Incidental Findings of Congenital Unileaflet Mitral Valves in Young Patient Presenting Complete Atrioventricular Block.

The singular leaflet mitral valve is a rare and complex entity that has been described in only a few case reports. It is commonly observed in infancy and combined with symptomatic mitral regurgitation (MR). In most asymptomatic individuals, this complication is attributed mainly to a hypoplastic posterior mitral leaflet and is usually revealed in adulthood. We present the case of a 30-year-old man who presented with chest pain and dyspnea for two days. The electrocardiogram showed complete atrioventricular block with a beat rate of 30 bpm. Echocardiography revealed an elongated anterior mitral valve leaflet and an almost completely absent posterior mitral valve leaflet with no MR. Our case is unusual presentation of a unileaflet mitral valve that should be investigated even in adulthood as these patients are likely to be at risk of developing or worsening MR later in life; hence, performing periodic echocardiograms is important for detecting the progression of MR early.

Valvular unvolvement in carcinoid disease. a case report.

Carcinoid tumors are rare, mainly located in the gastrointestinal tract particularly in the small intestine. Cardiac involvement, fairly frequent and usually affecting right sided heart valves, had a poor prognosis that is improved by an earlier detection and valve surgery. We report the case of a 50-years old woman with neuroendocrine tumor and liver metastases, in whom carcinoid involvement of the right heart was diagnosed following exertional dyspnea. She had dilated right cavities, severe tricuspid regurgitation, mild tricuspid stenosis and a moderate pulmonary stenosis. She underwent a double valve replacement by bioprosthesis with improvement of symptoms and recovery of normal right cavities size.

Impact of obstructive sleep apnea on the right ventricle.

BACKGROUND: Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI). METHODS: Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI<5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h. RESULTS: There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p<0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH. CONCLUSIONS: In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

Can CS gas induce myocardial infarction?

"2-chlorobenzylidene malononitrile" also named CS gas is the most used riot-control agent in the world. Its reputation as the least toxic tear gas explains its large use by different authorities. Early exposure to CS spray commonly induces visual irritation, skin reactions, with increased mucous secretion in order to temporarily incapacitate targeted people. However, there is a large agreement that safety data of this product is limited and further studies need to be performed since serious problems could occur after heavy exposure such as loss of consciousness, laryngospasm, pulmonary edema and hemorrhage... Herein, we report a case of a young man who had acute myocardial infarction with serious cardiac sequelae after exposure to tear gas. To our knowledge, this is the second case since forty years in the literature that directly links documented acute heart infarction to CS gas exposure.

Impact of obstructive sleep apnea on the right ventricle.

BACKGROUND: Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI). METHODS: Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI<5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h. RESULTS: There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p<0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH. CONCLUSIONS: In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

Can CS gas induce myocardial infarction?

"2-chlorobenzylidene malononitrile" also named CS gas is the most used riot-control agent in the world. Its reputation as the least toxic tear gas explains its large use by different authorities. Early exposure to CS spray commonly induces visual irritation, skin reactions, with increased mucous secretion in order to temporarily incapacitate targeted people. However, there is a large agreement that safety data of this product is limited and further studies need to be performed since serious problems could occur after heavy exposure such as loss of consciousness, laryngospasm, pulmonary edema and hemorrhage... Herein, we report a case of a young man who had acute myocardial infarction with serious cardiac sequelae after exposure to tear gas. To our knowledge, this is the second case since forty years in the literature that directly links documented acute heart infarction to CS gas exposure.

Left Atrial Strain for assessment of left ventricle diastolic dysfunction in acute coronary syndrome patients.

INTRODUCTION: Patients with acute coronary syndrome (ACS) have a high incidence of Left ventricle diastolic dysfunction (DD). Latest algorithms for the assessment of DD lay on 2D parameters and describe a grading to quantify its severity. However, there persists a "gray zone" of values in which DD remains indeterminate. AIM: to analyze the diagnostic value of Left atrium strain (LAS) for categorization of LV DD and assessment of LV filling pressures in ACS patients. METHODS: Cross-sectional study that prospectively evaluated 105 patients presenting ACS with preserved LV ejection fraction (LVEF). Patients were divided in 4 groups according to the DD grade. Mean values of LAS, corresponding to three phases of atrial function: reservoir (LASr), conduit (LAScd) and contraction (LASct), were obtained by speckle-tracking echocardiography. RESULTS: Mean age was 60±10 years, with a gender ratio of 6.14. LASr and LASct were significantly lower according to DD severity (p combined=0.021, p combined=0.034; respectively). E/e' ratio was negatively correlated to LASr (r= - 0.251; p= 0.022) and LASct (r= -0.197; p=0.077). Left atrial volume index (LAVI) was also negatively correlated to LASr (r= -0.294, p= 0.006) and LASct (r= -0.3049, p=0.005). Peak tricuspid regurgitation was negatively correlated to LASr (r=-0.323, p=0.017) and LASct (r=-0.319, p=0.020). Patients presenting elevated LV filling pressures had lower LASr and LASct (p=0.049, p=0.022, respectively) compared to patients witn normal LV filling pressures. ROC curve analysis showed that a LASr < 22% (Se= 75%, Sp= 73%) and a LASct < 13% (Se= 71%, Sp=58%) can increase the likelihood of DD grade II or III by 4.6 (OR= 4.6; 95% CI: 1.31-16.2; p=0.016) and 3.7 (OR= 3.7; 95% CI: 1.06-13.1; p= 0.047), respectively. CONCLUSION: LAS is a valuable tool, which can be used to categorize DD in ACS patients.

Echocardiographic Predictive Factors of Worsening Outcome in Type 1 Cardiorenal Syndrome.

Introduction: Type 1 cardiorenal syndrome (CRS) is defined as acute decompensated heart failure (AHF) leading to secondary acute kidney injury. Few studies have evaluated the reliability of transthoracic echocardiography (TTE) in assessing outcomes in patients with type 1 CRS. We sought to identify echocardiographic predictors of outcomes (death and rehospitalization) in patients with type 1 CRS. Methods: This was a prospective longitudinal monocentric study, conducted from December 2020 to December 2022 in the cardiology department of the Internal Security Forces Hospital in Marsa, Tunisia. 68 patients with type 1 CRS were included prospectively. Physical, biological, and echocardiographic data were collected during the index hospitalization and at 3 and 6 months of follow-up. Results: The mean age was 69 ± 10.1 years with a male predominance (72.0%). The mortality rate during initial hospitalization for AHF was 11.7%. The all-cause mortality rate at six months was 22.0%. The rehospitalization rate was 38.0%. Severe tricuspid regurgitation (p = 0.031), the subaortic velocity time integral (LVOT-VTI) with a cut-off value of 16, a sensitivity (Se) of 65%, and a specificity (Sp) of 85% (Area under the curve (AUC) = 0.818, p < 0.001), the right ventricular fractional area change (RV-FAC) with a cut-off value of 16, a Se of 60% and a Sp of 81% (AUC = 0.775, p < 0.001) were independent predictors of the cumulative rates of rehospitalization and mortality at six months. Left ventricular ejection fraction (LVEF) < 35% (HR = 0.828, 95% CI: 0.689-0.995, p = 0.044) and the RV-FAC (HR = 0.564, 95% CI: 0.361-0.881, p = 0.012) were independent predictors of all-cause mortality. LVOT-VTI (AUC = 0.766, p < 0.001) was a significantly independent predictor of rehospitalization. Conclusion: This study confirmed that type 1 CRS is associated with a poor prognosis. LVEF, LVOT-VTI, and RV-FAC are simple, reproducible, and sensitive ultrasound parameters for predicting outcomes in patients with type 1 CRS.

Prognostic value of the echocardiographic ratio tricuspid annular plane systolic excursion / pulmonary arterial systolic pressure in acute pulmonary embolism.

INTRODUCTION: The occurrence of death from acute pulmonary embolism (PE) is often linked to right ventricular (RV) failure, arising from an imbalance between RV systolic function and heightened RV afterload. In our study, we posited that an echocardiographic ratio derived from this disparity [RV systolic function assessed by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] could offer superior predictive value for adverse outcomes compared to individual measurements of TAPSE and PASP alone. METHODS: We conducted a retrospective analysis using data from a University Hospital Centre spanning from 2017 to 2023. All individuals with confirmed PE and a formal transthoracic echocardiogram within 7 days of diagnosis were included. The primary endpoint was a composite outcome of death, hemodynamic deterioration needing introduction of inotropes or thrombolysis within 30 days. Secondary endpoints included 6 months all-cause mortality and onset of right-sided heart failure. RESULTS: Thirty-eight patients were included. Mean age was 58 ±15 years old. A male predominance was noted: 23 male patients (60.5%) and 15 female patients (39.5%). Eight patients met the primary composite endpoint while nine patients met the secondary composite endpoint. In multivariate analysis, the TAPSE/PASP ratio was independently associated with the primary outcome (OR=2.77, 95% CI 1.101-10.23, P=0.042). A TAPSE/PASP ratio <0.3 was independently associated with the secondary outcome (OR=3.07, 95% CI 1.185-10.18, P=0.034). CONCLUSION: This study suggests that a combined echocardiographic ratio of RV function to afterload is effective in predicting adverse outcomes in acute PE.

Role of depression in blood pressure control. A cross-sectional multicentric study.

RESEARCH PROBLEM: Hypertension is a multifactorial disease that affects approximately one third of the Tunisian adult population. It is a major risk factor for stroke and cardiovascular disease. Environmental and psychosocial factors play an important role in hypertension onset and control. The prevalence of depression among hypertensive patients is 26, 8% and its presence is associated with increased risk of cardiovascular related morbi-mortality. Our study aims to evaluate the role of depression in blood pressure control among ambulatory hypertensive patients. Investigative process: This study is a cross-sectional, multicentric and descriptive study. We intend to include three hundred and two patients. A 24-hour ambulatory blood pressure monitor will be used to evaluate blood pressure control. Depression will be assessed by the 9-item Patient Health Questionnaire (PHQ-9) in Tunisian dialect. Clinical, socio-environmental, psychosocial and therapeutic and prognosis data will be collected from medical records. Patients will be classified into two groups: Controlled versus non-controlled hypertension. PHQ-9 scores will be then compared between the two cohorts. RESEARCH PLAN: Ethical considerations will be undertaken and respected. All patients should express an informed oral consent before enrollment. This trial will run for three months from the 15th August 2022. TRIAL REGISTRATION: NCT05516173.

Prognostic value of ambulatory blood pressure monitoring in treated hypertensive patients.

INTRODUCTION: Ambulatory blood pressure monitoring (AMBP) has become a valuable tool for analyzing patient blood pressure (BP) pro-file to make a more accurate prognosis compared to clinical office BP. AIM: To identify the prognostic value of different parameters of ABPM and the future course of cardiovascular events (CVE) in treated hypertensive patients. METHODS: We conducted a prospective, descriptive study, including treated hypertensive patients which had consulted between 2015 and 2016 and had a systematic ABPM during their follow-up. Patients were followed at the outpatient clinics for 4 years, and we searched in the computerized medical file the occurrence of CVE. RESULTS: A total of 240 patients were included in our study with masculine predominance (57%). The mean age was 57.4±9.5 years. During 4 years of follow-up, 30 patients (12.5%) experienced a CVE. The total number of CVE was 32: acute heart failure (3), acute co-ronary syndrome (15), atrial fibrillation (12), stroke (2). Daytime systolic blood pressure (SBP), night-time SBP, 24-h SBP and 24-h pulse pressure (PP), had similar performances to predict CVE. Only the 24-h PP (OR= 1.072; 95% IC: 1.019-1.128; p= 0.007) was found to be an independent predictor of CVE. A 24-h PP> 55 mmHg increased the risk of CVE by 3.2. CONCLUSION: SBP and PP were associated with CVE in treated hypertensive patients. the 24-h PP was found to be an independent pre-dictor of CVE so it may serve as a therapeutic target in hypertension therapy.

Assessment of debriefing in high-fidelity mannequin simulation: study among students in cardiology.

INTRODUCTION: Debriefing is the fundamental step in the learning process when teaching by simulation. The Debriefing Assessment for Simulation in Healthcare (DASH) guide is a tool designed to assess and develop the debriefing skills of trainers using healthcare simulation. AIM: To evaluate the debriefing in high-fidelity mannequin simulation in the management of cardiological emergency by the DASH tool, student version. METHODS: This was a bicentric, prospective, cross-sectional and evaluative study including five groups of students in the first year of the second cycle of medical studies completing their internship in the cardiology departments of the Habib Thameur hospital and the Internal Security Forces Hospital of Marsa during the first semester of the 2021-2022 academic year. The simulation scenario included the diagnosis and emergency management of degenerative syncopal atrioventricular block. RESULTS: Forty-four students completed the DASH assessment form (28 female, 16 male). According to the students, the trainers had maintained a climate conducive to learning (6.51±0.74). They had conducted the debriefing in a structured way (6.35±0.75). They had aroused engagement in the exchange leading the learner to analyze his performance (6.01±1.03). They had effectively identified the learner's strengths and areas for improvement as well as their reasons (6.39±1.04). The trainers had helped the learners to consider how to improve or maintain a good level of performance (6.57±0.77). The mean DASH score evaluating the trainers was 6.36±0.88. CONCLUSION: The DASH tool allows trainers to highlight the strengths and areas for improvement in the debriefing, which is the key step in the simulation to optimize the clinical reasoning process and improve the quality of care.

Correlation between left atrial strain and left ventricular filling pressure in patients suspected of heart failure with a preserved left ventricular ejection fraction.

INTRODUCTION: Despite different ultrasound parameters, left ventricular filling pressures (LVFP) assessment remains inconclusive in some cases. AIM: To determine the contribution of left atrial strain (LAS) in estimating LVFP in patients with exertional symptoms and preserved left ventricular ejection fraction. METHODS: This was a monocentric study, carried out in the cardiology department of the Interior Security Forces Hospital, La Marsa, between October 2021 and March 2022. Patients with exertional symptoms had a physical examination, a biological assessment and an ultrasound examination at rest and, if necessary, during exercise. We investigated the performance of LAS components (Peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS) and conduit function (FnC) in predicting LVFP rising. Patients were categorized into two final groups according to LVFP: Group A= high LVFP at rest or during exercise (25 patients) and Group B= not-high LVFP at rest and during exercise (48 patients). RESULTS: Seventy-three patients were enrolled in the study, with a mean age of 61±12 years and a majority being female (57%). The median PALS was 29.3% [21.4-32.4]. The mean PACS and FnC values were 13.4%±4.9 and 13.7%±4.7, respectively. Patients with high LVFP demonstrated lower LAS parameters and elevated NT-Pro BNP levels. LAS showed negative correlations with the E/e' ratio and NT-Pro BNP. PALS emerged as an independent predictor of LVFP elevation (HR=0.71; 95% CI: 0.513-0.986; p=0.041). CONCLUSION: This study highlights that LAS, as a simple ultrasound parameter, can effectively predict high LVFP.

Can we achieve ESC 2019 guidelines LDL-cholesterol target in Tunisia?

INTRODUCTION: Dyslipidemias are a major cardiovascular risk factor. The control of LDLc level is one of the major targets in patients admitted for an acute coronary syndrome (ACS). AIM: To study the lipid profile after ACS and to assess the degree of applicability of the European guidelines in Tunisia. METHODS: This was a prospective, multicentric, non-randomized study involving consecutive patients admitted for ACS between October 2019 and March 2020; for whom a lipid assessment was carried out on admission and checked after four to six weeks under high dose of statin. RESULTS: One hundred patients were included. The mean age of our population was 58.7 years and the sex ratio was 5.7. Obesity was present in 15%, Diabetes in 35%, hypertension in 34% and smoking in 61% of cases. Our patients presented with ST segment elevation myocardial infraction in 51%. The mean total plasma LDLc level was 1.04±0.26g/L. A reduction in LDLc levels of more than 50% was noted in 33% of patients. A value less than 0.55g/L of LDLc was noted in 46% of patients. The therapeutic target (LDLc.

Management of patients with cardiovascular diseases during Ramadan.

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

COPD prevalence in smokers with stable ischemic heart disease: A cross-sectional study in Tunisia.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD) are common causes of mortality worldwide, with shared risk factors. COPD continues to be largely underdiagnosed and undertreated, especially in patients with IHD. OBJECTIVE: To investigate the prevalence of COPD in smokers with confirmed IHD and to compare IHD characteristics between COPD patients and those without COPD. METHODS: It was a cross-sectional study, conducted between August and December 2017, including patients over 40 years of age, current or former smokers, with stable and confirmed IHD. Spirometry was undertaken for all participants, and COPD was defined according to GOLD criteria. RESULTS: A total of 122 patients, with mean age of 59.3 years and mean pack-year of 52.3, were enrolled. Spirometry was normal in 63.2% of patients and airflow limitation was the most frequent ventilatory disorder (20.5%). COPD was diagnosed in 19.7% of patients. Of the 24 COPD patients, 17 (70.8%) were previously undiagnosed. Airflow limitation severity in COPD patients was classified mild, moderate, severe and very severe in 25%, 62.5%, 8.3% and 4.2% of patients. Comparison between COPD patients and non-COPD patients showed that comorbidities, respiratory symptoms, chest x-ray abnormalities, life-threatening lesions, three vessel disease, pulmonary hypertension and right ventricle dysfunction were significantly more frequent in COPD patients. CONCLUSIONS: There was a high prevalence of COPD among smoking patients with IHD, and most were undiagnosed despite being symptomatic. Smokers with IHD, especially if having respiratory symptoms, radiological or ultrasound abnormalities or life-threatening coronary lesions should be evaluated for airflow limitation.

Distance education in times of covid 19: a leap into the future?

INTRODUCTION: Online education has grown a lot in recent months in our country during the global health crisis (COVID19). It has been widely used at all levels and fields of education ranging from elementary school to graduate and postgraduate studies. The aim of this study is to evaluate this teaching method compared to classical face-to-face teaching by referring to the learner's point of view. METHODS: It was a prospective and descriptive cross-sectional study targeting residents in medical imaging (all levels approximately 200 people) It was based on an online questionnaire sent to all residents after attending synchronous online teaching sessions at the College of Medical Imaging and Nuclear Medicine. The assessment was done by the learners using a 5 points Likert scale. RESULTS:    Ninety-seven residents answered the questionnaire. Sixty percent of our learners were satisfied with this new way of teaching. 73% of the students found the logistical means suitable for this course. The main advantages noted by our residents were accessibility to sessions from any location and the ability to replay lessons later. The weaknesses put forward were the lack of interaction with the teacher compared to face-to-face teaching and the occurrence of technical problems which could sometimes hamper the smooth running of the sessions. CONCLUSION: Our study allowed us to get feedback from our learners on this teaching. The multiplication of learning means, in particular a hybrid education should be considered to overcome the shortcomings of exclusive online teaching.

Tunisian Consensus document on magnetic resonance imaging in patients with intracardiac devices.

INTRODUCTION: Patients with ferromagnetic cardiac devices, particularly cardiac implantable electronic devices (CIED) such as pacemakers or implantable cardioverter defibrillators, are often inappropriately deprived of magnetic resonance imaging (MRI) for safety reasons. This consensus document is written by a multidisciplinary working group involving rhythmologists, interventional cardiologists, echocardiographists and radiologists. Its objective is to establish good practice recommendations to optimize the management of patients with cardiac devices requiring MRI examination, while ensuring their safety and facilitating their access to MRI.

Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF).

BACKGROUND: Contemporary registries on atrial fibrillation (AF) are scare in North African countries. HYPOTHESIS: In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal. METHODS: NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described. RESULTS: A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA2 DS2 VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died. CONCLUSIONS: NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.