The amount of late gadolinium enhancement outperforms current guideline-recommended criteria in the identification of patients with hypertrophic cardiomyopathy at risk of sudden cardiac death.

BACKGROUND: Identifying the patients with hypertrophic cardiomyopathy (HCM) in whom the risk of sudden cardiac death (SCD) justifies the implantation of a cardioverter-defibrillator (ICD) in primary prevention remains challenging. Different risk stratification and criteria are used by the European and American guidelines in this setting. We sought to evaluate the role of cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) in improving these risk stratification strategies. METHODS: We conducted a multicentric retrospective analysis of HCM patients who underwent CMR for diagnostic confirmation and/or risk stratification. Eligibility for ICD was assessed according to the HCM Risk-SCD score and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) algorithm. The amount of LGE was quantified (LGE%) and categorized as 0%, 0.1-10%, 10.1-19.9% and ≥ 20%. The primary endpoint was a composite of SCD, aborted SCD, sustained ventricular tachycardia (VT), or appropriate ICD discharge. RESULTS: A total of 493 patients were available for analysis (58% male, median age 46 years). LGE was present in 79% of patients, with a median LGE% of 2.9% (IQR 0.4-8.4%). The concordance between risk assessment by the HCM Risk-SCD, ACCF/AHA and LGE was relatively weak. During a median follow-up of 3.4 years (IQR 1.5-6.8 years), 23 patients experienced an event (12 SCDs, 6 appropriate ICD discharges and 5 sustained VTs). The amount of LGE was the only independent predictor of outcome (adjusted HR: 1.08; 95% CI: 1.04-1.12; p <  0.001) after adjustment for the HCM Risk-SCD and ACCF/AHA criteria. The amount of LGE showed greater discriminative power (C-statistic 0.84; 95% CI: 0.76-0.91) than the ACCF/AHA (C-statistic 0.61; 95% CI: 0.49-0.72; p for comparison < 0.001) and the HCM Risk-SCD (C-statistic 0.68; 95% CI: 0.59-0.78; p for comparison = 0.006). LGE was able to increase the discriminative power of the ACCF/AHA and HCM Risk-SCD criteria, with net reclassification improvements of 0.36 (p = 0.021) and 0.43 (p = 0.011), respectively. CONCLUSIONS: The amount of LGE seems to outperform the HCM Risk-SCD score and the ACCF/AHA algorithm in the identification of HCM patients at increased risk of SCD and reclassifies a relevant proportion of patients.

Development and validation of a risk score for predicting atrial fibrillation recurrence after a first catheter ablation procedure - ATLAS score.

Aims: Several predictors of relapse after catheter ablation of atrial fibrillation (AF) have been established, but assessing each patient's individual risk remains challenging. Our aim was to develop and validate a score to estimate the risk of AF recurrence after the first radiofrequency pulmonary vein isolation (PVI) procedure. Methods and results: Independent predictors of AF relapse were identified retrospectively in a two-centre registry of 1934 patients who underwent a first PVI procedure. Using the Cox regression hazard ratios of designated variables, a risk score was developed in a random sample of 50% of the patients (development cohort) and validated in the remaining (validation cohort) half. The accuracy and discriminative power of the predictive model were assessed in both subgroups. During a follow-up of 4.2 ± 2.7 years, 522 patients (27%) relapsed. Five independent predictors of AF recurrence were identified and included in the score: age >60 years (1 point), female sex (4 points), non-paroxysmal AF (2 points), current smoking (7 points) and indexed left atrial volume (1 point for each 10 mL/m2). The score showed good discriminative power (censored c-statistic of 0.75 in both cohorts). In the development group, AF relapse rates were 8, 11, and 17%/year for low (<6 points), intermediate (6-10 points), and high-risk patients (>10 points), respectively (P < 0.001). In the validation group, AF recurrence rates were 8, 11, and 18%/year, respectively (P < 0.001). Conclusion: A simple risk score to estimate the rate of AF recurrence after ablation was developed and validated. An external assessment of its usefulness as a patient selection tool seems warranted.

Safety and Long-Term Outcomes of Catheter Ablation of Atrial Fibrillation Using Magnetic Navigation versus Manual Conventional Ablation: A Propensity-Score Analysis.

INTRODUCTION: Whether or not the potential advantages of using a magnetic navigation system (MNS) translate into improved outcomes in patients undergoing atrial fibrillation (AF) ablation is a question that remains unanswered. METHODS AND RESULTS: In this observational registry study, we used propensity-score matching to compare the outcomes of patients with symptomatic drug-refractory AF who underwent catheter ablation using MNS with the outcomes of those who underwent catheter ablation using conventional manual navigation. Among 1,035 eligible patients, 287 patients in each group had similar propensity scores and were included in the analysis. The primary efficacy outcome was the rate of AF relapse after a 3-month blanking period. At a mean follow-up of 2.6 ± 1.5 years, AF ablation with MNS was associated with a similar risk of AF relapse as compared with manual navigation (18.4% per year and 22.3% per year, respectively; hazard ratio 0.81, 95% CI 0.63-1.05; P = 0.108). Major complications occurred in two patients (0.7%) using MNS, and in six patients (2.1%) undergoing manually navigated ablation (P = 0.286). Fluoroscopy times were 21 ± 10 minutes in the manual navigation group, and 12 ± 9 minutes in the MNS group (P < 0.001), whereas total procedure times were 152 ± 52 minutes and 213 ± 58 minutes, respectively (P < 0.001). CONCLUSIONS: In this propensity-score matched comparison, magnetic navigation and conventional manual AF ablations seem to have similar relapse rates and a similar risk of complications. AF ablations with magnetic navigation take longer to perform but expose patients to significantly shorter fluoroscopy times.

Assessment of myocardial strain patterns in patients with left bundle branch block using cardiac magnetic resonance.

Recently, a classification with four types of septal longitudinal strain patterns was described using echocardiography, suggesting a pathophysiological continuum of left bundle branch block (LBBB)-induced left ventricle (LV) remodeling. The aim of this study was to assess the feasibility of classifying these strain patterns using cardiovascular magnetic resonance (CMR), and to evaluate their association with LV remodeling and myocardial scar. Single center registry included LBBB patients with septal flash (SF) referred to CMR to assess the cause of LV systolic dysfunction. Semi-automated feature-tracking cardiac resonance (FT-CMR) was used to quantify myocardial strain and detect the four strain patterns. A total of 115 patients were studied (age 66 ± 11 years, 57% men, 28% with ischemic heart disease). In longitudinal strain analysis, 23 patients (20%) were classified in stage LBBB-1, 37 (32.1%) in LBBB-2, 25 (21.7%) in LBBB-3, and 30 (26%) in LBBB-4. Patients at higher stages had more prominent septal flash, higher LV volumes, lower LV ejection fraction, and lower absolute strain values (p < 0.05 for all). Late gadolinium enhancement (LGE) was found in 55% of the patients (n = 63). No differences were found between the strain patterns regarding the presence, distribution or location of LGE. Among patients with LBBB, there was a good association between strain patterns assessed by FT-CMR analysis and the degree of LV remodeling and LV dysfunction. This association seems to be independent from the presence and distribution of LGE.

Cardiac magnetic resonance in a patient with MRI-conditional pacemaker.

An implanted pacemaker is generally considered a contraindication for magnetic resonance imaging (MRI). The increasing number of indications for MRI and the rising prevalence of implanted cardiac pacemakers have prompted the recent development of MRI-conditional pacemaker systems. We present the case of a 68-year-old woman with left ventricular hypertrophy, hypertension, aortic valve stenosis and a family history of cardiac amyloidosis, who developed complete heart block. In view of the foreseeable need for cardiac MRI, an MRI-conditional dual chamber pacemaker was implanted. The MRI scan confirmed moderate left ventricular hypertrophy and aortic valve stenosis, and showed no delayed enhancement suggestive of amyloid heart disease. This case illustrates the feasibility of cardiac MRI in this setting and the usefulness of the recently introduced MRI-conditional pacemaker systems.

[Pre- and post-test probability of obstructive coronary artery disease in two diagnostic strategies: relative contributions of exercise ECG and coronary CT angiography]. / Probabilidade teórica de doença coronária pré- e pós-teste em duas estratégias diagnósticas - Contributo relativo da prova de esforço e da angio-TC cardíaca.

INTRODUCTION: The purpose of this study was to assess the change in theoretical probability of coronary artery disease (CAD) in patients with suspected CAD undergoing coronary CT angiography (CCTA) as first line test vs. patients who underwent CCTA after an exercise ECG. METHODS: Pre- and post-test probabilities of CAD were assessed in 158 patients with suspected CAD undergoing dual-source CCTA as the first-line test (Group A) and in 134 in whom CCTA was performed after an exercise ECG (Group B). Pre-test probabilities were calculated based on age, gender and type of chest pain. Post-test probabilities were calculated according to Bayes' theorem. RESULTS: There were no significant differences between the groups regarding pre-test probability (median 23.5% [13.3-37.8] in group A vs. 20.5% [13.4-34.5] in group B; p=0,479). In group A, the percentage of patients with intermediate likelihood of disease (10-90%) was 90% before testing and 15% after CCTA (p<0,001), while in group B, it was 95% before testing, 87% after exercise ECG (p=NS), and 17% after CCTA (p<0,001). CONCLUSION: Unlike exercise testing, CCTA is able to reclassify the risk in the majority of patients with an intermediate probability of obstructive CAD. The use of CCTA as a first-line diagnostic test for CAD may be beneficial in this setting.

[Consensus document on coding of cardiac magnetic resonance examinations in Portugal]. / Documento de consenso sobre codificação de exames de ressonância magnética cardíaca em Portugal.

One of the obstacles to more frequent and appropriate use of cardiac magnetic resonance (CMR) in Portugal has been the lack of specific codes that accurately describe these examinations as they are currently performed. In this consensus document, recommendations are made for updating and standardizing CMR codes in Portugal. Guidance on which techniques and codes should be used in the most common clinical scenarios is also provided.

Knowledge and Risk Behaviors Regarding Human Immunodeficiency Virus Transmission among Portuguese Healthcare Students.

BACKGROUND: Human immunodeficiency virus (HIV), the agent responsible for acquired immunodeficiency syndrome, remains a worldwide public health problem. Therefore, this study aimed to assess Portuguese healthcare students' knowledge of HIV, identify risk behaviors for HIV transmission, and assess the frequency of HIV testing and its dissemination by general practitioners. METHODS: A cross-sectional observational study was conducted using an anonymous questionnaire published online. The questionnaire was administered to Portuguese healthcare students who voluntarily agreed to participate in the study after clarifying its objectives and procedures. RESULTS: Most students were aware of the three main HIV transmission routes; however, 66.3% were unaware of the level A recommendation for HIV screening in adolescents and adults. In addition, 59.6% of the students were never informed by their general practitioner about HIV screening tests or risk behaviors for HIV transmission. Of the sample, 78.9% had never been tested for HIV infection. Of the 74.6% of sexually active students, 82.0% had or had already had unprotected sex (without a condom). Men showed riskier sexual behaviors than women. None of the inquiries reported intravenous drug use, and most students (69.9%) never shared personal objects. CONCLUSION: General practitioners and awareness campaigns need to alert and disseminate HIV screening tests. Sexual health and risk behaviors should be addressed more frequently in schools to educate this population because prevention is the best strategy against HIV transmission/contraction.

2021/22 Rugby Europe Injury Surveillance Report: SuperCup, Under-20, and Under-18 Championship.

We conducted a prospective cohort study to determine the incidence rate and characterization of the injuries sustained by players during the 2021/22 season of the Rugby Europe SuperCup, Under-20, and Under-18 championships. Team medics reported the injuries, using an online platform. Ethical approval and informed consent were obtained. The overall incidence of injuries ranged from 33.33 (95% CI: 18.97-54.60) in the under-18s to 83.33 (95% CI: 60.34-112.40) in the under-20s, while in the SuperCup it was 41.35 (95% CI: 30.30-55.18) injuries per 1000 player-match-hours. Injury severity (mean days) was higher in the SuperCup (38.33) and lower in the Under-18 tournament (28.50). Lower limb and soft tissue were the most common type of injuries. Tackles caused almost two-thirds of all injuries. Concussion accounted for 10.0% to 25.6% of all injuries. Our data are consistent with previous reports for similar levels of competition and age grades. The injury incidence was higher in the senior competitions (Under-20s and SuperCup). However, for the under-20s, injury rates were higher than in the SuperCup. This might be related to the competition format; however, more studies need to be conducted in the future. Concussion is a common injury and the protocols used at this level seems to be effective to identify it.

Outcomes of a combined vs non-combined endo-epicardial ventricular tachycardia ablation strategy.

BACKGROUND: Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and non-ischemic cardiomyopathy (NICM) populations. METHODS: Multicentric observational registry included 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-day mortality and procedure-related complications. RESULTS: Most of the patients were male (85%), with IHD (67%) and mean age of 63 ± 13 years. During a mean follow-up of 3 ± 2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class III / IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The identified independent predictors of mortality were C-ABL, ES, LVEF, age, and NYHA class III / IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction = 0.04). Mortality at 30 days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P = 0.777), as was complication rate (10.3% vs. 15.1%, respectively, P = 0.336). CONCLUSION: A combined or sequential endo-epicardial VT ablation strategy was associated with lower VT recurrence and lower all-cause death in IHD and NICM patients undergoing repeated procedures. Both approaches seemed equally safe.

Predictive value of a positive stress single-photon emission computed tomography or stress cardiac magnetic resonance for ruling in obstructive coronary artery disease in a real-world setting.

INTRODUCTION AND OBJECTIVES: Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). There are few data on whether this remains true in routine clinical practice. The aim of this study was to assess clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after stress CMR or SPECT, and to compare their positive predictive value with published results from the CE-MARC trial. METHODS: In this retrospective tertiary-center analysis, we included 429 patients undergoing ICA after a positive stress CMR or positive SPECT performed within the previous 12 months. Obstructive CAD was defined as any coronary artery stenosis ≥50% in a vessel compatible with the ischemic territory on stress testing. RESULTS: Of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ according to age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p=0.046). The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p=0.385). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial. CONCLUSION: In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial. This finding supports the emerging adoption of CMR in clinical practice for the diagnosis and management of CAD.

Predictors of pacemaker implantation after TAVI in a registry including self, balloon and mechanical expandable valves.

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve implantation (TAVI). The aim of our study was to evaluate different anatomical, clinical, electrocardiographic, and procedural variables associated with the development of conduction abnormalities after TAVI across the entire device spectrum. Single-center prospective cohort of consecutive patients who underwent TAVI since March 2017. Final cohort was studied to detect areas of calcium within aortic valve characterized by leaflet sector and region. Membranous septum (MS) length was assessed throughout a modified coronal view. Device selection and positioning were performed according to the operator criteria. Device selection and positioning were performed according to the operator criteria. From the 273 patients included, 57 underwent PPMI (20.8%). Univariate analysis determined right bundle branch block (RBBB), QRS duration, MS length and calcium within LVOT of non-coronary cuspid as independent predictors. After multivariable logistic regression, both RBBB (OR 6.138; 95% CI 1.23-30.73, P = 0.027) and MS length (OR 0.259; 95% CI 0.164-0.399, P < 0.005) emerged as statistically significant. As a model, they could predict PPMI in 88.7%, independently of which valve used. Youden index analysis yielded 7.69 mm as the optimal cut-off with a negative and positive predictive value of 94.7 and 71.9%, respectively. In our experience, both RBBB pattern and short membranous septum (< 8 mm) were strongly and independently associated with new permanent pacemaker implantation, regardless of the device type. Our findings suggest that this simple evolved measure of MS length may guide device selection and implantation technique and facilitate early discharge.

The Relationship between Epicardial Fat and Atrial Fibrillation Cannot Be Fully Explained by Left Atrial Fibrosis. / Relação entre Gordura Epicárdica e Fibrilação Atrial Não Pode Ser Totalmente Explicada pela Fibrose Atrial Esquerda.

BACKGROUND: Epicardial adipose tissue (EAT) has been associated with atrial fibrillation (AF), but its pathophysiological mechanisms remain unclear. OBJECTIVES: To measure the correlation between EAT and left atrium (LA) fibrosis, and to assess their ability to predict relapse after pulmonary vein isolation (PVI). METHODS: Patients with AF enrolled for a first PVI procedure underwent both cardiac computerized tomography (CT) and cardiac magnetic resonance (CMR) imaging within less than 48 hours. EATLMwas quantified on contrast-enhanced CT images at the level of the left main. LA fibrosis was quantified on isotropic 1.5 mm 3D delayed enhancement CMR. After pulmonary vein isolation (PVI), patients were followed up for AF relapse. Statistical significance was set at p<0.05. RESULTS: Most of the 68 patients (46 men, age 61±12 years) had paroxysmal AF (71%, n=48). Patients had a median EATLMvolume of 2.4 cm3/m2(interquartile range [IQR] 1.6-3.2 cm3/m2), and a median amount of LA fibrosis of 8.9 g (IQR 5-15 g). The correlation between EATLMand LA fibrosis was statistically significant but weak (Spearman's R=0.40, p=0.001). During a median follow-up of 22 months (IQR 12-31), 31 patients (46%) had AF relapse. Multivariate analysis yielded two independent predictors of AF relapse: EATLM(HR 2.05, 95% CI 1.51-2.79, p<0.001), and non-paroxysmal AF (HR 2.36, 95% CI 1.08-5.16, p=0.031). CONCLUSION: The weak correlation between EAT and LA suggests that LA fibrosis is not the main mechanism linking EAT and AF. EAT was more strongly associated with AF relapse than LA fibrosis, supporting the existence of other more important mediators of EAT and AF.

FUNDAMENTO: O tecido adiposo epicárdico (TAE) tem sido associado à fibrilação atrial (FA), mas seus mecanismos fisiopatológicos permanecem obscuros. OBJETIVOS: Medir a correlação entre TAE e fibrose do átrio esquerdo (AE), e avaliar sua capacidade de prever recidiva após o isolamento da veia pulmonar (IVP). MÉTODOS: Pacientes com FA inscritos para um primeiro procedimento de IVP foram submetidos à tomografia computadorizada (TC) cardíaca e ressonância magnética cardíaca (RMC) em menos de 48 horas. Quantificou-se o TAECE em imagens de TC realçadas com contraste no nível do tronco da coronária esquerda. Quantificou-se a fibrose do AE em RMC tridimensional com realce tardio isotrópico de 1,5 mm. Após o isolamento da veia pulmonar (IVP), os pacientes foram submetidos a seguimento para checar a recidiva da FA. A significância estatística foi definida com p<0,05. RESULTADOS: A maioria dos 68 pacientes (46 homens, idade 61±12 anos) tinha FA paroxística (71%, n=48). Os pacientes apresentavam volume TAECE mediano de 2,4 cm3/m2 (intervalo interquartil [IIQ] 1,6­3,2 cm3/m2) e um volume médio de fibrose do AE de 8,9 g (IIQ 5­15 g). A correlação entre TAECE e fibrose do AE foi estatisticamente significativa, mas fraca (coeficiente de correlação de postos de Spearman = 0,40, p=0,001). Durante um seguimento médio de 22 meses (IIQ 12­31), 31 pacientes (46%) tiveram recidiva da FA. A análise multivariada produziu dois preditores independentes de recidiva da FA: TAECE (FC 2,05, IC de 95% 1,51­2,79, p<0,001) e FA não paroxística (FC 2,36, IC de 95% 1,08­5,16, p=0,031). CONCLUSÃO: A correlação fraca entre TAE e AE sugere que a fibrose do AE não é o principal mecanismo que liga o TAE e a FA. O TAE mostrou-se mais fortemente associado à recidiva da FA do que à fibrose do AE, corroborando a existência de outros mediadores mais importantes do TAE e da FA.

Consensus document on magnetic resonance imaging in patients with cardiac implanted electronic devices. / Documento de Consenso sobre a realização de ressonância magnética em doentes com dispositivos cardíacos electrónicos implantados.

Magnetic resonance imaging (MRI) is currently considered an essential complementary method for diagnosis in many conditions. Exponential growth in its use is expected due to the aging population and a broader spectrum of clinical indications. Growth in its use, coupled with an increasing number of pacemaker implants, implantable cardioverter-defibrillators and cardiac resynchronization therapy, has led to a frequent clinical need for this diagnostic modality in patients with cardiac implantable electronic devices (CIED). This clinical need has fueled the development of devices specifically designed and approved for use in a magnetic resonance (MR) environment under certain safety conditions (MR-conditional devices). More than a decade after the introduction of the first MR-conditional pacemaker, there are now several dozen MR-conditional devices with different safety specifications. In recent years, increasing evidence has indicated there is a low risk to MRI use in conventional (so-called non-MR-conditional) CIED patients in the right circumstances. The increasing number, as well as the greater diversity and complexity of implanted devices, justify the need to standardize procedures, by establishing institutional agreements that require close collaboration between cardiologists and radiologists. This consensus document, prepared jointly by the Portuguese Society of Cardiology and the Portuguese Society of Radiology and Nuclear Medicine, provides general guidelines for MRI in patients with CIED, ensuring the safety of patients, health professionals and equipment. In addition to briefly reviewing the potential risks of MRI in patients with CIED and major changes to MRI-conditional devices, this article provides specific recommendations on risk-benefit analysis, informed consent, scheduling, programming strategies, devices, monitoring and modification of MRI sequences. The main purpose of this document is to optimize patient safety and provide legal support to facilitate easy access by CIED patients to a potentially beneficial and irreplaceable diagnostic technique.

Temporal trends in referral patterns for invasive coronary angiography - a multicenter 10-year analysis.

AIM: To assess the temporal trends in the usage pattern of non-invasive testing before invasive coronary angiography (ICA) and its diagnostic yield in patients with suspected coronary artery disease (CAD). METHODS: Cross-sectional observational multicenter study of 4805 consecutive patients (60% male, mean age 66 ± 10 years) with suspected CAD undergoing elective ICA due to angina pectoris in two centers, from 2008 to 2017. The use of noninvasive testing and the proportion of patients with obstructive CAD (defined as the presence of at least one ≥50% stenosis on ICA) were assessed. RESULTS: There were 4038 (84%) patients referred for ICA with positive noninvasive test, mainly SPECT (38%, n = 1828) and exercise ECG (36%, n = 1731). Obstructive CAD was found in 54.5% (n = 2621) of the patients and 37.9% (n = 1822) underwent revascularization. The prevalence of obstructive CAD was higher in patients with vs. without previous noninvasive testing (55.8% vs. 48.1%, respectively, P < 0.001) and tended to decrease during the study period (P for trend <0.001). Both the presence of obstructive CAD and revascularization rate were higher in patients who underwent anatomical evaluation with CCTA compared with noninvasive functional tests (P = 0.001 and P = 0.018, respectively). The number of patients referred after exercise testing and SPECT decreased (p for trend 0.005 and 0.006, respectively) and after CCTA and stress CMR increased (both P for trend <0.001). The proportion of patients referred without previous testing remained stable. CONCLUSION: Nearly half of the patients undergoing ICA for suspected CAD did not have obstructive coronary lesions. This proportion tended to increase over the 10-year span of this study. Better clinical assessment tools and diagnostic pathways for stable CAD are warranted.

Medication adherence to direct anticoagulants in patients with non-valvular atrial fibrillation - A real world analysis.

INTRODUCTION: Direct oral anticoagulants (DOACs) changed the landscape of atrial fibrillation (AF) treatment, but also brought with them new challenges in terms of accessibility and compliance. The purpose of this study was to assess adherence to DOACs, and its determinants in a population of AF patients. METHODS: Single-center retrospective study including all patients with non-valvular AF treated with a DOAC from the outpatient general cardiology list at a tertiary center, whose first DOAC prescription was between 1 April 2016 and August 2018. The number of pharmacy refills from the day of first prescription to 31 August 2018 was counted (by means of an electronic prescription platform). Medication refill adherence (MRA) was calculated by dividing the total days' supply by the number of days under therapy. Non-compliance was defined as MRA <90%. RESULTS: A total of 264 patients (120 men, mean age 74 ±â€¯12 years) met the inclusion criteria. The median CHA2DS2VASC score was 3 (interquartile range (IQR) 2-5) and the median HAS-BLED was 1 (IQR 1-2). Rivaroxaban, apixaban, dabigatran and edoxaban were prescribed in 45%, 41%, 24% and 13% of patients, respectively. During the study 51 patients (19%) used at least two DOACs .Patients took DOACs for a median period of 439 days (IQR 269-638), during which the included population adhered to therapy 90% of the time (IQR 75-100%). Half of the patients (51%) were classified as non-compliant; therapy duration (adjusted odds ratio 1.06 per month, 95% confidence interval (CI) 1.03-1.08, p<0.001), DOACs twice daily (adjusted OR 1.73, 95%CI 1.08-2.75, p=0.022), and higher out-of-pocket costs (adjusted OR 2.13, 95%CI 1.28-3.45, p=0.003) were independent predictors of non-compliance. CONCLUSION: Half of the patients (51%) were classified as non-compliant (medication refill adherence <90%). Therapy duration, DOACs twice daily and higher out out-of-pocket costs were independent predictors of non-compliance, which could be targets to improve patient adherence.

Coronary artery calcium scoring and cardiovascular risk reclassification in patients undergoing coronary computed tomography angiography.

INTRODUCTION: Coronary artery calcium (CAC) scoring is used for both cardiovascular risk reclassification and as a gatekeeper for coronary computed tomography angiography (CCTA). The aims of this study were to assess to what extent CAC score results can reclassify the cardiovascular risk of patients without obstructive coronary artery disease (CAD) on CCTA, and to measure the proportion of these patients whose primary prevention medication is changed after the exam. METHODS: In a retrospective analysis of a multicenter registry of individuals who underwent CCTA for suspected CAD during a two-year period, the Systematic COronary Risk Evaluation (SCORE) and Multi-Ethnic Study of Atherosclerosis (MESA) risk scores were calculated for each individual. In a subset of 184 patients, we also assessed the prescription of statins and antiplatelet agents before and after the test. RESULTS: A total of 467 patients (248 women, mean age 60±9.10 years) were included. Median CAC score was 0 (interquartile range 0-40). Overall, 249 patients (53%) and 159 (34%) were classified as being of moderate/intermediate risk according to the SCORE and MESA risk scores, respectively. Among these, 29 (12%) and 30 (19%) patients had CAC score >100 AU, making them eligible for statin therapy. The inclusion of CAC scoring in the MESA score resulted in the reclassification of 215 patients (46%). The proportion of patients who were prescribed statins or antiplatelet agents did not change significantly after the test. CONCLUSION: CAC scoring can reclassify cardiovascular risk in a significant proportion of patients undergoing CCTA. Despite this, little change was seen in the prescription of statins and antiplatelet agents.

Craniofacial Polyostotic Fibrous Dysplasia Initially Diagnosed in a Primary Care Unit.

Fibrous dysplasia (FD) is a non-malignant bone tumor that typically behaves as a slow and indolent growing mass lesion. We report the case of a female patient presenting with headache and facial deformity and later diagnosed with polyostotic fibrous dysplasia (PFD). A 29-year-old woman visited Mealhada Primary Health Care Unit complaining of headache, nasal congestion, and hyposmia for several weeks. She also presented with facial deformity and painful swelling of the upper left orbit. X-ray imaging revealed a suspicious opacity in the left frontal sinus and a right shift of the nasal septum. Computed tomography and bone scintigraphy later confirmed a tumor involving the ethmoid and frontal bone. The patient was referred to the neurosurgery and otorhinolaryngology departments of a central hospital and the suspected diagnosis of PFD was confirmed. A watchful waiting approach with regular imaging screenings was proposed and accepted by the patient, who is now free of symptoms and more acceptant of the benign condition of her tumor. With this case, we aim to make family physicians more aware of this rare but relevant condition that can be difficult to diagnose. FD is a rare but benign tumor that occurs mainly in adolescents and young adults. Symptoms depend on the location and type of the tumor and include facial deformity, vision changes, nasal congestion, and headache. No clear guidelines exist for its treatment, and options include monitoring the progression of the tumor, in addition to medical or surgical approaches.

Additional cardiac investigation prior to the introduction of the CAD-RADS classification in coronary computed tomography angiography reports.

INTRODUCTION: The CAD-RADSTM classification was recently introduced in an attempt to standardize coronary computed tomography angiography (CCTA) reports and to provide recommendations for further management. The aim of this study was to assess how additional cardiac investigations were being ordered before the introduction of the CAD-RADS classification in a tertiary hospital's CCTA reports. METHODS: We conducted a single-center retrospective analysis of 200 patients (103 women, mean age 59±13 years) who underwent CCTA for suspected or known coronary artery disease prior to the systematic introduction of the CAD-RADS classification in the reports. For each case, we assessed whether further cardiac investigation was requested after CCTA and what type of test was performed (functional testing, invasive coronary angiography or viability testing). RESULTS: The majority of patients (n=158; 79%) were classified as CAD-RADS 0-2. In patients with lower (0-2) or higher (4 or 5) scores, further testing was in accordance with CAD-RADS recommendations in 98% of cases (n=168). In patients with CAD-RADS 3 (intermediate stenosis), functional testing was requested as recommended in only 36% of cases (n=5), while 50% (n=7) proceeded directly to invasive coronary angiography. In patients in whom CCTA was non-diagnostic, most did not undergo further cardiac investigation. CONCLUSION: In patients with CAD-RADS classifications at the ends of the spectrum, additional cardiac investigation after CCTA was almost always in accordance with the recommendations. However, in patients with intermediate scores, invasive coronary angiography prevailed over functional testing.