Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 2

Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of clinical data that has led to major recommendations in all practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region, based on updated information in the field that includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.

Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 1

Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of evidence that has led to major recommendations in clinical practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region based on updated information in the field that including both wire- and image-based physiologic assessment. This is Part 1 of the whole consensus document, which describes the general concept of coronary physiology, as well as practical information on the clinical application of physiologic indices and novel image-based physiologic assessment.

Mistaking a Tumour for an Infection - Acrometastasis of the Finger from Endocervical Adenosquamous Carcinoma: A Case Report

Acrometastasis is rare with a very low incidence of all bone metastasis. It can present with swelling, pain and warmth with erythema that may mimic an infection especially in the distal phalanx. Due to its rarity and subtle clinical presentation, it can be misdiagnosed as an infection causing the treatment to be delayed. We report a 42-year-old female with an acrometastasis to the distal phalanx of the left middle finger which we mistook as an infection thus delaying her treatment. It was a terminal presentation of her endocervical adenosquamous carcinoma. We would like to highlight that acrometastasis has an indistinct presentation and in cases where the lesion does not respond to treatment, acrometastasis should be included as one of the differential diagnoses. Thus, physicians need to have a high level of suspicion in patients with a primary malignant tumour.

Efficacy and Safety Outcomes of Short Duration Antiplatelet Therapy with Early Cessation of Aspirin Post Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

BACKGROUND

The optimal duration of dual antiplatelet therapy is a matter of ongoing research. Clinical studies are assessing the optimal duration with the most favourable risk to benefit ratio. The efficacy of P2Y12 receptor inhibitors comparable to aspirin in preventing recurrent ischaemic events in patients with coronary artery diseases.

OBJECTIVES

To investigate the outcomes of short-duration dual antiplatelet therapy after PCI with early discontinuation of aspirin while maintaining patients on P2Y12 inhibitor through systematic review and meta-analysis of available literature.

METHODS

We systematically searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov. We included randomized controlled studies that measured clinical outcomes of efficacy (mortality and ischaemic events) and safety (bleeding) of short and standard-duration dual antiplatelet therapy. The protocol of this study was registered in the international prospective register of systematic reviews PROSPERO registry (CRD42020171468).

RESULTS

Four randomized controlled trials were included; GLOBAL LEADERS, SMARTCHOICE, STOPDAPT-2, and TWILIGHT. The total number of patients was 29,089. The safety outcomes showed a significant reduction in major bleeding events with short-duration dual antiplatelet therapy; the risk ratio was 0.61 (95% CI 0.38-0.99; z=2,00, p=0.05). There was no difference between short and standard-duration dual antiplatelet therapy regarding efficacy outcomes (all- cause death, major adverse cardiovascular events, myocardial infarction, stroke, and stent thrombosis).

CONCLUSION

Short-duration dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy after PCI is a feasible option and can be adopted, especially in patients with a high risk of bleeding.

Consensus guidelines for interventional cardiology services delivery during covid-19 pandemic in Australia and new Zealand

The global coronavirus disease (COVID-19) pandemic poses an unprecedented stress on healthcare systems internationally. These Health system-wide demands call for efficient utilisation of resources at this time in a fair, consistent, ethical and efficient manner would improve our ability to treat patients. Excellent co-operation between hospital units (especially intensive care unit [ICU], emergency department [ED] and cardiology) is critical in ensuring optimal patient outcomes. The purpose of this document is to provide practical guidelines for the effective use of interventional cardiology services in Australia and New Zealand. The document will be updated regularly as new evidence and knowledge is gained with time. Goals Considerations.

Prognostic Value of Coronary Microvascular Function Measured Immediately After Percutaneous Coronary Intervention in Stable Coronary Artery Disease

Background:

The prognostic impact of coronary microvascular dysfunction after percutaneous coronary intervention (PCI) remains unclear in patients with stable coronary artery disease. This study sought to investigate the prognostic value of microvascular function measured immediately after PCI in patients with stable coronary artery disease.

Methods:

We enrolled 572 patients with stable coronary artery disease who underwent PCI and elective measurement of the index of microcirculatory resistance (IMR) immediately after PCI from 8 centers in 4 countries. Impaired microvascular function was defined as IMR≥25 (high IMR). Major adverse cardiac events, including death, myocardial infarction (MI) and target vessel revascularization, were evaluated.

Results:

During a median follow-up duration of 4.0 years, the cumulative major adverse cardiac events rate was significantly higher in the high IMR group (n=66/148) compared with the low IMR group (n=128/424; hazard ratio [HR], 1.56; 95% CI, 1.16−2.105; P =0.001), primarily due to a higher rate of periprocedural MI (HR, 1.59; 95% CI, 1.11−2.28; P =0.004) but also due to higher rates of mortality (HR, 1.59; 95% CI, 0.76−3.35; P =0.22), spontaneous MI (HR, 2.10; 95% CI, 0.67−6.63; P =0.20) and target vessel revascularization (HR, 1.40; 95% CI, 0.77−2.54; P =0.27). Cumulative risk for death, spontaneous MI, and target vessel revascularization was higher in the high IMR group (HR, 1.55; 95% CI, 0.99−2.43; P =0.056), as was death and spontaneous MI alone (HR, 1.79; 95% CI, 0.96−3.36; P =0.065). On multivariable analysis, high IMR post-PCI was an independent predictor of major adverse cardiac events.

Conclusions:

IMR measured immediately after PCI predicts adverse events in patients with stable coronary artery disease.

Invasive physiological indices to determine the functional significance of coronary stenosis

Physiological measurements are now commonly used to assess coronary lesions in the cardiac catheterisation laboratory, and this practice is evidence-based and supported by clinical guidelines. Fractional flow reserve is currently the gold standard method to determine whether coronary lesions are functionally significant, and is used to guide revascularization. There are however several other physiological measurements that have been proposed as alternatives to the fractional flow reserve. This review aims to comprehensively discuss physiological indices that can be used in the cardiac catheterisation laboratory to determine the functional significance of coronary lesions. We will focus on their advantages and disadvantages, and the current evidence supporting their use.

Relapse of chronic myeloid leukaemia 14 years after allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation (BMT) is the treatment of choice for patients with chronic myeloid leukaemia (CML) who are relatively young and have suitable donors. Relapse is rare more than 5 years after allografting. We describe a patient who relapsed with myeloid blast transformation 14 years after allografting. This case suggests that leukaemia stem cells may on occasion remain quiescent for long periods and emphasises the importance of long-term follow-up after transplantation for CML.

Epidemiology of aplastic anaemia in the state of Sabah, Malaysia

Aplastic anaemia is a rare disease which is more prevalent in the Far East. In Malaysia, it appears to be unusually common in the state of Sabah. A retrospective analysis of all cases of aplastic anaemia diagnosed between January 1993 and March 1996 was undertaken. The criteria of the International Aplastic Anaemia and Agranulocytosis Study (IAAAS) was used. In this 39 month period, 31 cases were confirmed by marrow trephine biopsy to be aplastic anaemia. The male-to-female ratio was 3.4. Median age of diagnosis was 23 years. There were 24 patients (77%) who were from the Kadazan-Dusun ethnic group, which forms 18% of the population of Sabah. The incidence of aplastic anaemia in Sabah appears to be higher than that reported elsewhere in the Far East, at 4.8 per million population per year. Peak incidence is in the elderly group at 8.6 per million followed by a second peak in young people aged 15 to 24 (7.9 per million). The aplastic anaemia to total acute leukaemia ratio is 0.37. The marked male preponderance and apparent susceptibility of the Kadazan-Dusun people are also notable. A further prospective study to address the true incidence of aplastic anaemia and possible aetiologic factors accounting for these observations is necessary.

Cicatricial pemphigoid presenting as upper airways obstruction

A 53-year-old woman presented with a history of increased shortness of breath, stridor and dryness of the eyes. Flow volume loops demonstrated evidence of upper airways obstruction. Conjunctival and laryngeal biopsies suggested a diagnosis of cicatricial pemphigoid. Immunosuppressive therapy improved symptoms and the flow volume loops returned to normal.