Addition of FFRct in the diagnostic pathway of patients with stable chest pain to reduce unnecessary invasive coronary angiography (FUSION) : Rationale and design for the multicentre, randomised, controlled FUSION trial.

BACKGROUND: Coronary computed tomography angiography (CCTA) is widely used in the diagnostic work-up of patients with stable chest pain. CCTA has an excellent negative predictive value, but a moderate positive predictive value for detecting coronary stenosis. Computed tomography-derived fractional flow reserve (FFRct) is a non-invasive, well-validated technique that provides functional assessment of coronary stenosis, improving the positive predictive value of CCTA. However, to determine the value of FFRct in routine clinical practice, a pragmatic randomised, controlled trial (RCT) is required. We will conduct an RCT to investigate the impact of adding FFRct analysis in the diagnostic pathway of patients with a coronary stenosis on CCTA on the rate of unnecessary invasive coronary angiography, cost-effectiveness, quality of life and clinical outcome. METHODS: The FUSION trial is a prospective, multicentre RCT that will randomise 528 patients with stable chest pain and anatomical stenosis of ≥ 50% but < 90% in at least one coronary artery of ≥ 2 mm on CCTA, to FFRct-guided care or usual care in a 1:1 ratio. Follow-up will be 1 year. The primary endpoint is the rate of unnecessary invasive coronary angiography within 90 days. CONCLUSION: The FUSION trial will evaluate the use of FFRct in stable chest pain patients from the Dutch perspective. The trial is funded by the Dutch National Health Care Institute as part of the research programme 'Potentially Promising Care' and the results will be used to assess if FFRct reimbursement should be included in the standard health care package.

Family screening in patients with isolated bicuspid aortic valve : Restriction to those with aortic dilatation is not justified.

AIM: To determine the prevalence of undiagnosed bicuspid aortic valve (BAV) and isolated aortic dilatation in first-degree relatives (FDRs) of patients with isolated BAV and to explore the recurrence risk of BAV in different subgroups of probands with BAV. Recent American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines recommend family screening in patients with associated aortopathy only. METHODS: During follow-up visits, patients with isolated BAV received a printed invitation for their FDRs advising cardiac screening. RESULTS: From 2012-2019, 257 FDRs of 118 adult BAV patients were screened, among whom 63 (53%) index patients had undergone aortic valve surgery (AVS), including concomitant aortic replacement in 25 (21%). Of the non-operated index patients, 31 (26%) had aortic dilatation (> 40 mm). Mean age of the FDRs was 48 years (range 4-83) and 42% were male. The FDR group comprised 20 parents, 103 siblings and 134 offspring. Among these FDRs, 12 (4.7%) had a previously undiagnosed BAV and 23 (8.9%) had an isolated aortic dilatation. FDRs of the probands with previous AVS (n = 147) had a risk ratio for BAV of 2.25 (95% confidence interval (CI) 0.62-8.10). FDRs of the probands with BAV and repaired or unrepaired aortic dilatation (n = 127) had a risk ratio for BAV of 0.51 (95% CI 0.16-1.66). CONCLUSION: Screening FDRs of patients with isolated BAV resulted in a reasonable yield of 14% new cases of BAV or isolated aortic dilatation. A trend towards an increased risk of BAV in FDRs was observed in the probands with previous AVS, whereas this risk seemed to be diminished in the probands with associated aortic dilatation. This latter finding does not support the restrictive ACC/AHA recommendation.

Recognition of cognitive impairment and depressive symptoms in older patients with heart failure.

INTRODUCTION: Cognitive impairment and depression in patients with heart failure (HF) are common comorbidities and are associated with increased morbidity, readmissions and mortality. Timely recognition of cognitive impairment and depression is important for providing optimal care. The aim of our study was to determine if these disorders were recognised by clinicians and, secondly, if they were associated with hospital admissions and mortality within 6 months' follow-up. METHODS: Patients (aged ≥65 years) diagnosed with HF were included from the cardiology outpatient clinic of Gelre Hospitals. Cognitive status was evaluated with the Montreal Cognitive Assessment test (score ≤22). Depressive symptoms were assessed with the Geriatric Depression Scale (score >5). Patient characteristics were collected from electronic patient files. The clinician was blinded to the tests and asked to assess cognitive status and mood. RESULTS: We included 157 patients. Their median age was 79 years (65-92); 98 (62%) were male. The majority had New York Heart Association functional class II. Cognitive impairment was present in 56 (36%) patients. Depressive symptoms were present in 21 (13%) patients. In 27 of 56 patients (48%) cognitive impairment was not recognised by clinicians. Depressive symptoms were not recognised in 11 of 21 patients (52%). During 6 months' follow-up 24 (15%) patients were readmitted for HF-related reasons and 18 (11%) patients died. There was no difference in readmission and mortality rate between patients with or without cognitive impairment and patients with or without depressive symptoms. CONCLUSION: Cognitive impairment and depressive symptoms were infrequently recognised during outpatient clinic visits.

Differences at surgery between patients with bicuspid and tricuspid aortic valves.

AIM: To determine differences in surgical procedures and clinical characteristics at the time of surgery between native bicuspid aortic valves (BAV) and tricuspid aortic valves (TAV) in patients being followed up after aortic valve surgery (AVS). METHODS: In this retrospective cohort study in a non-academic hospital, we identified patients who had a surgeon's report of the number of native valve cusps and were still being followed up. We selected patients with BAV and TAV, and used multivariable regression analyses to identify associations between BAV-TAV and pre-specified clinical characteristics. RESULTS: Of 439 patients, 140 had BAV (32%) and 299 TAV (68%). BAV patients were younger at the time of surgery (mean age 58.6 ± 13 years) than TAV patients (69.1 ± 12 years, p < 0.001) and were more often male (64% vs 53%; p = 0.029). Cardiovascular risk factors were less prevalent in BAV than in TAV patients at the time of surgery (hypertension (31% vs 55%), hypercholesterolaemia (29% vs 58%) and diabetes (7% vs 16%); all p < 0.005). Concomitant coronary artery bypass grafting (CABG) was performed less often in BAV than in TAV patients (14% vs 39%, p < 0.001), even when adjusted for confounders (adjusted odds ratio (adj.OR) 0.45; 95% CI: 0.25-0.83). In contrast, surgery of the proximal aorta was performed more often (31% vs 11%, respectively, p < 0.001; adj.OR 2.3; 95% CI: 1.3-4.0). CONCLUSIONS: Whereas mechanical stress is the supposed major driver of valvulopathy towards AVS in BAV, prevalent cardiovascular risk factors are a suspected driver towards the requirement for AVS and concomitant CABG in TAV, an observation based on surgical determination of the number of valve cusps.

Appropriate use criteria for echocardiography in the Netherlands.

INTRODUCTION: Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way. METHODS: All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively). RESULTS: Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper. CONCLUSIONS: Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity.

Prognostic factors in infective endocarditis in general hospitals in the Netherlands.

INTRODUCTION: Despite advances in treatment, infective endocarditis (IE) still ranks amongst the most lethal infectious diseases. We sought to determine prognostic factors in general hospitals in the Netherlands as research in this setting is scarce. RESULTS: Between 2004 and 2011, we identified 216 cases of IE, 30.1 % of which were prosthetic valve IE. This leads to an annual incidence of IE of 5.7 new cases per 100,000 persons per year. Women were less likely to undergo surgical intervention (OR = 1.96, 95 % CI 1.06-3.61, p = 0.031). Also, ageing was an independent prognostic factor for not receiving surgery in a multivariate analysis (annual OR = 1.04, 95 % CI 1.02-1.06, p < 0.001). Female sex was a prognostic factor for mortality (OR = 2.35, 95 % CI 1.29-4.28, p = 0.005). Age was also an independent prognostic factor for mortality (OR = 1.05, 95% CI 1.03-1.08, p < 0.001). Conservative treatment was a prognostic factor for mortality (OR = 3.39, 95 % CI 1.80-6.38, p < 0.001) whereas surgical intervention was an independent prognostic factor for adverse events (OR = 3.03, 95% CI 1.64-5.55, p < 0.001). Staphylococcus aureus was an independent prognostic factor for adverse events (OR = 2.05, 95 % CI 1.10-3.84, p = 0.024) but not for mortality. CONCLUSION: This study shows that endocarditis in general hospitals has a high rate of morbidity and mortality. Even when treated, it ranks as one of the most lethal infectious diseases in the Netherlands, especially in women and the elderly.

A prospective validation of the HEART score for chest pain patients at the emergency department.

BACKGROUND: The focus of the diagnostic process in chest pain patients at the emergency department is to identify both low and high risk patients for an acute coronary syndrome (ACS). The HEART score was designed to facilitate this process. This study is a prospective validation of the HEART score. METHODS: A total of 2440 unselected patients presented with chest pain at the cardiac emergency department of ten participating hospitals in The Netherlands. The HEART score was assessed as soon as the first lab results and ECG were obtained. Primary endpoint was the occurrence of major adverse cardiac events (MACE) within 6 weeks. Secondary endpoints were (i) the occurrence of AMI and death, (ii) ACS and (iii) the performance of a coronary angiogram. The performance of the HEART score was compared with the TIMI and GRACE scores. RESULTS: Low HEART scores (values 0-3) were calculated in 36.4% of the patients. MACE occurred in 1.7%. In patients with HEART scores 4-6, MACE was diagnosed in 16.6%. In patients with high HEART scores (values 7-10), MACE occurred in 50.1%. The c-statistic of the HEART score (0.83) is significantly higher than the c-statistic of TIMI (0.75)and GRACE (0.70) respectively (p<0.0001). CONCLUSION: The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (0-3), exclude short-term MACE with >98% certainty. In these patients one might consider reserved policies. In patients with high HEART scores (7-10) the high risk of MACE may indicate more aggressive policies.

Right ventricular ejection fraction measured by multigated planar equilibrium radionuclide ventriculography is an independent prognostic factor in patients with ischemic heart disease.

BACKGROUND: The number of studies on the prognostic value of the right ventricular ejection fraction (RVEF) in patients with ischemic heart disease (IHD) is limited, whereas it is widely accepted that the left ventricular ejection fraction (LVEF) is a strong prognostic factor. We assessed whether RVEF measured by multigated planar equilibrium radionuclide ventriculography (RNV) is an independent prognostic factor in patients with IHD. METHODS AND RESULTS: We retrospectively identified 347 consecutive patients with IHD (mean age 71 ± 11 years; 18% women) who underwent multigated planar equilibrium RNV between 2004 and 2008 to determine the LVEF, which also provided the RVEF (mean 44.7% ± 11.0%). We categorized patients according to RVEF in ≥40% (n = 240) and <40% (n = 107). Patients were followed for a median of 826 days (range 3-2,400) for the occurrence of events [all-cause mortality (n = 60), cardiac mortality (n = 33), and cardiac hospitalization (n = 78)]. Cox regression analysis with significant univariate predictors [coronary artery revascularization (P = .003), diuretics (P = .03), and statins (P < .001)] showed that an RVEF <40% was associated with a 2.90 (1.68-5.00)-fold higher risk of all-cause death. Accordingly, a decreased RVEF was associated with a 2.15 (1.34-3.43)-fold increase in the risk of cardiac hospitalization and a 5.11(2.32-11.23)-fold risk of cardiac death. CONCLUSION: RVEF measured by multigated planar equilibrium RNV is an independent prognostic factor in patients with chronic IHD.

Aortic aneurysm formation following coarctation repair by Dacron patch aortoplasty.

We describe the finding of an aortic aneurysm in an asymptomatic 43-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 25 years before. The role of magnetic resonance angiography as standard imaging technique in lifelong postoperative surveillance is discussed subsequently. (Neth Heart J 2010;18:376-7.).

Rupture of right coronary sinus of Valsalva aneurysm into right ventricle.

A sinus of Valsalva aneurysm is a rare cardiac anomaly that may be congenital or acquired; a coexisting cardiac lesion might be present. If the aneurysm ruptures, it causes acute symptoms of dyspnoea. Echocardiography and cardiac magnetic resonance imaging are useful for diagnosis. The treatment of choice is surgery. We present a case of a patient with acute onset of symptoms due to a ruptured sinus of Valsalva aneurysm. (Neth Heart J 2010;18:209-11.).

[Unexplained right-sided heart failure following open heart surgery: mind the pericardium]. / Onverklaarde rechtsdecompensatie na een openhartoperatie: denk aan het hartzakje.

Three men, aged 67 years, 80 years and 53 years, respectively, developed signs and symptoms of progressive right-sided heart failure following open heart surgery. They were diagnosed with constrictive pericarditis based on echocardiography, cardiac magnetic resonance and cardiac catheterisation. Following pericardiectomy, two of the patients fully recovered, while one, the 80-year-old man, died during convalescence. When signs and symptoms of progressive right-sided heart failure develop after open heart surgery, a diagnosis of constrictive pericarditis should be considered. Constrictive pericarditis after open heart surgery may be caused by inflammation of the pericardium; an old, fibrotic haemopericardium, which may be diffuse or loculated; pericardial adhesions; or a combination of these entities. Diagnosing constrictive pericarditis is difficult and may take a long time. However, it is important to recognise this disorder early before it has progressed to an advanced stage. Pericardiectomy is the only effective therapy. When performed too late, survival is significantly reduced.

[No response to antihypertensive therapy: consider non-adherence]. / Geen reactie op antihypertensieve therapie: denk aan therapieontrouw.

In 3 patients, 2 men aged 62 and 43 years, respectively, and 1 woman aged 53 years, the medication prescribed to reduce blood pressure was insufficiently effective. Drug adherence was questioned. The first patient was afraid of the side effects mentioned in the medication information leaflet. The second patient had insufficient plasma levels of the medication but would not discuss the subject. The blood pressure of the third patient was uncontrolled despite treatment with three antihypertensive drugs. During a short hospital stay, her blood pressure responded favourably to treatment with only one of the three drugs. Subsequent repeated instruction did not improve her situation. Drug adherence is an important issue in daily clinical practice. In patients with asymptomatic conditions like hypertension, adherence is expected to be poor and worsen over time. Adherence is very difficult to measure. Risk factors for poor adherence include complex medication schedules, multiple dosing times, depression and real or suspected side effects. Measures to improve drug adherence include simplifying the medication schedule, discussing the schedule during check-ups, using automated blood pressure measuring devices at home, maintaining e-mail contact with the patient and involving a specialised nurse. Increased awareness of poor adherence is an important step toward improving hypertension treatment.

Be smart, don't kick the heart.

Blunt chest trauma is a rare cause of cardiac pathology. Nevertheless, a variety of life-threatening cardiac diseases can be caused by blunt chest traumas. In this case report we describe a myocardial infarction associated with kickboxing. We also review the literature describing myocardial infarction associated with blunt chest trauma.