Introduction: The guidelines for the management of acute coronary syndrome in patients presenting without persistent ST-segment elevation (NSTE-ACS) recommend against the routine use of pre-treatment with P2Y12 inhibitors when early invasive management is planned. Recently, multiple randomized clinical trials (RCTs) were published to compare the efficacy and safety of pre-treatment with P2Y12 inhibitors Hypothesis: Pre-treatment with P2Y12 inhibitors improves clinical outcomes in NSTE-ACS. Methods: We conducted a meta-analysis of all studies that evaluated clinical outcomes of pre-treatment with P2Y12 inhibitors versus no-pretreatment in the treatment of NSTE-ACS. The primary outcome was 30-days major adverse cardiovascular events (MACE). Secondary outcomes included risk of major bleeding, all-cause mortality, myocardial infarction (MI), and target vessel revascularization (TVR). Results: A total of 7 studies, and 103,678 patients were included. In regards to the primary outcome, the rate of MACE was similar between the two groups (OR 0.89; 95% CI 0.67-1.19; p=0.44). On the other hand, the rate of major bleeding was significantly higher in the pre-treatment group when compared to no- pre-treatment (Pre-treatment 2.6% vs control 1.7%, p=0.008). All-cause mortality, risk of MI, and risk of TVR were similar between the two treatment groups (Figure 1). Conclusions: Our findings correlate with the ESC guidelines, and we recommend against the routine use of pre-treatment with P2Y12 inhibitors in patients with NSTE-ACS.

Introduction: Left ventricular (LV) thrombus is a well-recognized complication of LV systolic dysfunction, especially in the setting of acute myocardial infarction. Multiple recent studies looked into the efficacy and safety of direct oral anticoagulants but limited number of studies reported outcomes in patients on rivaroxaban specifically. Hypothesis: Rivaroxaban is as effective as vitamin K antagonists (VKAs) in the treatment of LV thrombus. Methods: We conducted a meta-analysis of all studies that evaluated clinical outcomes of rivaroxaban versus warfarin in the treatment of LV thrombus. The primary outcome was thrombus resolution. Secondary outcomes included bleeding events, and systemic embolism. Results: One randomized clinical trial (RCT), and 3 retrospective observational studies with a total of 988 patients were included. Heterogeneity was low-moderate across the trials (19-54%). Thrombus resolution was numerically higher in the rivaroxaban arm but did not reach statistical significance (Rivaroxaban 80% vs VKAs 70%, p=0.57). Bleeding events (Rivaroxaban 9% vs VKAs 11%, p=0.77) and systemic embolism (Rivaroxaban 21.5% vs VKAs 30.9%, p=0.57) were both similar between the two arms (Figure). Conclusions: Rivaroxaban has similar efficacy and safety when compared to VKAs in the treatment of LV thrombus. Large RCTs are needed to confirm these results.

Cocaine overdose remains a significant public health concern worldwide, with potentially life-threatening consequences. The range of presentation can vary from mild autonomic hyperactivity to severe vasoconstriction, causing multiorgan ischemia and even death. In cases of high-dose intoxication, the presentation can be atypical. In this case report, we present a compelling case of a patient who initially presented with cardiac arrest and atypical signs. The patient made a remarkable recovery and returned almost to her baseline. This case provides valuable prognostic insight into the outcomes of severe multiorgan failure resulting from cocaine toxicity.