Hybrid coronary revascularization is a safe alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. However, in high-risk patients with complex coronary artery disease (≥33 SYNTAX/>5 euroSCORE), coronary artery bypass grafting is superior to hybrid coronary revascularization.

An estimated 16 million people in the United States have coronary artery disease (CAD), and approximately 325,000 people die annually from cardiac arrest. About two-thirds of unexpected cardiac deaths occur without prior recognition of cardiac disease. A vast majority of these deaths are attributable to the rupture of ‘Vulnerable atherosclerotic plaques’. Clinically, plaque vulnerability is typically assessed through imaging techniques, and ruptured plaques leading to acute myocardial infarction are treated through angioplasty or stenting. Despite significant advances, it is clear that current imaging methods are insufficiently capable for elucidating plaque composition—which is a key determinant of vulnerability. Further, the exciting improvement in the treatment of CAD afforded by stenting procedures has been buffered by significant undesirable host-implant effects, including restenosis and late thrombosis. Nanotechnology has led to some potential solutions to these problems by yielding constructs that interface with plaque cellular components at an unprecedented size scale. By leveraging the innate ability of macrophages to phagocytose nanoparticles, contrast agents can now be targeted to plaque inflammatory activity. Improvements in nano-patterning procedures have now led to increased ability to regenerate tissue isotropy directly on stents, enabling gradual regeneration of normal, physiologic vascular structures. Advancements in immunoassay technologies promise lower costs for biomarker measurements, and in the near future, may enable the addition of routine blood testing to the clinician’s toolbox—decreasing the costs of atherosclerosis-related medical care. These are merely three examples among many stories of how nanotechnology continues to promise advances in the diagnosis and treatment of vulnerable atherosclerotic plaques.

No abstract

No abstract

A 38-year-old man presents to his primary care physician for follow-up and review of the results of a 24-hour ambulatory monitor that was placed after an emergency department evaluation for palpitations and chest pain 2 days earlier.He had been hospitalized 2 months earlier for severe headaches and elevated blood pressure. A workup for secondary causes of hypertension was negative, and he was started on bisoprolol and hydrochlorothiazide. He subsequently began experiencing intermittent episodes of lightheadedness and presyncope. Three days before seeing his primary care physician, he developed palpitations and central chest pressure radiating to his back associated with dyspnea at rest. When his wife, a registered nurse, checked his pulse and blood pressure, his heart rate was 140 to 160 beats per minute and regular. It slowed with a coached Valsalva maneuver. His wife noted his blood pressure was 140/70 mm Hg. He was taken to a local emergency department where, on arrival, his symptoms resolved and his vital signs normalized. The evaluation in the emergency department included electrolytes, a troponin, and a chest film that were all reportedly normal. He was discharged wearing a 24-hour ambulatory monitor with instructions to follow up with his primary care physician. He reported no syncopal episodes and denied orthopnea, paroxysmal nocturnal dyspnea, or lowerextremity edema.His past medical history includes hypertension and degenerative joint disease. His only medications are the bisoprolol, hydrochlorothiazide, and an occasional nonsteroidal anti-inflammatory drug for back pain. He has no allergies, but he had had an intolerable cough when taking an angiotensin-converting enzyme inhibitor for his hypertension in the past. He has no history of tobacco or illicit drug use. He occasionally drinks alcohol and 1 caffeinated beverage daily. He is married with 2 young daughters and is employed as a mechanical engineer. He recalls that a paternal cousin died shortly after receiving morphine for a kidney stone and that a paternal cousin died in his twenties of uncertain causes. He gives no family history of premature coronary artery disease or confirmed sudden cardiac death.On physical examination, his temperature is 98.0°F, blood pressure is 114/64 mm Hg while lying down, pulse is regular at 77 beats per minute, and respiratory rate is 18 breaths per minute with an oxygen saturation of 98% on room air. On standing, his blood pressure falls to 94/61 mm Hg and heart rate increases to 93 beats per minute. He is a muscular white man in no distress. There is no thyromegaly, and his jugular venous pressure is <8 cm H 2 O. The carotid upstrokes are brisk without bruits. On cardiac examination, the point of maximal impulse is not displaced with a normal S 1 and S 2 . There is no murmur, rub, or gallop. The lungs are clear to auscultation. The abdomen is soft and without pulsatile masses or bruits. The extremities are without edema. The femoral and pedal pulses are easily palpable.Dr Clair: Palpitations are among the most com...