Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry.

BACKGROUND: Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. METHODS: We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1­year follow-up data were gathered. RESULTS: At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). CONCLUSIONS: Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

Pulsed Doppler regurgitant flow patterns of normal valves.

Although Doppler echocardiography allows recording of regurgitant turbulent flow patterns in normal persons, sparse information is available concerning the incidence, characteristics and mechanism of these flow patterns. Therefore, pulsed Doppler echocardiograms were recorded in 25 normal persons to detect regurgitation. A regurgitant turbulent flow pattern was recorded at the pulmonic valve in 23 subjects (92%), covered up to 81% of the diastole and could never be recorded in early diastole. An early to midsystolic regurgitant flow pattern was recorded at the mitral valve in 10 subjects (40%) and covered up to 60% of systole. A similar regurgitant flow was recorded at the tricuspid valve in 11 subjects (44%) and was holosystolic in 1 subject. An early diastolic regurgitant flow with low maximal velocities and rapid decrease in velocities was recorded at the aortic valve in 8 subjects (33%) and covered up to 26% of the diastole. In no person could those flows be recorded farther than 1 cm proximal to the valve closure. Whatever the still-debated mechanisms of those regurgitant flow patterns in normal subjects, one should be aware of their existence and characteristics when assessing valvular function by Doppler.

Myocardial stunning in hypertrophic cardiomyopathy with normal coronary arteries.

A patient with an obstructive hypertrophic cardiomyopathy and normal epicardial coronary arteries developed myocardial ischemia accompanied by a transitory apical akinesia. This wall motion dysfunction persisted for hours after the relief of myocardial ischemia.

Alterations of atrial repolarization after tricyclic antidepressant drugs absorption.

We describe a case of voluntary intoxication with tricyclic antidepressant drugs: initial electrocardiogram showed alterations of atrial repolarization (Ta segment) which were more pronounced than usual ST-T alterations. Evolution was uneventful (and repolarization normalized). Tricyclic antidepressant drugs absorption can lead to Ta segment alterations, which may be a useful clue in the differential diagnosis of drugs intoxication.

U wave alternans in severe ischaemia.

A patient with unstable angina and known heart failure, and marked U wave alternans on the electrocardiogram is reported. Alternans of the U wave with no change in the QRS complex is extremely rare. The relevant literature is reviewed.

[Ultrasonic association between false tendons and ventricular aneurysm. Apropos of 2 cases]. / Association échographique entre faux tendons et anévrysme ventriculaire. A propos de 2 observations.

The authors report 2 clinical cases of ventricular aneurysm associated with a false tendon attached to the neck of the aneurysm. The first patient had no signs of false tendon before myocardial infarction. When the aneurysm developed, a false tendon was observed at its neck; a second false tendon attached to the first was also seen and appeared to have ruptured. The second patient had a right ventricular aneurysm with the same appearances of false tendon. These two cases suggested that the formation of an aneurysm might project a common muscular band into the ventricular cavity giving electrocardiographic appearances of a false tendon. We observed this association in 6 out of 23 cases of ventricular aneurysms in a prospective study. It is important to recognise this phenomenon and to differentiate it from other echogenic structures (thrombus).

[Isolated pulmonary valve endocarditis: a case report]. / Endocardite valvulaire pulmonaire isolée. A propos d'un cas.

The authors report the very rare case of isolated pulmonary valve endocarditis in the absence of classical predisposing factors and discuss the therapeutic approach. In the absence of large series, a maximum of information is developed from this new case, especially with respect to its unusual context.

[Apical bilateral hypertrophic myocardiopathy with mitral and greater tricuspid valve insufficiency]. / Myocardiopathie hypertrophique apicale bilatérale avec insuffisances mitrale et tricuspide majeures.

The case of a patient with non-obstructive apical hypertrophic cardiomyopathy diagnosed on criteria that are now conventional is reported. This case exhibited two special features: the apical hypertrophic cardiomyopathy was bilateral (i.e. the two ventricles were simultaneously involved) and it was associated with massive mitral and tricuspid valve regurgitation. These two features are frequent in other types of hypertrophic cardiomyopathy, but they have not yet been described in apical hypertrophic cardiomyopathy. They support the concept that there is no definite border between the different types of hypertrophic cardiomyopathy.

[Medical treatment of coronary insufficiency in the elderly]. / Le traitement médical de l'insuffisance coronaire du sujet âgé.

Age does not modify the logical approach of the medical treatment of angina pectoris. Triggering factors have to be searched and treated. Age is not a contra-indication, but the physician has to be familiar with the drugs used in the elderly (side-effects, contra-indications, metabolism, dosages, etc.). The choice based on side-effects and contra-indications favours calcium inhibitors and nitrates. Nevertheless, beta-blocking agents give good results in the elderly, if care is taken to use them correctly. Aspirin is given at reduced dosage. Sublingual nitrates are necessary for the anginal crisis or before stress (prophylaxis). Compliance and safety are favoured by a rational therapy.

[Hypertrophic cardiomyopathy]. / La cardiomyopathie hypertrophique.

Hypertrophic cardiomyopathy is an uncommon disease, important to recognize. Family screening is mandatory, with physical examination, EKG and echocardiography. Genetic diagnosis will modify our approach in a near future. The different treatments are described: drugs, surgery, pacing. The role of the general practitioner is complementary to the cardiologist's. His task is especially important in the first step of the diagnosis.

[Pulmonary embolism and anterior septal ischemia on the electrocardiogram: diagnostic trap. Two case reports]. / Embolies pulmonaires et ischemie antero-septale a l'electrocardiogramme: piege diagnostique. A propos de deux cas.

The authors reports two cases of pulmonary embolism which have, on ECG, an anteroseptal subepicardial ischemia which could indicate a coronary origin. The value and role of electrocardiographic findings in the diagnosis of pulmonary embolism are analysed. Once the diagnosis of pulmonary embolism has been established, the rest-ECG could allow the massive forms to be distinguished from the non-massive ones. The anteroseptal subepicardial ischemia pattern in the precordial leads is the most frequent sign of pulmonary embolism. This parameter is easy to obtain and reflects the severity of pulmonary embolism.

[Anticoagulation in cardiac pathologies (except atrial fibrillation)]. / L'anticoagulation dans les pathologies cardiaques (hors fibrillation auriculaire).

Anticoagulants, including heparins and antivitamins K are medicines which are largely prescribed in cardiology. Even though the outlines of the treatment have been clearly established for a few decades, new cardiological indications have recently appeared. The long-term treatment of cardiac valvular prosthesis by oral anticoagulants significantly reduces the risk of thrombo-embolic incident among people carrying a cardiac valvular prosthesis. In case of non-operated valvulopathy, treatment indication must be evaluated for each patient; in so doing, the connection benefit/risk must always be taken into account. In case of dilated cardiomyopathy, the treatment prescription must be limited to the patients with a high embolic risk. Other cardiological indications (apart from atrial fibrillation) must be carefully weighed up.

[2 cases of isolated tricuspid endocarditis following colonic intervention]. / Deux cas d'endocardite tricuspidienne isolée après intervention colique.

We report two cases of tricuspid valve endocarditis with related organisms (Enterococcus faecalis and Gemella morbillorum), some months after colonic operation. This association, without preexistent valvular pathology and without any other classical aetiology of tricuspid endocarditis, has only exceptionally been described.