Day 1 :
University of Cambridge
Time : 10:00-10:45
Myocardial bridges are congenital anomalies. When a segment of an epicardial artery courses intramyocardially, the muscle overlying it forms the "myocardial bridge”. This case highlights the important of multi-modality imaging in diagnosing and planning treatment for patients with myocardial bridges.
33-year-old previously healthy male, with no significant family history, was admitted after an out-of- hospital VF arrest that occurred whilst running. The patient recalls light-headedness immediately before collapsing. ROSC was achieved after 1 shock with subsequent normal GCS. Initial ECG (figure 1) showed benign early repolarization in V1-4. Coronary angiography revealed myocardial bridging affecting a 2cm portion of the left anterior descending artery, with atherosclerotic plaque proximal to the bridge.
Resting echocardiogram and non-perfusion CMR were normal. However, exercise TTE demonstrated marked LAD territory hypokinesis and apical ballooning Figures 2 and 3) at peak exercise accompanied by ST elevation in V3-V6. After multidisciplinary discussions the patient was offered single-vessel CABG with LIMA to the LAD, but he declined. Fully informed of the risks, he opted instead for medical management and will further consider the need for surgical intervention in the future.
Management of patients with symptomatic bridges remains controversial due to the absence of prospective multi-centre data.. First line pharmacological therapy is with beta-blockers +/- calcium channel blockers. Revascularisation by intracoronary stent placement can be done, but complications include in-stent restenosis. Surgical options include bridge myectomy and bypass grafting. There is currently no data confirming which approach leads to the best outcome.
St. Luke’s Medical Center
Keynote: Direct oral anticoagulants in preventing venous thromboembolism in ambulatory patients with cancer: A systematic review and meta-analysis
Time : 10:45 - 11:30
Venous thromboembolism (VTE) is the second highest cause of mortality among cancer patients1. Routine thromboprophylaxis is not being given to ambulatory cancer patient based on recent guidelines.Methods: A literature search of randomized controlled trials evaluating the use of direct oral anticoagulants (DOACs) as prophylaxis for VTE among ambulatory cancer patients was conducted in the following databases: PubMed, Cochrane Library, CENTRAL, clinicaltrials.gov, and HERDIN. The primary outcome was the incidence of VTE and the secondary outcomes were major and non-major bleeding episodes. Two independent reviewers assessed the methodological quality of the studies using the Cochrane risk of bias tool. The random effects model for dichotomous data was used with a 95% confidence interval. Results: Two randomized controlled trials were included in this study (N=1404). The incidence of VTE among ambulatory cancer patients on DOACs was significantly decreased (OR 0.53; 95% CI 0.31-0.89, I2=31%). The rates of major (OR 1.97; 95% CI 0.88-4.43, I2=0%) and non-major (OR 1.37; 95% CI 0.79-2.37, I2=0%) bleeding were not statistically significant. Conclusion: This meta-analysis showed that the use of direct oral anticoagulants is associated with a statistically significant decrease in the rates of venous thromboembolism among high risk ambulatory cancer patients receiving chemotherapy. There was no statistically significant difference in the rates of major and non-major bleeding. DOACs can be used as primary VTE prophylaxis. Further evaluation on more homogeneous population of cancer patients and more powered studies is needed.