Platypnea orthodeoxia syndrome after recent stroke:A case report of a sandwiched right atrium

Background: Platypnea orthodeoxia syndrome (POS) is a condition characterized by onset or worsening of dyspnoea and desaturation in upright position that is relieved by returning to a supine position. This case report illustrates a sudden onset of severe platypnea caused by compression of the right atrium (RA) due to aortic dilatation and unilateral diaphragmatic paralysis after a recent stroke. Case summary: A 71-year-male patient with a medical history of recent stroke of the left hemisphere was referred to emergency department with acute dyspnoea. During observation in the emergency department, desaturation was noted in upright position. A contrast computed tomography excluded pulmonary embolism but revealed a dilated aortic root and an elevated right hemidiaphragm. The RA was compressed between these two structures (sandwiched). Given the clinical suspicion of a POS, a transoesophageal echocardiography was performed which confirmed the presence of a persistent foramen ovale (PFO) in supine position. In upright position, there was a torrential increase in right-to-left shunting. The PFO was closed using an Occlutech™ device. Directly after the procedure, the patient was symptom free. Discussion: A rise in RA pressure or difference in flow pattern in the RA can make a PFO become symptomatic. Elevated RA pressure was ruled out. Most anatomical pathologies influencing the flow pattern develop slowly over time. This case shows a presentation of POS after a recent stroke possible due to change in anatomy because of right hemidiaphragm paralysis in combination with the aortic dilatation

Effectiveness and safety of dabigatran versus acenocoumarol in 'real-world' patients with atrial fibrillation

Aims Randomized trials showed non-inferior or superior results of the non-vitamin-K-antagonist oral anticoagulants (NOACs) compared with warfarin. The aim of this study was to assess the effectiveness and safety of dabigatran (direct thrombin inhibitor) vs. acenocoumarol (vitamin K antagonist) in patients with atrial fibrillation (AF) in daily clinical practice. Methods and results In this observational study, we evaluated all consecutive patients who started anticoagulation because of AF in our outpatient clinic from 2010 to 2013. Data were collected from electronic patient charts. Primary outcomes were stroke or systemic embolism and major bleeding. Propensity score matching was applied to address the non-randomized design. In total, 920 consecutive AF patients were enrolled (442 dabigatran, 478 acenocoumarol), of which 2 x 383 were available for analysis after propensity score matching. Mean follow-up duration was 1.5 +/- 0.56 year. The mean calculated stroke risk according to the CHA(2)DS(2)-VASc score was 3.5%/year in dabigatran vs. 3.7%/year acenocoumarol-treated patients. The actual incidence rate of stroke or systemic embolism was 0.8%/year [95% confidence interval (CI): 0.2-2.1] vs. 1.0%/year (95% CI: 0.4-2.1), respectively. Multivariable analysis confirmed this lower but non-significant risk in dabigatran vs. acenocoumarol after adjustment for the CHA(2)DS(2)-VASc score [hazard ratio (HR)(dabigatran) = 0.72, 95% CI: 0.20-2.63, P = 0.61]. According to the HAS-BLED score, the mean calculated bleeding risk was 1.7%/year in both groups. Actual incidence rate of major bleeding was 2.1%/year (95% CI: 1.0-3.8) in the dabigatran vs. 4.3%/year (95% CI: 2.9-6.2) in acenocoumarol. This over 50% reduction remained significant after adjustment for the HAS-BLED score (HRdabigatran = 0.45, 95% CI: 0.22-0.93, P = 0.031). Conclusion In 'real-world' patients with AF, dabigatran appears to be as effective, but significantly safer than acenocoumarol

Measurement of coronary calcium scores or exercise testing as initial screening tool in asymptomatic subjects with ST-T changes on the resting ECG: an evaluation study

Background: Asymptomatic subjects at intermediate coronary risk may need diagnostic testing for risk stratification. Both measurement of coronary calcium scores and exercise testing are well established tests for this purpose. However, it is not clear which test should be preferred as initial diagnostic test. We evaluated the prevalence of documented coronary artery disease (CAD) according to calcium scores and exercise test results. Methods: Asymptomatic subjects with ST-T changes on a rest ECG were selected from the population based PREVEND cohort study and underwent measurement of calcium scores by electron beam tomography and exercise testing. With calcium scores ≥10 or a positive exercise test, myocardial perfusion imaging (MPS) or coronary angiography (CAG) was recommended. The primary endpoint was documented obstructive CAD (≥50% stenosis). Results: Of 153 subjects included, 149 subjects completed the study protocol. Calcium scores ≥400, 100-399, 10-99 and <10 were found in 16, 29, 18 and 86 subjects and the primary endpoint was present in 11 (69%), 12 (41%), 0 (0%) and 1 (1%) subjects, respectively. A positive, nondiagnostic and negative exercise test was present in 33, 27 and 89 subjects and the primary endpoint was present in 13 (39%), 5 (19%) and 6 (7%) subjects, respectively. Receiver operator characteristics analysis showed that the area under the curve, as measure of diagnostic yield, of 0.91 (95% CI 0.84-0.97) for calcium scores was superior to 0.74 (95% CI 0.64-0.83) for exercise testing (p = 0.004). Conclusion: Measurement of coronary calciu

Measurement of coronary calcium scores by electron beam computed tomography or exercise testing as initial diagnostic tool in low-risk patients with suspected coronary artery disease

We determined the efficiency of a screening protocol based on coronary calcium scores (CCS) compared with exercise testing in patients with suspected coronary artery disease (CAD), a normal ECG and troponin levels. Three-hundred-and-four patients were enrolled in a screening protocol including CCS by electron beam computed tomography (Agatston score), and exercise testing. Decision-making was based on CCS. When CCS≥400, coronary angiography (CAG) was recommended. When CCS<10, patients were discharged. Exercise tests were graded as positive, negative or nondiagnostic. The combined endpoint was defined as coronary event or obstructive CAD at CAG. During 12±4 months, CCS≥400, 10–399 and <10 were found in 42, 103 and 159 patients and the combined endpoint occurred in 24 (57%), 14 (14%) and 0 patients (0%), respectively. In 22 patients (7%), myocardial perfusion scintigraphy was performed instead of exercise testing due to the inability to perform an exercise test. A positive, nondiagnostic and negative exercise test result was found in 37, 76 and 191 patients, and the combined endpoint occurred in 11 (30%), 15 (20%) and 12 patients (6%), respectively. Receiver-operator characteristics analysis showed that the area under the curve of 0.89 (95% CI: 0.85–0.93) for CCS was superior to 0.69 (95% CI: 0.61–0.78) for exercise testing (P<0.0001). In conclusion, measurement of CCS is an appropriate initial screening test in a well-defined low-risk population with suspected CAD

Basal infarct location but not larger infarct size is associated with a successful outcome after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: a cardiovascular magnetic resonance imaging study

Alcohol septal ablation (ASA) is successful in most but not in all patients with obstructive hypertrophic cardiomyopathy (HCM). We therefore sought to investigate the relation between infarct location versus infarct size with outcome after ASA in patients with obstructive HCM. Baseline characteristics, procedural characteristics, and cardiovascular magnetic resonance findings at baseline and 4-6 month follow-up after ASA were analysed in 47 patients with obstructive HCM in a single-center retrospective study. Infarct size was determined using late gadolinium enhancement. Infarct location was divided into "basal infarction" and "distal infarction" based on an optimal cut-of value of the distance from the basal septum to the beginning of the infarction. A "successful" outcome was defined as 80 % reduction of the invasive gradient with a post-procedural gradient of <10 mmHg. Basal infarctions (n = 31) compared to distal infarctions (n = 16) were associated with successful outcome (100 vs. 38 %, P <0.001). Larger infarct size (n = 20) compared to smaller infarct size (n = 27) was not associated with successful outcome (75 vs. 82 %, P = 0.72). A more distal location of the infarction, was the only predictor of a less successful outcome (odds ratio 0.76, 95 % confidence interval 0.54-0.98, P = 0.03). Basal versus distal infarctions were also associated with a lower provoked gradient at late (2.6 +/- A 2.2 years) follow-up (11 (6-20) vs. 27 (12-94) mmHg, P = 0.01). Basal infarctions were associated with a successful outcome after ASA. A larger infarct size was not associated with a better outcome

C-reactive protein and angiographic characteristics of stable and unstable coronary artery disease: Data from the prospective PREVEND cohort

Aims: High sensitive-C-reactive protein (hs-CRP) is associated with coronary risk, which may be explained by an association with (unstable) coronary artery disease (CAD). Until now, histopathological and angiographic studies have failed to consistently demonstrate a strong relationship. However, most of these studies were limited by a cross-sectional design. Our aim was to prospectively evaluate the association between hs-CRP and plaque instability. Therefore, firstly, we investigated the relation between hs-CRP measured long before coronary angiography (CAG) and angiographic characteristics of stable and unstable CAD. In addition, we investigated the association with coronary events during follow up in the total PREVEND population. Methods and results: Of the population based Prevention of Renal and Vascular Endstage Disease (PREVEND) study, 8139 subjects without previous documented CAD were followed for the incidence of CAG and coronary events from 1997 to 2003. For the qualitative angiographic analysis, 216 CAGs were available. Mean time to CAG was 37 +/- 19 months. The 864 coronary vessels were graded as follows: 436 coronary vessels as normal, 175 as non-obstructive CAD, 179 as stable obstructive CAD and 74 as unstable obstructive CAD. Multilevel ordinal regression analysis was performed to study associations between baseline clinical variables and angiographic findings. Hs-CRP contributed significantly to the multivariate model after adjustment for age, gender, smoking, lipids and blood pressure. In 8139 subjects, 201 (2.5%) first coronary events occurred during follow up. Cox survival analysis showed age- and sex-adjusted hazard ratios for hs-CRP 1-3 and > 3 mg/L of, respectively, 1.26 (95% CI 0.67-2.40) and 3.16 (95% CI 1.26-3.16), relative to hs-CRP <1 mg/L Conclusion: In the prospective PREVEND study of subjects without previous documented CAD, hs-CRP levels at baseline were associated with angiographic characteristics and clinical consequences of plaque instability during follow up. This observation supports the concept that hs-CRP significantly contributes to coronary atherogenesis. (C) 2006 Elsevier Ireland Ltd. All rights reserve

Measurement of coronary calcium scores or exercise testing as initial screening tool in asymptomatic subjects with ST-T changes on the resting ECG: an evaluation study-0

<p><b>Copyright information:</b></p><p>Taken from "Measurement of coronary calcium scores or exercise testing as initial screening tool in asymptomatic subjects with ST-T changes on the resting ECG: an evaluation study"</p><p>http://www.biomedcentral.com/1471-2261/7/19</p><p>BMC Cardiovascular Disorders 2007;7():19-19.</p><p>Published online 13 Jul 2007</p><p>PMCID:PMC1959245.</p><p></p>breviations: neg., negative; nond., nondiagnostic; pos., positiv