor cells

A cytostatic, homo-aza-steroidal ester of [p-[bis-(2-chloroethyl) amino]phenyl]acetic acid (ASE) was reduced with NaB3H4 and [3H]ASE-treated DNA prepared in vitro. We found that: (1) ASE reacts preferentially with purines; (2) ASE decreases the thermal stability of the double helix upon binding to DNA; (3) [3H]ASE binding sites are clustered along the DNA molecules; (4) ASE binding sites probably represent oligo- or polypurine sequences.

[Chemotherapy of the non-small cell bronchogenic carcinoma]

From 1976 to 1981 61 patients (50 men and 11 women) with non-small cell bronchogenic carcinoma (i.e. squamous cell or adeno-carcinoma) received a chemotherapy treatment based on two cytostatic drug combinations for each histological group. The drugs which were used were cyclophosphamide, adriamycin, vincristine, methotrexate, bleomycin, 5-fluorouracil and procarbazine. All patients had advanced disease and 6 of them had had previous surgical excision of the primary tumor. A large proportion of the patients had received irradiation to the primary site prior to chemotherapy. 1 patient developed a complete remission, 5 developed a partial remission and 34 showed stabilization of their disease. In 21 patients the disease progressed in spite of the treatment. Responders had a significantly longer survival than non-responding patients.

Hodgkin's disease in Greece: a retrospective clinicopathologic study of 78 cases

The Rye histologic classification of Hodgkin's disease has been applied retrospectively to a series of 78 previously untreated cases of Hodgkin's disease. The patients have been followed for periods varying from 1 to 12 years. Mixed cellularity was the most common histologic type. Nodular sclerosis had an intermediate frequency, and lymphocytic predominance and lymphocytic depletion showed the lowest incidence. The sex incidence showed a male predominance in all histologic types except the nodular sclerosis, where prevalence of females was noted. The study confirms the better prognosis of the lymphocytic predominance and nodular sclerosis in comparison with the poor prognosis of the mixed cellularity and the very poor prognosis of the lymphocytic depletion. Nodular sclerosis presented with higher incidence in the mediastinum; it occurred mainly in young females and it exhibited a relatively good prognosis, findings which support the accepted view that nodular sclerosis comprises a distinct clinical and biological type of the disease. A marked difference in the survival rates in Stages I and II as compared to those of Stages III and IV was found.

New compounds: antitumor activity of 3beta-hydroxy-13alpha-amino-13,17-seco-5alpha-androstan-17-oic-13,17-lactam 4-[p-[bis(2-chloroethyl)amino]phenyl]butyrate

3beta-Hydroxy-13alpha-amino-13,17-seco-5alpha-androstan-17-oic-13,17-lactam 4-[p[bis(2chloroethyl)amino]phenyl]butyrate was prepared by reacting 4-[p-[bis(2-chloroethyl)amino]phenyl]butyryl chloride hydrochloride with 3beta-hydroxy-13alpha-amino-13,17-seco-5alpha-androstan-17-oic-13,17-lactam. They cytostatic action of the ester was investigated on two tumor systems (B16 melanoma on C57 b1 mice and T8-Guerin on rats).