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.

Evaluating patients' satisfaction and preferences with a secondary prevention cardiovascular polypill: the Aurora Study.

Aim: To evaluate the satisfaction, preferences and adherence of patients in secondary cardiovascular prevention treated with the Spanish National Cardiovascular Research Centre cardiovascular polypill compared with patients treated with the separate monocomponents. Methods: Observational, cross-sectional and multicenter study. Satisfaction was evaluated by the Treatment Satisfaction Questionnaire for Medication 9 items, adherence by the Morisky-Green questionnaire and ad-hoc questions were asked regarding patient preferences. Results: Polypill patients reported higher satisfaction than patients treated with the monocomponents (77.3 vs 71.2%; p < 0.0001). 72.8% of patients treated with the monocomponents would prefer to change to the polypill. Patients treated with the polypill had significantly higher adherence than patients treated with the monocomponents (57.7 vs 41.1%; p = 0.0027). Conclusion: Polypill patients show higher satisfaction and better adherence. Most patients receiving the monocomponents would prefer a polypill regime.

Impact of different anticoagulation management strategies on outcomes in atrial fibrillation: Dutch and Belgian results from the GARFIELD-AF registry.

BACKGROUND: The uptake rate of non-vitamin K oral anticoagulants (NOAC) for the treatment of non-valvular atrial fibrillation (AF) was far lower in the Netherlands (NL) compared to Belgium (BE). Also, patients on VKA in NL were treated with a higher target international normalized ratio (INR) range of 2.5 to 3.5. OBJECTIVES: To explore the effect of these differences on thromboembolism (TE) and bleeding. METHODS: Data from the GARFIELD-AF registry was used. Patients with new-onset AF and ≥1 investigator-determined risk factor for stroke were included between 2010 and 2016. Event rates from 2 years of follow-up were used. RESULTS: In NL and BE, 1186 and 1705 patients were included, respectively. Female sex (42.3% vs 42.2%), mean age (70.7 vs 71.3 years), CHA2 DS2 -VASc (3.1 vs 3.1), and HAS-BLED score (1.4 vs 1.5) were comparable between NL and BE. At diagnosis in NL vs BE, 72.1% vs 14.6% received vitamin K antagonists (VKA) and 17.8% vs 65.5% NOACs, varying greatly across cohorts. Mean INR was 2.9 (±1.0) and 2.4 (±1.0) in NL and BE, respectively. Event rates per 100 patient-years in NL and BE, respectively, of all-cause mortality (3.38 vs 3.90; hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.65-1.15), ischemic stroke/TE (0.82 vs 0.72; HR 1.14, 95% CI 0.62-2.11), and major bleeding (2.06 vs 1.54; HR 1.33, 95% CI 0.89-1.99) did not differ significantly. CONCLUSIONS: In GARFIELD-AF, despite similar characteristics, patients on anticoagulants were treated differently in NL and BE. Although the rate of major bleeding was 33% higher in NL, variations in bleeding, mortality, and TE rates were not statistically significant.

Treatment patterns in anticoagulant therapy in patients with newly diagnosed atrial fibrillation in Belgium: results from the GARFIELD-AF registry.

Background: AF, anticoagulation, NOACs, changing patterns of prescription. Methods: We describe baseline data and treatment patterns of patients recruited in Belgium in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF). Recruitment began when novel oral anticoagulants (NOACs) were introduced and provides a unique picture of changing treatment patterns over time. 1713 patients with a new (≤6 weeks duration) diagnosis of non-valvular atrial fibrillation (NVAF) and at least one investigator-defined stroke risk factor were recruited between May 2012 and August 2016, and will be prospectively followed for at least 2 years. Results: Overall, anticoagulant use in Belgium was higher than in the rest of Europe: 80.1% of patients received an anticoagulant ± antiplatelet (AP) therapy (14.5% on vitamin K antagonists; 65.6% on NOAC), 10.7% AP therapy and 9.3% no antithrombotic therapy. Over time, we observed an increase in anticoagulant use and a decrease in AP use for stroke prevention. NOAC use in Belgium was the highest of Europe at the study start, with many countries catching up later. In high stroke risk patients (CHA2DS2-VASc ≥2), anticoagulants were used in 84.3%, leaving 15.7% unprotected. In low risk patients (CHA2DS2-VASc 0-1) anticoagulants were overused (58.7%). Factor Xa inhibitors were used more frequently than direct thrombin inhibitors. Conclusion: Guideline adherence on stroke prevention was higher in Belgium than in the rest of Europe, and increased over time. NOAC use in Belgium was the highest of Europe at the study start, with many countries catching up later. Possible reasons are discussed. Clinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT01090362.

Atrial Myxoma With Feeding Vessels From Both the Right and Left Coronary Arteries: A Rare Finding During Coronary Angiography.

A 73-year-old woman presented with exertional chest pain and mild dyspnea for several months. In this case, preoperative coronary angiography showed neovascularization originating from the right coronary artery (RCA) and left circumflex (LCX). Vascular supply in left atrial myxomas usually originates from the LCX and sometimes from the RCA, but vascular supply from both the right and left coronary arteries is rarely seen.

Carcinoid heart disease: typical findings on echocardiography and cardiac magnetic resonance.

Carcinoid syndrome is often complicated by carcinoid heart disease. Deposition of carcinoid plaques on the endocardium of the tricuspid and pulmonary valves causes the typical echocardiographic iconography with thickening of the leaflets and valvular insufficiency and/or stenosis leading to right heart failure. Additionally, the fibrous plaques can be visualized with cardiac magnetic resonance using delayed enhancement sequences. Accurate assessment of the dimensions of the dilated right ventricle by magnetic resonance implicates therapeutic options and defines prognosis. We report the case of a patient with advanced right heart failure as the clue to the diagnosis of carcinoid syndrome. Echocardiography was suggestive. Advanced investigation with magnetic resonance confirmed carcinoid plaque deposition on the tricuspid and the pulmonary valves, and we also had evidence of plaque deposition in the right ventricle. Multimodality imaging is essential in the investigation of this rare disorder.

Isolated rupture of the left atrial appendage after blunt chest trauma.

Traumatic cardiac damage is caused by penetrating or blunt injury.The majority of disruptures in blunt trauma are the result of deceleration traumas. We present the case of an 8-year-old boy who fell off his horse. Afterwards the horse stepped on his chest. He was successfully treated for pericardial tamponade due to an isolated left appendage rupture. The lesion was probably caused by a sudden elevated intra-atrial blood pressure during chest compression.

Superior vena cava syndrome and infection of pacing leads in one patient.

The superior vena cava (SVC) syndrome is an uncommon complication due to permanent transvenous pacemaker electrodes. Infection of the leads is a risk factor for its occurrence. After being treated for SVC syndrome, due to multiple pacemaker leads, with thrombolysis and coumarine therapy, our patient was diagnosed with repetitive positive blood cultures. Because of relapsing SVC syndrome all pacemaker material was surgically removed. Recovery was complete and the patient remained pacemaker-independent. Culture of the leads showed the same coagulase-negative staphylococci as in the blood cultures. The indications for pacemaker implantation should always be rigorously defined and complications thoroughly investigated and treated.