SummaryThere is a widespread belief that coronary arteries are smaller in Indo-Asians. The aim of the present study was to compare the size of atheroma-free proximal and distal epicardial coronary arteries of Indo-Asians and Caucasians. We analysed normal coronary angiograms from 77 Caucasians and 39 Indo-Asians. The two groups were comparable for dominance of the coronary arteries. Indo-Asian patients had generally smaller coronary arteries, with a statistically significant diVerence in the mean diameters of the left main coronary artery, proximal, mid and left anterior descending, and proximal and distal right coronary artery segments. There was a non-significant trend towards smaller coronary artery segment diameters for the distal left anterior descending, proximal and distal circumflex, and obtuse marginal artery segments. However, after correction for body surface area, none of these diVerences in size were statistically significant. Thus, the smaller coronary arteries in Indo-Asian patients were explained by body size alone and were not due to ethnic origin per se. This finding nevertheless has important therapeutic implications, since smaller coronary arteries may give rise to technical diYculties during bypass graft and intervention procedures such as percutaneous transluminal coronary angioplasty, stents and atherectomy. On smaller arteries, atheroma may also give an impression of more severe disease than on larger diameter arteries.

BackgroundProprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a major development in the prevention of cardiovascular disease (CVD) and is one of the most significant discoveries since the development of statin therapy. Administration of two human monoclonal antibodies to PCSK9 (alirocumab and evolocumab) can significantly reduce low-density lipoprotein cholesterol (LDL-c) concentrations, thus improving lipid management. Accordingly, guidelines on the specific indications for alirocumab and evolocumab usage have been released. This multicentre study aimed to estimate the proportion of patients treated for an acute myocardial infarction (MI) who could be considered for PCSK9 inhibitors under the current National Institute for Health and Care Excellence (NICE) lipid targets criteria.MethodsThe records of 596 patients in two large hospitals in Liverpool, UK were analysed. Information was collected on lipid profiles during and after admission, lipid-lowering therapy and previous CVD.ResultsAt least 2.2% of patients were eligible for PCSK9 inhibitors post-MI under the current NICE guidance. Additionally, 29% of patients failed to achieve LDL-c concentrations <2.0 mmol/L despite maximum statin therapy and failed to meet eligibility for PCSK9 inhibitors as per the NICE criteria. This cohort represents a group of patients ‘in limbo’, in which statin therapy alone is not sufficient to reduce LDL-c.ConclusionsPCSK9 inhibitors are expensive and so their use must be highly selective. At present, in a real-world setting with ezetimibe underprescribing, ~2% of patients are eligible and a further 30% are deprived of benefit and improved outcomes by lack of optimisation and/or potential use of PCSK9 inhibitors.

SummaryThrombosis within the target vessel is one of the most feared complications associated with coronary intervention, as it is often associated with severe adverse clinical sequelae. This thrombosis is mediated via the activation and aggregation of platelets and therefore considerable eVort has been directed at ways of inhibiting platelet function. It is now mandatory to consider the use of two and often three diVerent antiplatelet agents, particularly when intracoronary stents are inserted. Using these regimes, many of the adverse clinical outcomes associated with platelet activation can be reduced.

No abstract

Antithrombotic agents have verified efficacy in reducing the thromboembolic risk associated with atrial fibrillation. This article focuses on the emergence of a new oral direct thrombin inhibitor, ximelagatran, into the arena of atrial fibrillation thromboprophylaxis. This review does not cover atrial fibrillation in the context of valvular heart disease. The efficacy of aspirin and warfarin will be discussed briefly.