A 69-year-old male presented with typical angina while showering. He had history of CABG in 2008 (left internal mammary arterial [LIMA] to the first marginal and intermediate arteries and RIMA to the LAD artery), with preserved biventricular systolic function. On physical examination, an upper-arm systolic blood pressure differential >20mmHg and a decreased pulse amplitude on the left side was found. ECG revealed sinus tachycardia with RBBB, ST-segment depression and inverted T-waves in the lateral and inferior leads. Troponin and BNP levels were elevated. Echocardiogram showed reduced left ventricular ejection fraction (22%) and de novo akinesia of the inferior and posterior walls. The diagnosis of non-ST-segment elevation myocardial infarction was assumed. Coronary angiography revealed patent bypass grafts without disease and a 90% stenosis of the left subclavian artery (LSA) proximal to the ostia of the LIMA, with retrograde flow ‘stealing’ the myocardial blood supply. Ultrasound scan detected systolic reversal of flow in the left vertebral artery, suggesting subclavian-vertebral steal phenomenon. CT-angiography revealed a 14-mm stenosis with a useful lumen of 2 mm in the LSA. A percutaneous balloon angioplasty with stenting of the LSA was performed by the Vascular team, restoring the normal blood supply. Coronary subclavian steal syndrome can manifest as myocardial infarction or heart failure, due to functional LIMA graft failure by inadequate blood supply to the myocardium. Anamnesis and physical examination are fundamental in order not to miss the diagnosis. Subclavian angiography is the gold standard to confirm the diagnosis and can be performed during coronary angiography. Revascularization of the LSA is the definitive treatment. Figure 1Coronary angiography revealed chronic occluded native coronary vessels with patency and no significant disease of the bypass grafts, and high grade (90%) left subclavian artery (LSA) stenosis proximal to the ostia of the LIMA, conditioning the blood flow to the left upper limb and ‘stealing’ the myocardial blood supply because of retrograde flow in the LIMA graft.
Introduction Adult Congenital Heart Disease(ACHD) patients are an increasing population with known high risk for thromboembolic events.Validated scores are uncertain in this population. Although apparently safe, data is scarce about the use of NOAC. Purpose To evaluate all patients on-NOAC followed in an ACHD outpatients clinic and observe its safety and efficacy during a median follow-up of 34 months (IQR 7–60 months). Major bleeding was defined according to types 3 to 5 in BARC scale. Adverse event was defined as ≥ 1 of the follows: death, stroke, myocardial infarction, systemic embolism or major bleeding. Results A total of 65 patients were included, with a mean age of 52 ± 14 year-old, 66% female. Most frequent ACHD were atrial septal defect (22%) and tetralogy of Fallot (22%), followed by atrioventricular septal defect (17%) and transposition of great arteries (9%). Most patients had preserved biventricular function, 20% presented systemic ventricle systolic dysfunction and 12% subpulmonic ventricle systolic dysfunction. Atrial fibrillation or atrial flutter (AF/AFL) were the major reasons for anticoagulation (94%); the remaining were on NOAC due to previous ischaemic stroke, intra-cardiac thrombus or deep venous thrombosis. At the time of NOAC initiation, 49% had a CHA2DS2-VASc score ≥ 2 (median 1, IQR 1-3) and median HAS-BLED score was 0 (IQR 0-2);43% were medicated with apixaban, 29% with rivaroxaban,22% with edoxaban and 6% with dabigatran.During a median follow-up of 34 months, none had ischaemic complications or major bleeding and one patient died after pulmonic prothesis dysfunction surgery. Concerning time-to- adverse-event analysis, all patients kept uneventful after 2 years and more than 95% continued event-free after 8 years on-NOAC.
COVID-19 pandemic has unquestionably influenced care of acute myocardial infarction (AMI). Still, its impact on patients (pts) characteristics, presentation, treatment, and outcomes remains not well established in late pandemic times. To address this issue, we performed a prospective study of type-1 AMI pts admitted in a tertiary care hospital. Pts were enrolled during 6-months in 2019 (n=122; pre-COVID-19 (PC) group) and in 2021 (n=196; late-COVID-19 (C) group). Data was based on pts interview and review of medical records. Age and gender distribution, as well as ST/Non-ST-Elevation Myocardial Infarction (STEMI/NSTEMI) proportion and access to coronariography and revascularization were similar between groups. C pts presented more pre-existing established cardiovascular disease (CVD) (43% vs 30%; p=0,03); more frequent description of typical chest pain (94% vs 84%; p=0,002); higher levels of pain intensity, in a 0-10 scale (8±2 vs 7±2; p=0,02); higher frequencies of AMI complications (27% vs 15%; p=0,01) and worse Killip (K) class evolution (K≥2 in 22% C vs 13% PC pts; p=0,05). In conclusion, late pandemic AMI pts presented worse in-hospital outcomes in our study, though pre-hospital and hospital care were comparable to pre-pandemic times. Covid pts had a higher burden of pre-existing established CVD and a more typical and intense symptom presentation. Therefore, it can be hypothesized that "sicker" pts continued to look for help when presenting AMI symptoms, while "less sick" pts and the ones with less typical and intense symptoms possibly avoided contact with health care services during late pandemic period.
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