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INTRODUCTION: This prospective, single-arm, crossover pharmacodynamic study assessed the effect of Bayer® low-dose enteric-coated aspirin 81 mg tablets (LD EC-ASA) (Bayer AG, Leverkusen, North Rhine-Westphalia, Germany) compared to Vazalore® low-dose phospholipid-aspirin liquid-filled 81 mg capsules (LD PL-ASA) (PLx Pharma Inc., Sparta, NJ, USA) on platelet reactivity with respect to aspirin reaction units (ARU). METHODS: Forty-seven healthy volunteers were recruited. Platelet function was evaluated with the VerifyNow™ ARU assay (Werfen, Bedford, MA, USA) and assessed post-initiation of Bayer® LD EC-ASA daily for 14 days, with a washout period of 28 days, followed by Vazalore® LD PL-ASA daily for 14 days, again followed by ARU testing. RESULTS: Participants on LD EC-ASA had a mean ARU score of 426, with 19.1% of participants having an ARU > 550; patients on LD PL-ASA derived a mean ARU score of 435, with 14.9% achieving an ARU > 550. There were no significant differences in aspirin resistance (ARU > 550) according to the formulation (Bayer® LD EC-ASA vs. Vazalore® LD PL-ASA) used. Aspirin resistance was independent of ethnicity regardless of the formulation used. In addition, there were no significant associations between body surface area (BSA) and Bayer® LD EC-ASA ARU value (p value 0.788) or Vazalore® LD PL-ASA ARU value (p value 0.477). No patients experienced any serious adverse events or treatment-emergent adverse events. CONCLUSIONS: There were no significant differences in aspirin resistance between Bayer® LD EC-ASA and Vazalore® LD PL-ASA. This dedicated pharmacodynamic study could potentially be informative and applicable for Trinidadian patients on dual antiplatelet therapy (DAPT). Further studies are required to confirm these exploratory findings. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT06228820, prospectively registered 1/18/2024.

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The Tityus trinitatis, a black scorpion species endemic to the fauna of Trinidad, has been implicated in envenomation with devastating clinical sequelae such as acute pancreatitis and major adverse cardiovascular events. We present the first in-Caribbean case of a 59-year-old Caribbean South Asian male with human immunodeficiency virus who presented with a non-ST-segment-elevation acute coronary syndrome after being stung, which was managed with comprehensive, guideline-directed medical therapy. The clinician should be cognizant of scorpion-induced acute coronary syndrome (ACS) as a potential sequela of envenomation and its clinical management.

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The South African flag sign (SAFS) is an acute, dynamic electrocardiographic (ECG) finding typically associated with first diagonal (D1) artery occlusion. We report the case of a 47-year-old woman who exhibited this pattern but subsequently revealed the dreaded "widow-maker" lesion (100% occluded proximal left anterior descending [LAD] artery) and severe multivessel disease (90% stenosis of the posterior left ventricular [PLV] artery and 80% stenosis of the left circumflex artery [LCx]).

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We present the case of a 23-year-old man with a previous deceased-donor renal transplant maintained on tacrolimus and prednisone who developed culture-negative endocarditis (CNE) of the mitral and aortic valves. He was suspected of being co-infected with Bartonella henselae and Coxiella burnetii, confirmed with serology testing. He was successfully managed with appropriate antibiotics and dual valve replacement.

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Cardiac manifestations in leptospirosis usually involve atrial arrhythmias, conduction abnormalities, and nonspecific ST-T changes, while left ventricular dysfunction is rare. We present the case of a 45-year-old male without a pre-existing cardiovascular history who developed atrial fibrillation and atrial and ventricular tachycardia, in addition to new-onset cardiomyopathy in the setting of fulminant leptospirosis infection.

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INTRODUCTION: This study aimed to determine whether there was any correlation between coronary artery disease (CAD) and retinal artery diameter at an academic tertiary medical center in Trinidad and Tobago. METHODS: This prospective study evaluated patients (n = 77) with recent invasive coronary angiography (CAG) and the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score who subsequently underwent optical coherence tomography-angiography (OCT-A) at the Eric Williams Medical Sciences Complex (EWMSC) from January 2021 to March 2021. Routine medical history and cardiovascular medications were also recorded. Spearman's rank correlation coefficient and Mann-Whitney U-tests were used to compare correlations and medians between groups. RESULTS: The average patient age was 57.8 years old, with the majority being male [n = 55 (71.4%)] and of South Asian ethnicity [n = 53 (68.8%)]. Retinal artery diameter was negatively correlated with the SYNTAX score (-0.332 for the right eye, p = 0.003 and -0.237 for the left eye, p = 0.038). A statistically significant relationship was also demonstrated in females and diabetic patients. There were no serious adverse events (SAEs). CONCLUSION: A significantly negative correlation was observed between retinal artery diameter and SYNTAX score. This study alludes to the practical use of optical coherence tomography-angiography (OCT-A) as a noninvasive diagnostic modality for patients with cardiovascular disease (CVD). Further large-scale, multicentric studies are required to confirm these exploratory findings. TRIAL REGISTRATION NUMBER: NCT04233619.

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Pericardial effusions refer to an excess accumulation of fluid within the pericardial cavity. The etiology is diverse, with most cases being idiopathic in nature. We report a case of suspected cannabis vaping-induced pericardial effusion in a 31-year-old South Asian patient, which was successfully managed with high-dose aspirin, colchicine therapy, and cannabis vaping cessation.Key Clinical Message: Clinicians should be aware of the possible cardiovascular complications of cannabis vaping.

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We present the case of a 26-year-old man, without any apparent cardiovascular risk factors, who experienced an ST-segment-elevation acute coronary syndrome after binge drinking high-proof alcohol, which was successfully managed with primary percutaneous coronary intervention and comprehensive, guideline-directed medical therapy.

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INTRODUCTION: This prospective pharmacodynamic nutraceutical study assessed the effect of a 1-week trial of 30 g/day of 65% cocoa (dark chocolate) (Theobroma cacao L.) consumption intervention on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) (n=20) who were on maintenance dual antiplatelet therapy of aspirin (ASA) 81 mg/day and clopidogrel 75 mg/day were recruited. Platelet function was evaluated with the VerifyNow P2Y12 reaction unit (PRU) and aspirin reaction unit (ARU) assays (Werfen, Bedford, Massachusetts, USA) and assessed prior to initiation of and after a 1-week trial of 30 g/day of 65% cocoa consumption intervention. Results were compared with a paired t-test. RESULTS: Cocoa augmented the inhibitory effect of clopidogrel, demonstrated by a reduction of 11.9% (95% CI 5.7% to 18.0%, p value 0.001), significantly decreasing the PRU by 26.85 (95% CI 12.22 to 41.48, p value 0.001). The inhibitory effect of ASA was not impacted by cocoa, reflected by a non-significant reduction in ARU of 17.65 (95% CI 21.00 to 56.3, p value 0.351). No patients experienced any serious adverse events. CONCLUSIONS: Cocoa augmented the inhibitory effect of clopidogrel but not ASA. This nutraceutical study could be potentially informative and applicable for patients with stable CAD. Further long-term studies are required to confirm these exploratory findings. TRIAL REGISTRATION NUMBER: NCT04554901.

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Wellens' syndrome is an electrocardiographic harbinger of a critical left anterior descending (LAD) coronary artery stenosis in acute coronary syndromes (ACS), whereas pseudo-Wellens' syndrome typically has angiographically normal coronary arteries. Myocardial bridging (MB) occurs when an epicardial coronary artery segment takes a tunneled intramuscular course. We describe a rare case of MB-induced pseudo-Wellens' syndrome in a young patient presenting with unstable angina (USA).

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INTRODUCTION: This prospective pharmacodynamic (PD) study assessed the effect of the sodium-glucose co-transporter-2 inhibitor (SGLT2i), dapagliflozin, on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) (n = 27) who were on maintenance dual antiplatelet therapy (DAPT) of aspirin 81 mg daily, and clopidogrel 75 mg daily were recruited. Platelet function was evaluated with the VerifyNow™ P2Y12 assay (Werfen, Bedford, MA, USA) and assessed prior to initiation of and after 10 days of treatment with dapagliflozin 10 mg once-daily dose regimen. Results were compared with a paired t test. RESULTS: Treatment with dapagliflozin significantly decreased P2Y12 reaction units (PRU) by 20%, (95% confidence interval (CI) 8.5-32.6%, p value 0.002). The mean difference in PRU was 36.70 (95% CI 16.66-56.75). No patients experienced any serious adverse events (SAEs). CONCLUSIONS: Significantly diminished platelet reactivity was observed on dapagliflozin as compared to without dapagliflozin. This dedicated pharmacodynamic study could be potentially informative and applicable for Trinidadian stable CAD patients with T2DM on DAPT. Further studies are required to confirm these exploratory findings. CLINICAL TRIAL REGISTRATION: EDGE ClinicalTrials.gov number NCT04400760.

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Ventricular noncompaction is a rare, heterogeneous cardiomyopathy characterized by marked trabeculations and deep intertrabecular spaces with clinical sequelae of heart failure, arrhythmias, and cardioembolic events. In this article, we describe a patient with isolated right ventricular noncompaction who presented with submassive pulmonary embolism, which was managed with long-term direct oral anticoagulation.

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Pectus excavatum (PEX) is an anterior chest wall deformity with sternal depression relative to the costal cartilages. We describe a patient status post remote PEX repair who presented with presyncope attributed to bifascicular block, partial right ventricular outflow tract (RVOT) obstruction, and right coronary artery (RCA) ischemia. Key Clinical Message: The clinician should be cognizant of the hemodynamic impact and electrocardiographic changes in a symptomatic patient status post pectus excavatum repair.

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INTRODUCTION: This prospective pharmacodynamic (PD) study aimed to assess the effect of the sodium-glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) (n = 20) who were actively treated with dual antiplatelet therapy (DAPT) of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow™ P2Y12 assay (Instrumentation Laboratory, Massachusetts, USA) and assessed before the initiation of and after 10 days of treatment with empagliflozin 25 mg once daily maintenance dose regimen. Results were compared with a paired t test. RESULTS: The mean P2Y12 reaction units (PRU) on empagliflozin was significantly less than without empagliflozin at baseline (187.35, 95% confidence interval (CI) 155.38-219.32 vs. 217.25, CI 180.60-253.90; p < 0.030). The mean difference in PRU was 29.90 (95% CI 3.17-56.63). No patients experienced any serious adverse events (SAEs). CONCLUSIONS: Significantly attenuated platelet reactivity was observed on empagliflozin as compared to without empagliflozin. This dedicated pharmacodynamic study could be clinically pertinent for Trinidadian patients with stable CAD and T2DM on DAPT. Further studies are required to confirm these exploratory findings. (Funded by the University of the West Indies, St. Augustine; EFFECT). CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov number NCT04342819.

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Coronary artery disease (CAD) is amongst the leading causes of death in human immunodeficiency virus (HIV)-infected persons. Severe left main disease (LMD) occurs in approximately five percent of HIV-infected patients, with chronic total occlusion (CTO) of this vessel being an even rarer phenomenon. We describe a non-adherent HIV-infected patient with a left main coronary artery (LMCA) CTO that presented with heart failure with mildly reduced ejection fraction (HFrEF) and ventricular tachycardia (VT).

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BACKGROUND: This study aimed to screen cardiovascular patients for depressive symptoms at a tertiary centre in Trinidad and Tobago; and to determine any significant associations amongst patients' demographics, comorbidities, and cardiovascular medications with depressive symptoms. METHODS: In this observational, cross-sectional study, patients (n = 1203) were randomly selected from the cardiology outpatient clinics at the Eric Williams Medical Sciences Complex. After meeting selection criteria, informed consent was obtained, and patients were administered a case report form, which included the Patient Health Questionnaire-9 (PHQ-9). Descriptive analyses included frequency, percentage and summary statistics. Inferential analyses included 95% confidence intervals (CIs), independent sample t-test, Fisher's exact test, Chi-square test, and multivariate logistic regression. RESULTS: The study had a 96% respondent rate, whereby the average age was 62 years old. Slightly less than half were male, and 52.5% were female. Over 90 % of the sample had cardiovascular disease (CVD). One-quarter of the sample had a PHQ-9 score of ≥10, with almost one-fifth having no depressive symptoms. Females, lower levels of education and income were all found to be statistically significant at risk for depressive symptoms (all p-values < 0.001). Comorbidities associated with depressive symptoms included hypertension, prior cerebrovascular events, chronic kidney disease, and chronic obstructive pulmonary disease with odds ratios (ORs) and 95% confidence intervals (CIs) of OR 1.988 (CI 1.414-2.797), OR 1.847 (CI 1.251-2.728), OR 1.872 (CI 1.207-2.902) and OR 1.703 (CI 1.009-2.876) respectively. Only the cardiovascular medication of ticagrelor was found to be significantly associated with depressive symptoms (p-value < 0.001). CONCLUSIONS: Twenty-five percent of screened cardiovascular patients displayed significant depressive symptoms with a PHQ-9 ≥ 10. This study also highlights the importance of implementing a multidisciplinary approach to managing cardiovascular disease and screening for depressive symptoms in this subpopulation. Further studies are required to validate these findings. TRIAL REGISTRATION: ClinicalTrials.gov number, NCT03863262 . This trial was retrospectively registered on 20th February 2019.

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INTRODUCTION: This prospective, pharmacodynamic study aimed to explore the potential applicability of a low-dose ticagrelor regimen in a heterogeneous Trinidadian subpopulation. METHODS: Patients with stable coronary artery disease (n = 25) who were actively treated with dual antiplatelet therapy of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow P2Y12 assay (Accriva Diagnostics, San Diego, CA, USA) and assessed before initiation of and after 14 days of treatment with a low-dose ticagrelor 45 mg twice daily maintenance dose regimen. Results were compared with a paired t test. RESULTS: The mean P2Y12 reaction units (PRU) score on ticagrelor was significantly less compared to that of clopidogrel (50.4, 95% confidence interval (CI) 29-73.9; vs. 149.6, 95% CI 129.4-169.9; p value < 0.001). Of the patients, 4% experienced Medical Research Council class 1 dyspnea, and Bleeding Academic Research Consortium class 1 bleeding on the ticagrelor regimen (one patient each). CONCLUSIONS: Significantly attenuated platelet reactivity was seen on the low ticagrelor maintenance dose as compared to clopidogrel. This dedicated pharmacodynamic study could be applicable and informative for Trinidadian stable coronary artery disease patients. Further studies are required to confirm these exploratory findings.(Funded by the University of the West Indies, St. Augustine). TRIAL REGISTRATION: ClinicalTrials.gov number NCT04206176.

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Penetrative cardiac injury can often result in life-threatening sequelae such as myocardial contusion or rupture, coronary vessel and valvular damage, pericardial effusion with tamponade, and arrhythmias of which gunshot injury is a chief culprit. We report a case of a suspected acute coronary syndrome after a cardiac gunshot injury that was conservatively managed.

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Cardiac myxomas are the most frequently encountered tumors of the heart. However, they are unusual to be newly diagnosed in the geriatric population. Myxomas are among the great mimickers, with a myriad of clinical presentations related to heart failure, embolic events, and constitutional symptoms. We describe a rare case of a giant atrial myxoma in a nonagenarian presenting with heart failure, which was medically managed.

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In isolated partial anomalous pulmonary venous connections (PAPVCs), an abnormal vein connects venous blood from the pulmonary circulation to the systemic circulation, resulting in an extracardiac shunt. A single aberrant pulmonary vein (PV) is usually hemodynamically insignificant, and affected patients are generally asymptomatic. We describe a young Caribbean-Black woman with an isolated, singular PAPVC from the left inferior PV to the left innominate (brachiocephalic) vein that was hemodynamically significant, obfuscated by recurrent pleural effusions from catamenial pleural endometriosis.

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