No abstract

Background: Red blood cell distribution width (RDW) is a strong predictor of adverse outcomes in patients with heart failure, stable coronary artery disease, stroke and acute myocardial infarction. The aim of our study was to explore the predictive value of RDW on all-cause mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Method: This observational study includes 619 NSTEMI patients, discharged from Staten Island University Hospital between September 2004 and December 2006. Patients were divided into equal RDW tertiles and survival was evaluated in each tertile. Result: Patients in the highest RDW tertile (RDW >14) had higher in-patient (7 vs. 1%) and 4-year (30 vs. 7%) mortality rates compared to those in the lowest tertile (RDW <13) (Wilcoxon χ² = 34.64, p < 0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores and other confounding variables, the RDW adjusted hazard ratio for 4-year all-cause mortality increased by 1.10 for each one unit increase in RDW (confidence interval 1.004–1.213, p = 0.042). Conclusion: RDW is an independent predictor of all-cause long-term mortality in NSTEMI patients. Further studies are needed to clarify the mechanisms of this association between RDW and adverse outcomes in patients with coronary artery disease.

We report two cases of immune thrombocytopenic purpura (ITP) associated with acute coronary artery syndrome highlighting the interventions done in every case along with the medications used during intervention and as outpatient. The first case is that of a woman with ITP exacerbation while on dual antiplatelet therapy and the second case is that of a male presenting with non-ST elevation myocardial infarction (NSTEMI) while in a thrombocytopenic crisis. In both cases antiplatelet therapy was held and thrombopoietic therapy was initiated before resuming full anticoagulation and coronary intervention. Given the paucity of data on ITP and antiplatelets treatment in the setting of acute coronary syndrome, no strict recommendations can be proposed, but antiplatelets appear to be safe acutely and in the long term in this category of patients as long as few measures are undertaken to minimize the risks of bleeding and thrombosis.

A male patient in his early 90s with a past medical history of hypertension and dyslipidemia and a surgical history of prosthetic (mechanical) aortic valve replacement (AVR) performed 27 years ago (1988) for aortic stenosis presented to our hospital with a chief medical complaint of fatigue, weakness, and chills for a duration of one day. His medications at home included clopidogrel, chlorthalidone, valsartan, and metoprolol. He had discontinued taking warfarin a few weeks after being discharged from his valve replacement surgery because of excessive bruising. His primary care doctor later started him on clopidogrel in 2001.His initial vitals in the emergency department were stable, except for a low-grade temperature of 100.4 °F. The physical examination revealed dry mucous membranes and a grade 3/6 systolic murmur, and metallic aortic valve opening and closing clicks at the aortic area along with a grade 2/6 systolic murmur at the apex. His electrocardiography revealed a normal sinus rhythm with signs of chamber enlargements. Chest X-ray revealed enlarged cardiac silhouette and the presence of heart valve prosthesis. Initial blood tests included total biochemistry, complete blood count, prothrombin time, partial thromboplastin time, fibrinogen, and thyroid function tests. All were unremarkable, except for creatinine of 2.30 and BUN of 51. A functional aortic prosthetic (metallic) valve with a maximum/mean gradient of 72/39 mmHg was verified with transthoracic echocardiography. In addition, a mildly elevated pulmonary artery pressure of 40 mmHg and a left ventricular ejection fraction of 55-65% were estimated; there was no evidence of thrombus or pannus formation.The patient was admitted with a diagnosis of acute kidney injury secondary to dehydration, and he was successfully treated with intravenous (IV) hydration. After educating the patient about the consequences of thrombosis and thromboembolism (TE) in patients with metallic heart valves, he was immediately bridged with IV heparin onto oral warfarin, with which he was discharged on. His international normalized ratio (INR) at discharge was in the therapeutic range at 2.6. Case 2The second case is a male patient in his 60s with a past medical history of chronic hepatitis C and rheumatic aortic valve disease and a surgical history of prosthetic AVR performed 37 years ago for aortic valve incompetence. He underwent AVR with Braunwald-Cutter prosthesis at 22 years of age. The aortic valve was replaced again five years later with a Björk-Shiley (B-S) valve due to fractures of the valve's outlet AbstrACt: Sixty percent of the patients going for valve replacement opt for mechanical valves and the remaining 40% choose bioprosthetics. Mechanical valves are known to have a higher risk of thrombosis; this risk further varies depending on the type of valve, its position, and certain individual factors. According to current guidelines, long-term anticoagulation is indicated in patients with metallic prosthetic valve disease. We report two unique cases of patients who s...

Hypertension has a major impact on cardiovascular and renal mortality and morbidity, with a 90% lifetime risk of developing hypertension. 1 Optimal blood pressure control reduces the risk of stroke by 38% and of myocardial infarction by 16%. 2 Compared to peripheral arterial pressure measurements, aortic pressures were shown to better predict coronary artery disease (CAD) 3,4 and cardiovascular risk. 5 Brachial arterial pressure does not correctly reflect aortic pressure, especially its systolic component, due to pulse pressure amplification. 6,7 It is also important to mention that central (aortic) pressures are the pressures directly affecting coronary and cerebral circulations, as well as the left ventricle, much more than pressures measured in the arm, and the latter is of paramount importance in end-organ damage related to hypertension. 8 Several ascending aortic blood pressure indices were studied, among which aortic pulse pressure (APP) correlated with increased cardiovascular complications. 9 Moreover, a higher APP was associated with more extensive CAD at time of coronary angiography. 10 A recent large prospective study has shown the superiority of central (aortic) over peripheral (brachial) pressures, as well as the superiority of APP and pulsatility over mean pressure in predicting adverse cardiovascular events. 11 Higher APP is related to arterial stiffness, a feature of aging and multiple cardiovascular conditions. 7 Although arterial stiffening is thought to represent by itself a form of cardiovascular end-organ damage, 7 and although APP is only an indirect indicator of arterial stiffness, higher APP may link arteriosclerosis (arterial stiffening) to other forms of end-organ damage such as atherosclerosis. The role of cyclical stretch due to pulsatile pressure in atherosclerosis is recognized. 12 BackgroundAortic pulse pressure (APP) is related to arterial stiffness and associated with the presence and extent of coronary artery disease (cAD). Besides, the left coronary artery (LcA) has a predominantly diastolic flow while the right coronary artery (RcA) receives systolic and diastolic flow. thus, we hypothesized that increased systolicdiastolic pressure difference had a greater atherogenic effect on the RcA than on the LcA.