Optimizing anticoagulation therapy for in-hospital patients on direct oral anticoagulants: a single-centre modified Delphi study.

AIMS: The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non-surgical patients regarding temporary DOAC discontinuation. METHODS: We executed a two-step modified Delphi study in a 1000-bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non-surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face-to-face group session. RESULTS: After the two-round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re-intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non-surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios. CONCLUSIONS: We have updated and developed guidelines for DOAC management in surgical and non-surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists.

iFR uncovers profound but mostly reversible ischemia in CTOs and helps to optimize PCI results.

OBJECTIVES: The study aimed to demonstrate through instant wave-free ratio (iFR) measurements that myocardium distal to a chronic total occlusion (CTO) is ischemic, that ischemia is reversible by PCI, and that iFR assessment after PCI can be used to optimize PCI results. BACKGROUND: The greatest benefit of revascularization is found in patients with low fractional flow reserve. In patients with CTOs, iFR measurement may be more appropriate to evaluate ischemia as it does not require maximal microvascular vasodilation, which may be hampered by microvascular dysfunction. METHODS: The iFR was measured in 81 CTO patients, both pre- and post-PCI in 63 patients, and only post-PCI in the following 18 patients. A pressure wire pullback was performed post-PCI if iFR ≤0.89. RESULTS: The first 63 patients all had significant ischemia distal to the CTO with a median iFR of 0.33 [0.22; 0.44], improving significantly post-PCI to a median iFR of 0.93 [0.89;0.96] (p < .001). In the complete cohort, the median iFR post-PCI was 0.93 [0.86;0.96] but still ≤0.89 in 23 patients (30%). 12 of these patients had further PCI optimization because of a residual focal pressure gradient on pullback, after which only two had a final iFR ≤0.89. CONCLUSIONS: In CTO patients with an indication for PCI, iFR consistently demonstrated profound myocardial ischemia. Successful PCI immediately relieved ischemia in 70% of patients. In the remaining 30% of cases, a manual iFR pullback proved helpful in guiding further optimization of the PCI result.

Physiology-Based Revascularization of Left Main Coronary Artery Disease.

It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.

Medical Treatment in Coronary Patients: Is there Still a Gender Gap? Results from European Society of Cardiology EUROASPIRE V Registry.

PURPOSE: This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD). METHODS: Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80 years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6 months to < 2 years after hospitalization) was collected. RESULTS: Data was available for 8261 patients (25.8% women). Overall, no gender differences were observed in the prescription and use of cardioprotective medication like aspirin, beta-blockers, and ACE-I/ARBs (P > 0.01) at discharge and follow-up respectively. However, a statistically significant difference was found in the use of statins at follow-up, in disfavor of women (82.8% vs. 77.7%; P < 0.001). In contrast, at follow-up, women were more likely to use diuretics (31.5% vs. 39.5%; P < 0.001) and calcium channel blockers (21.2% vs. 28.8%; P < 0.001), whereas men were more likely to use anticoagulants (8.8% vs. 7.0%; P < 0.001). Overall, no gender differences were found in total daily dose intake (P > 0.01). Furthermore, women were less likely than men to have received a CABG (20.4% vs. 13.2%; P < 0.001) or PCI (82.1% vs. 74.9%; P < 0.001) at follow-up. No gender differences were observed in prescribed (P = 0.10) and attended (P = 0.63) cardiac rehabilitation programs. CONCLUSION: The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness about risk in female CHD patients.

Different dynamics of new-onset electrocardiographic changes after balloon- and self-expandable transcatheter aortic valve replacement: Implications for prolonged heart rhythm monitoring.

BACKGROUND: New onset electrocardiographic (ECG) changes after transcatheter aortic valve replacement (TAVR) are used to assess the risk for late atrioventricular block. However, the time of ECG evaluation remains controversial. We aimed to compare the time course and dynamics of new onset ECG changes according to valve design in balloon- (BEV) and self-expandable (SEV) TAVR. METHODS AND RESULTS: This single center study enrolled 133 consecutive TAVR patients (28.6% SEV, 71.4% BEV). Patients with pre-existent permanent pacemaker implant (PPMI), procedural death or incomplete ECG registration were excluded. Standard 12­lead ECG was performed before the procedure, at 1, 24, 48 and 120 h and 1 month. In BEV patients, no significant PR prolongation occurred, whereas in SEV patients the PR interval prolonged significantly with 33.7 ± 22.0 ms (p < 0.001, compared to pre-TAVR) but only after 48 h after TAVR. Widening of QRS duration was comparable among both BEV and SEV patients (6.7 ± 21.5 versus 17.0 ± 26.9 ms, p = 0.061) and occurred immediately after TAVR. New-onset left bundle branch block was seen in 18.5% of BEV and 30.8% of SEV patients (p = 0.120) and occurred within 24 h after TAVR in both groups. Late PPMI (>24 h after TAVR) was higher in SEV compared to BEV patients (15.3% versus 1.5%, p = 0.008). CONCLUSION: Self-expandable valves cause more impairment in atrioventricular conduction with a delayed time course compared to balloon expandable valves. This might explain the higher pacemaker need beyond 24 h after TAVR. Our findings suggest that patients with self-expandable valves require at least 48 h ECG monitoring post TAVR.

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction.

OBJECTIVES: To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction -(STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention. METHODS: A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression. RESULTS: Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours. CONCLUSIONS: After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.

The spectrum of spontaneous coronary artery dissection: illustrated review of the literature.

Spontaneous coronary artery dissection or SCAD is a rare and challenging disease that is increasingly diagnosed. It is characterized by a non-traumatic, non-iatrogenic separation of the coronary artery wall and occurs predominantly in young and middle-aged women without traditional cardiovascular risk factors. SCAD is often associated with predisposing conditions such as the peripartum period, systemic inflammatory disease and heritable connective tissue disease. More recently, independent investigators have demonstrated an important association with fibromuscular dysplasia. Extreme emotional or physical stress as well as intense hormonal therapy or drug abuse have been pointed out as precipitating factors. The diagnosis of SCAD can be challenging and starts with clinical suspicion. Advanced imaging techniques such as intravascular ultrasound and optical coherence tomography are useful for the differentiation from atherosclerotic disease and are increasingly used for this indication. The proposed treatment in the acute setting is based on findings from single-centre retrospective series: in stable patients with a TIMI-flow ≥2 a conservative management is proposed because of the high risk of procedural failure and complications as well as a high probability of spontaneous healing. Long-term treatment is comparable to that in non-SCAD acute coronary syndromes (ACS) but dual antiplatelet therapy should only be started in case of stenting and should be kept as short as possible in patients with vascular Ehlers-Danlos syndrome. Prognosis seems to be better compared to non-SCAD ACS but there is a reasonable risk of recurrence. In this review, we discuss the current knowledge of SCAD and provide a clinical pathway for the diagnosis, management and work-up of SCAD patients.

Quality assessment in Belgian ST elevation myocardial infarction patients: results from the Belgian STEMI database.

The present report describes the quality of care, including in hospital mortality for more than 22.000 STEMI patients admitted in 60 Belgian hospitals for the period 2008-2016. We found a strong increase in the use of primary PCI over time, particularly for patients that were admitted first in a non-PCI capable hospital, reaching a penetration rate of >95%. The transition of thrombolysis to transfer for pPCI in the setting of a STEMI network was, however, associated with an increase of the proportion of patients with prolonged (>120 min) diagnosis-to-balloon time (from 16 to 22%), suggesting still suboptimal interhospital transfer. The in-hospital mortality of the total study population was 6.5%. For non-cardiac arrest patients in-hospital mortality decreased from 5.1% to 3.7%, while it increased for cardiac arrest patients from 29 to 37%. The observation that quality indicators (QI's), such as modalities and timing of reperfusion therapy, were associated with lower levels of mortality, underscores the potential of QIs for STEMI to improve care and reduce unwarranted variation and premature death from STEMI.

Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey.

OBJECTIVE: Identification, selection and validation of key interventions and quality indicators for improvement of in hospital quality of care for ST-elevated myocardial infarction (STEMI) patients. METHODS AND RESULTS: A structured literature review was followed by a RAND Delphi Survey. A purposively selected multidisciplinary expert panel of cardiologists, nurse managers and quality managers selected and validated key interventions and quality indicators prior for quality improvement for STEMI. First, 34 experts (76% response rate) individually assessed the appropriateness of items to quality improvement on a nine point Likert scale. Twenty-seven key interventions, 16 quality indicators at patient level and 27 quality indicators at STEMI care programme level were selected. Eighteen additional items were suggested. Experts received personal feedback, benchmarking their score with group results (response rate, mean, median and content validity index). Consequently, 32 experts (71% response rate) openly discussed items with an item-content validity index above 75%. By consensus, the expert panel validated a final set of 25 key interventions, 13 quality indicators at patient level and 20 quality indicators at care programme level prior for improvement of in hospital care for STEMI. CONCLUSIONS: A structured literature review and multidisciplinary expertise was combined to validate a set of key interventions and quality indicators prior for improvement of care for STEMI. The results allow researchers and hospital staff to evaluate and support quality improvement interventions in a large cohort within the context of a health care system.

One-year and longer dual antiplatelet therapy after an acute coronary syndrome: a Belgian position paper.

Acute coronary syndrome patients receive DAPT up to one year after their initial event. Exceptions to the guideline-recommended one-year rule, however, are not uncommon. The reasoning behind shorter treatments, such as unacceptable bleeding risk or urgent surgery, should be well documented in the patient's charts and discharge letter. Based on recent evidence, patients at high risk for repetitive events should continue on low-dose ticagrelor without a significant interruption at one year and indefinitely in the absence of excess bleeding risk. As there is currently no reimbursement, policy makers and insurers should be made aware of the continuing risk and unmet clinical need in this patient population. Nevertheless, many unsolved questions need to be answered, both through additional analyses from recent trials such as PEGASUS-TIMI 54 or DAPT, as well as new carefully designed clinical studies.

Gender differences in the management and outcome of atrial fibrillation complicating acute heart failure.

BACKGROUND: Little is known about sex differences in the prevalence, treatment, and outcome of atrial fibrillation complicating acute heart failure. METHODS AND RESULTS: Among 957 patients (429 women, 528 men), included in the BIO-HF registry, 45.2% (n = 194) of the women and 45.1% (n = 238) of the men were admitted with atrial fibrillation. The primary end point was a composite of 1-year all-cause mortality and hospitalization for heart failure. Adjusted 1-year mortality and hospitalization rates were similar between sexes (women 38.5%, men 36.0%; OR for female gender: 1.1, 95% CI 0.65-1.86; P = .71. A significant interaction between female sex and age (P = .002) was observed; with worse prognosis for women <75 years (OR 7.17, 95% CI 1.79-28.66; P = .005) compared with men <75 years. No sex differences in in-hospital treatment, restoration of sinus rhythm (16.5% in women vs 14.2% in men; P = .58), or in-hospital mortality (5.7% in women vs 6.7% in men; P = .69) were observed. CONCLUSIONS: Among patients hospitalized with acute heart failure, no sex differences in the prevalence and management of atrial fibrillation were observed. In-hospital mortality and the composite of 1-year mortality and rehospitalization were not different between sexes, but a significant sex-age interaction was observed, with worse outcome in women <75 years versus men <75 years of age.

Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience.

BACKGROUND: Some patients with Takotsubo cardiomyopathy (TTC) develop cardiogenic shock due to left ventricular outflow tract (LVOT) obstruction - there is, however, a paucity of data regarding this condition. METHODS: Prevalence, associated factors and management implications of LVOT obstruction in TTC was explored, based on two-year data from two Belgian heart centres. RESULTS: A total of 32 patients with TTC were identified out of 3,272 patients presenting with troponin-positive acute coronary syndrome. In six patients diagnosed with TTC (19%), a significant LVOT obstruction was detected by transthoracic echocardiography. Patients with LVOT obstruction were older and had more often septal bulging, and presented more frequently in cardiogenic shock as compared to those without LVOT obstruction (P < 0.05). Moreover, all patients with LVOT obstruction showed systolic anterior motion (SAM) of the anterior mitral valve leaflet, which was associated with a higher grade of mitral regurgitation (2.2±0.7 vs. 1.0±0.6, P<0.001). Adequate therapeutic management including fluid resuscitation, cessation of inotropic therapy, intravenous ß-blocker, and the use of intra-aortic balloon pump resulted in non-inferior survival in TTC patients with LVOT obstruction as compared to those without LVOT obstruction. CONCLUSIONS: TTC is complicated by LVOT obstruction in approximately 20% of cases. Older age, septal bulging, SAM-induced mitral regurgitation and hemodynamic instability are associated with this condition. Timely and accurate diagnosis of LVOT obstruction by echocardiography is key to successful management of these TTC patients with LVOT obstruction and results in a non-inferior outcome as compared to those patients without LVOT obstruction.

Treatment of pre-existing cardiomyopathy during pregnancy.

Heart failure is an established predictor of primary cardiac events during pregnancy. Adequate heart failure treatment in pregnant women is hampered by important foetotoxicity of several conventional drugs. Hydralazine with or without long-acting nitrates has been proposed as an alternative for ACE inhibitors or angiotensin receptor blockers. There are no published data, however, on the use of hydralazine to treat heart failure during pregnancy. We describe the course and outcome of pregnancy in two patients with heart failure. A 31-year-old woman with dilated cardiomyopathy was not treated with hydralazine during pregnancy and developed worsening heart failure. A 36-year-old woman with ischaemic cardiomyopathy was treated with hydralazine early during pregnancy and remained stable throughout and after pregnancy. We assume that early initiation of hydralazine as an alternative for ACE inhibitors or angiotensin receptor blockers during pregnancy in patients with cardiomyopathy could prevent further left ventricular dilatation and worsening heart failure.

Renal dysfunction in STEMI-patients undergoing primary angioplasty: higher prevalence but equal prognostic impact in female patients; an observational cohort study from the Belgian STEMI registry.

BACKGROUND: Mortality in female patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty (pPCI) is higher than in men. We examined gender differences in the prevalence and prognostic performance of renal dysfunction at admission in this setting. METHODS: A multicenter retrospective sub-analysis of the Belgian STEMI-registry identified 1,638 patients (20.6% women, 79.4% men) treated with pPCI in 8 tertiary care hospitals (January 2007-February 2011). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. Main outcome measure was in-hospital mortality. RESULTS: More women than men suffered from renal dysfunction at admission (42.3% vs. 25.3%, p < 0.001). Mortality in women was doubled as compared to men (9.5 vs. 4.7%, OR (95% CI) = 2.12 (1.36-3.32), p<0.001). In-hospital mortality for men and women with vs. without renal dysfunction was much higher (10.7 and 15.3 vs. 2.3 and 2.4%, p < 0.001). In a multivariable regression analysis, adjusting for age, gender, peripheral artery disease (PAD), coronary artery disease (CAD), hypertension, diabetes and low body weight (<67 kg), female gender was associated with renal dysfunction at admission (OR (95% CI) 1.65 (1.20-2.25), p = 0.002). In a multivariable model including TIMI risk score and renal dysfunction, renal dysfunction was an independent predictor of in-hospital mortality in both men (OR (95% CI) = 2.39 (1.27-4.51), p = 0.007) and women (OR (95% CI) = 4.03 (1.26-12.92), p = 0.02), with a comparable impact for men and women (p for interaction = 0.69). CONCLUSIONS: Female gender was independently associated with renal dysfunction at admission in pPCI treated patients. Renal dysfunction was equally associated with higher in-hospital mortality in both men and women.

Inter-hospital variation in length of hospital stay after ST-elevation myocardial infarction: results from the Belgian STEMI registry.

OBJECTIVE: The aim of this paper was to assess the determinants of and variations in length of hospital stay (LOS) in Belgium after ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Data on LOS were collected from 2079 STEMI patients who were discharged alive from 33 Belgian hospitals (21 with PCI facilities) during 2010-201 1. Early discharge was defined as hospital discharge within 4 days after admission, and the hospitals were clustered according to their LOS for low-risk patients. Determinants of LOS were calculated by means of a negative binomial regression model. LOS was, on average, 6.5 days with a median of 5 days (IQR 4). Baseline risk profiles and reperfusion treatment explained only 13% of the LOS variation. Additional analysis revealed major in-hospital variations independent of the case mix of patients. For comparable baseline risk profiles, the average LOS in a cluster of 11 hospitals with short discharge policies was 5.3 + 5.6 days, with an early discharge rate of 58%, while in the cluster of 11 hospitals with long discharge policies, the average LOS was 7.9 + 8.5 days with an early discharge rate of 22% (P <0.0001). Among the clustered hospitals, there were no differences with regard to logistics (PCI facility, academic affiliation) or volume of STEMI patients. The 1-month mortality rate was less than 0.5% in the different clusters of hospitals (p = NS). CONCLUSIONS: Length of hospital stay is not only determined by baseline risk profiles of patients but is also highly dependent on hospital discharge policy, which seems to be unrelated to medical or logistical factors.

Gender differences in health-related quality of life and psychological distress among coronary patients: Does comorbidity matter? Results from the ESC EORP EUROASPIRE V registry.

AIMS: This study aimed to provide an overview on contemporary gender differences in HRQoL/psychological distress and their relationship with comorbidity burden among European coronary heart disease (CHD) patients. METHODS: Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey. Consecutive patients (aged 18-80 years), hospitalized for a first or recurrent coronary event were included in this study. Data at hospital discharge and at follow-up (6 to 24 months after hospitalisation) were collected. RESULTS: Data were available for 8261 patients of which 25.8% women. Overall, women reported a worse EQ-5D-5L index score (0.73 vs. 0.81; P < 0.001), EQ-VAS (63.1 vs. 66.0; P = 0.001), global HeartQoL (1.94 vs. 2.26; P < 0.001), physical HeartQoL (1.96 vs. 2.30; P < 0.001), emotional HeartQoL (1.88 vs. 2.18; P < 0.001), HADS-A (6.69 vs. 4.99; P < 0.001), and HADS-D (5.73 vs. 4.62; P < 0.001) compared to men. Also, women were more likely to have comorbidities compared to men (1 comorbidity: 38.7% vs. 35.0%, 2 comorbidities: 9.7% vs. 7.5%; P < 0.001). There is indication that heart failure (EQ-VAS) and diabetes (global HeartQoL, emotional HeartQoL, physical HeartQoL, and HADS-D) interacted with gender and modulate the relationship with HRQoL, in disfavour of women. CONCLUSION: Substantial gender-based health inequalities in terms of HRQoL and psychological distress were found, in disfavour of women. Women had worse HRQoL and psychological distress outcomes when having comorbidities. To a limited extent, comorbidity and women had a negative/synergistic effect on HRQoL. Special attention should be given to this population groups within daily clinical practice.

Gender differences in risk factor management and pharmacological treatment among CHD patients: Belgian results of the EUROASPIRE IV and EUROASPIRE V surveys.

AIMS: The aim of this study was to provide an up-to-date overview of gender differences or similarities in risk factor control and medical management in the Belgian CHD population. METHODS: All analyses are based on the ESC EORP EUROASPIRE IV and EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) surveys. Patients between 18 and 80 years old, hospitalised for a first or recurrent coronary event, were included in the survey. RESULTS: Data were available for 10,519 patients, of which 23.9% were women. Women had a worse risk factor profile compared to men. Women were more physical inactive (OR = 1.31, 95% CI = 1.19-1.44), had a higher prevalence of obesity (OR = 1.37, 95% CI = 1.25-1.50) and had a worse LDL-C control (OR = 1.52, 95% CI = 1.36-1.70). Moreover, women were less likely to use ACE-I/ARBs (OR = 0.84, 95% CI = 0.76-0.94) and statins (OR = 0.79, 95% CI = 0.70-0.90). In addition, little gender differences were found in patients' risk factor awareness, except on cholesterol awareness. Women were more aware about their total cholesterol levels (OR = 1.37, 95% CI = 1.21-1.56). CONCLUSION: Despite little to no gender differences in the management of CHD patients, women still have a worse risk factor profile, both in Belgian and in other European high-income countries.

iFR/FFR/IVUS Discordance and Clinical Implications: Results From the Prospective Left Main Physiology Registry.

OBJECTIVES: This study aimed to assess discordance between results of instantaneous wave-free ratio (iFR), fractional flow reserve (FFR), and intravascular ultrasound (IVUS) in intermediate left main coronary (LM) lesions, and its impact on clinical decision making and outcome. METHODS: We enrolled 250 patients with a 40%-80% LM stenosis in a prospective, multicenter registry. These patients underwent both iFR and FFR measurements. Of these, 86 underwent IVUS and assessment of the minimal lumen area (MLA), with a 6 mm2 cutoff for significance. RESULTS: Isolated LM disease was recognized in 95 patients (38.0%), while 155 patients (62.0%) had both LM disease and downstream disease. In 53.2% of iFR+ and 56.7% of FFR+ LM lesions, the measurement was positive in only one daughter vessel. iFR/FFR discordance occurred in 25.0% of patients with isolated LM disease and 36.2% of patients with concomitant downstream disease (P=.049). In patients with isolated LM disease, discordance was significantly more common in the left anterior descending artery and younger age was an independent predictor of iFR-/FFR+ discordance. iFR/MLA and FFR/MLA discordance occurred in 37.0% and 29.4%, respectively. Within 1 year of follow-up, major cardiac adverse events (MACE) occurred in 8.5% and 9.7% (P=.763) of patients whose LM lesion was deferred or revascularized, respectively. Discordance was not an independent predictor of MACE. CONCLUSIONS: Current methods of estimating LM lesion significance often yield discrepant findings, complicating therapeutic decision-making.