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Competing Interests: Conflict of interest: None declared.

Background: This study aimed to assess the reliability of pressure derived fractional flow reserve (FFR) measurement and the handling performance of the OptoWire Deux with an optical pressure sensor relative to both the PressureWire X and the Verrata Pressure wire with piezoresistive pressure sensors., Methods: This single centre study included 80 patients between October 2016 and May 2017 undergoing a diagnostic coronary angiography. The reliability of FFR measurement measured with the OptoWire Deux relative to the PressureWire X and Verrata Pressure wire was assessed by the presence of drift. Drift was defined as a Pd/Pa measurement different from 1.00 ± 0.02 when pulled back after a FFR measurement at the location of the initial equalisation. Handling characteristics for all pressure wires were assessed qualitatively with respect to the PressureWire Aeris., Results: Ninety-eight measurements in 78 patients were performed; two patients were excluded because the lesion could not be crossed. Very stable and reliable FFR measurements with the optical sensors were registered, relative to the piezoresistive pressure sensors. Drift was found in 11%, 37%, and 33% of the measurements for OptoWire Deux, PressureWire X, and Verrata Pressure wire respectively. The handling performance of the OptoWire Deux was better rated for steerability and torqueability in relation to the standard FFR wire. The handling of the PressureWire X was rated equally good whereas the handling of the Verrata pressure wire was rated inferior in relation to the standard FFR wire., Conclusions: In patients undergoing FFR measurement, the OptoWire Deux has a stable and reliable pressure hence FFR measurement with fewer drift events and has good handling characteristics.

Background: High-sensitivity cardiac troponin testing is used to detect myocardial damage in patients with acute chest pain. Heart-type fatty acid binding protein (H-FABP) may be an alternative, available as point-of-care test., Methods: Patients (n=203) referred by general practitioners for suspected acute coronary syndrome or presenting with typical chest pain and one major cardiovascular risk factor at the emergency department were prospectively included in a single-centre cohort study. High-sensitivity cardiac troponin T (hs-TnT) and point-of-care H-FABP testing were concomitantly performed at admission and after 6h., Results: Maximal hs-TnT levels above the 99th percentile were observed in 152 patients (75%) with 127 (63%) fulfilling criteria for myocardial infarction. Upon admission, hs-TnT and H-FABP were associated with an area under the curve (95% CI) of 0.83 (0.77-0.89) and 0.79 (0.73-0.85), respectively, to predict myocardial infarction, which increased to 0.93 (0.90-0.97) and 0.88 (0.84-0.93), respectively, after 6h. The diagnostic accuracy for non-ST-segment elevation myocardial infarction was somewhat lower with an area under the curve (95% CI) of 0.80 (0.72-0.87), 0.90 (0.84-0.96), 0.73 (0.64-0.81) and 0.77 (0.67-0.86), respectively. When assessment was performed within 3h of chest pain onset, diagnostic accuracy of H-FABP versus hs-TnT was similar. Each standard deviation increase in admission H-FABP was associated with a 68% relative risk increase of all-cause mortality (p-value=0.027) during 666 ± 155 days of follow-up., Conclusions: Point-of-care H-FABP testing has lower diagnostic accuracy compared with hs-TnT assessment in patients with high pre-test acute coronary syndrome probability, but might be of interest when assessment is possible early after chest pain onset., (© The European Society of Cardiology 2015.)

Background: Electrocardiographic abnormalities and premature ventricular contractions are common in athletes and are generally benign. However, the specific outcome of high-level endurance athletes with frequent and complex ventricular arrhythmias is unclear. Also, information on the predictive accuracy of different investigations in this subgroup is unknown., Results: We report on 46 high-level endurance athletes with ventricular arrhythmias (45 male; median age 31 years) followed-up for a median of 4.7 years. Eighty percent were cyclists. Hypertrophic cardiomyopathy or coronary abnormalities were present in < or =5%. Eighty percent of the arrhythmias had a left bundle branch morphology. Right ventricular (RV) arrhythmogenic involvement (based on a combination of multiple criteria) was manifest in 59% of the athletes, and suggestive in another 30%. Eighteen athletes developed a major arrhythmic event (sudden death in nine, all cyclists). They were significantly younger than those without event (median 23 years vs 38 years; P=0.01). Outcome could not be predicted by presenting symptoms, non-invasive arrhythmia evaluation or morphological findings at baseline. Only the induction of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during invasive electrophysiological testing was significantly related to outcome (RR 3.4; P=0.02). Focal arrhythmias were associated with a better prognosis than those due to reentry (P=0.02) but the mechanism could be determined in only 22 (48%)., Conclusions: Complex ventricular arrhythmias do not necessarily represent a benign finding in endurance athletes. An electrophysiological study is indicated for risk evaluation, both by defining inducibility and identifying the arrhythmogenic mechanism. Endurance athletes with arrhythmias have a high prevalence of right ventricular structural and/or arrhythmic involvement. Endurance sports seems to be related to the development and/or progression of the underlying arrhythmogenic substrate.

Hyperlipidemia is common in heart transplant patients. Lipid-lowering therapy poses special problems, yet may be important because accelerated graft atherosclerosis is the major factor limiting long-term survival. Simvastatin 5 mg/day was started > 6 months after surgery in 26 consecutive cardiac transplant recipients with a total serum cholesterol level of > 250 mg/dl. The dose of simvastatin was increased in 5-mg increments until total serum cholesterol fell below 220 mg/dl or until side effects developed or up to a maximal dose of 20 mg/day. The final average daily dose was 10 mg. Changes in serum lipid levels after 6 months of therapy were compared with data from a matched and concurrent control group of heart transplant patients not taking simvastatin. Immunosuppression for both groups consisted of CsA, AZA, and corticosteroids. In the simvastatin-treated group, the serum level of total cholesterol decreased by 27% from 315 +/- 53 to 230 +/- 38 mg/dl (P < 0.0001), low density lipoprotein cholesterol decreased by 40% from 205 +/- 30 to 123 +/- 32 mg/dl (P < 0.0001), and triglycerides decreased by 21% from 177 +/- 89 to 140 +/- 49 mg/dl (P < 0.01). There was no significant change in high density lipoprotein cholesterol level. Body weight and CsA blood levels remained stable. Steroid intake decreased during the study period to a similar extent in both the treated and the control groups. In the control group, no significant changes in serum lipid levels were observed. Two patients experienced a mild form of myotoxicity. In one other patient simvastatin treatment was stopped after an acute pancreatitis of uncertain etiology developed. Low dose simvastatin effectively lowers total serum cholesterol, low density lipoprotein cholesterol, and triglycerides in heart transplant patients. With due precautions, the safety profile of the drug in this patient population seems reasonable.

One hundred fourteen coronary stenoses were quantified before and after percutaneous transluminal coronary angioplasty (PTCA) using a semi-automated digital system. The values obtained were considered as standard for comparison with visual estimation by the PTCA operator as well as by independent consensus-reading. The measured percent stenosis was 62.7 +/- 13.7% before and 27.7 +/- 12.4% after angioplasty. Before PTCA, the operator consistently overestimated stenosis severity (87.8 +/- 8.5%, P < 0.0001) and consensus-reading reduced but did not eliminate this overestimation (78.0 +/- 12.3%, P < 0.05). The error in visual estimation was inversely correlated with the measured degree of stenosis: coefficients were -0.79 (P < 0.0001) and -0.51 (P < 0.0001) for operator and consensus-readers, respectively. After PTCA, the operator underestimated the residual stenosis (21.2 +/- 9.9%, P < 0.0001) but there was no systematic bias by consensus-reading (29.4 +/- 12.0%, NS). Again the error in visual estimation was inversely correlated with the measured degree of residual stenosis: coefficients were -0.76 (P < 0.0001) and -0.58 (P < 0.0001) for operator and consensus-reading, respectively. In conclusion, the operator overestimates lesion severity before and underestimates moderate residual stenoses after PTCA, a problem only partially corrected by independent consensus-readers.

Background: Several angiotensin-converting enzyme inhibitors have antiproliferative effects in a rat model after carotid artery balloon injury., Methods and Results: We conducted a randomized, double-blind, placebo-controlled trial to assess the effect of fosinopril, a novel angiotensin-converting enzyme inhibitor, in restenosis prevention after percutaneous transluminal coronary angioplasty (PTCA). Patients received fosinopril or matched placebo 10 mg at least 18 hours before PTCA, 20 mg at least 4 hours before PTCA, and 40 mg daily for 6 months. In addition, all patients received aspirin. Coronary angiograms before PTCA and immediately after PTCA as well as at 6-month follow-up were quantitatively analyzed. A total of 509 patients were recruited. The final per-protocol population consisted of 153 fosinopril-treated and 151 placebo-treated patients. Restenosis rates according to the National Heart, Lung, and Blood Institute criterion 4 (loss of > or = 50% of the initial gain [primary end point]) were 45.7% and 40.7% in the fosinopril and control groups, respectively (not significant). The respective mean differences in minimal coronary luminal diameter between post-PTCA and follow-up angiograms were -0.59 +/- 0.71 mm and -0.51 +/- 0.67 mm (not significant). Clinical events during the 6-month follow-up period, analyzed on an on-treatment basis, were ranked according to the most serious event. The respective numbers in the fosinopril and the control groups were for death, 0 and 0; myocardial infarction, 0 and 0; coronary artery bypass graft surgery, 1 and 3; repeat PTCA, 35 and 35; recurrent signs of ischemia necessitating early repeat coronary angiography and managed medically, 6 and 7; and none of the above, 111 and 106. All these differences were significant., Conclusions: Administration of fosinopril in a dose of 40 mg daily during 6 months after PTCA does not prevent restenosis and has no effect on overall clinical outcome.

To evaluate intra- and interobserver variability of an on-line quantitative coronary angiographic system, 2 independent observers measured 166 primary lesions excluding total occlusions before and after coronary angioplasty. Each observer repeated his measurement 3 times at 14 days interval. The average percent diameter stenosis results obtained by observer 1 and 2 were almost identical, before (62.2% +/- 12.0% and 62.6% +/- 11.4%, NS) and after (27.1% +/- 12.0% and 26.9% +/- 11.3%, NS) angioplasty. Variability was expressed as 95% limits of agreement (mean difference +/- 2 x SD). The intra-observer variability of observer 1 ranged from -6.6% to 6.6% before angioplasty and from -9.6% to 9.6% after angioplasty. The corresponding limits of observer 2 were -8.0% to 7.5% and -8.3% to 8.5%, respectively. The interobserver variability ranged from -10.4% to 9.6% before versus -12.5% to 13.1% after angioplasty. This variability was not influenced by vessel size. The widening of the limits observed after angioplasty was largely due to an increased variability in the measurements of the absolute minimal luminal diameter but not of the reference segment. We conclude that the intra- and interobserver variability of measurements obtained with an on-line quantitative angiographic system used for guiding coronary interventions is acceptable and without systematic bias in any direction for a wide range of primary coronary stenoses. However, the variability increases when images are acquired immediately after angioplasty.

Objective: To determine the usefulness of the Stack autopersion dilatation catheter in patients with acute recurrent vessel closure during coronary angioplasty., Design: Prospective data collection., Setting: University hospital., Patients: In 37 of 1003 consecutive patients undergoing angioplasty between November 1989 and December 1990 acute vessel closure developed that could not be redilated by a conventional balloon catheter. 13 (35%) of these 37 patients were sent immediately for emergency bypass surgery., Intervention: In the remaining 24 patients an attempt was made to reopen the vessel with a Stack catheter., Main Outcome Measure: Successful reopening of the vessel. All successfully treated patients were followed for at least six months to detect recurrent ischaemia., Results: In 16 patients (67%) the Stack procedure was successful. Of the eight patients in whom reopening of the occluded vessel was not achieved, seven were sent for bypass surgery and one was successfully treated by emergency stent implantation. The 16 patients successfully treated with the Stack autoperfusion system were followed up for a mean (SD) of 6.7 (2.6) (range 2 to 11) months. Ten patients remained symptom free but early clinical restenosis developed in four (25%). Overall, only three (19%) of 16 patients experienced recurrence of severe (class III-IV) symptoms and required further mechanical revascularisation., Conclusion: These data support the use of the Stack autoperfusion catheter system in selected patients with acute vessel closure not responsive to attempted redilatation with conventional balloon catheters. The short-term outcome seen in this series of patients who were successfully treated with this coronary autoperfusion system is encouraging.

To assess the results of a conservative coronary angioplasty strategy in unstable angina pectoris, the records of 1,421 consecutive patients without previous myocardial infarction undergoing a first percutaneous transluminal coronary angioplasty (PTCA) between 1986 and 1990 were reviewed. Of these patients, 631 had unstable and 790 had stable angina pectoris. Only after an intense effort to medically control symptoms, the unstable patients underwent PTCA at an average of 15.4 days (range 1 to 76) after hospital admission. Primary clinical success was achieved in 91.7% of patients with unstable and in 94.4% of those with stable angina pectoris (p = not significant). In-hospital mortality rates were 0.3 and 0.1%, respectively (p = not significant). Nonfatal in-hospital event rates for acute myocardial infarction, cerebrovascular accident and coronary bypass surgery were only slightly higher in patients with unstable angina pectoris; however, the difference from the stable group was significant when all events were combined (9 vs 5.9%; p less than 0.04). During 6-month follow-up, no significant difference in adverse events was found between the groups. The respective rates for the unstable and stable groups were 0.4 and 0.2% for death, 5.5 and 5.1% for major nonfatal events, and 17.7 and 20.1% for repeat PTCA. These results suggest that use of a conservative PTCA strategy in the treatment of patients with unstable angina pectoris results in favorable and similar immediate and 6-month outcomes compared with those in patients with stable angina pectoris.

To analyze the effect of the calcium antagonist diltiazem on coronary hemodynamics, epicardial coronary artery diameter, coronary blood flow and coronary blood flow velocity were assessed at baseline and after a 0.5 mg intracoronary bolus of diltiazem in nonstenotic coronary arteries of awake humans. Patients (n = 20) were first randomized to pretreatment with either placebo (n = 10) or isosorbide dinitrate (0.5 microgram/kg/min infusion; n = 10), and coronary flow reserve was measured before and after administration of diltiazem. There were significant increases in epicardial coronary artery diameter (10%; p = 0.0001) and coronary blood flow (30%; p = 0.0001) in all patients after administration of diltiazem. Whereas basal coronary blood flow velocity increased only slightly (7%; p = not significant), there was a significant decrease in coronary flow reserve (10%; p = 0.004). Increases in coronary diameter and blood flow after diltiazem were comparable in patients pretreated with placebo or nitrates. However, the decrease in coronary flow reserve was significant only in patients pretreated with placebo (19%; p = 0.0008). This reduction in coronary flow reserve could be due to "raising the floor" (increased baseline coronary blood flow) or "lowering the ceiling" (reduction of maximal coronary blood flow).

The purpose of this study was to determine the long-term prognosis of patients with an isolated total occlusion of the left anterior descending artery (LAD). A total of 173 male patients with a chronic LAD occlusion and less than 50% narrowing of the other coronary arteries (group I) was compared with a group of 177 male patients with only insignificant coronary artery disease and a normal left ventricular function (group II). Baseline characteristics of both groups were comparable except for the inclusion of 54 patients (31.2%) with moderately or markedly reduced left ventricular systolic function in group I. During an 8-year follow-up period there was a greater number of patients with cardiac events in group I when compared with group II: cardiac death 11.2% versus 0.6% (p less than 0.0001), myocardial infarction 12.7% versus 3.4% (p = 0.001), myocardial revascularization procedures 11.6% versus 3.4% (p = 0.04). Stepwise discriminant analysis showed that a reduced ejection fraction and a family history of coronary artery disease were the best predictors for these adverse cardiac events.

A patient with chest pain of recent onset, suggestive for angina pectoris, was referred for diagnostic coronary angiography, which showed the typical phenomenon of "slow dye progression" in the absence of any significant coronary artery stenosis. While intracoronary Doppler measurements confirmed the extremely slow blood flow velocity, the coronary flow reserve and the calculated coronary blood flow proved to be within normal range. The present findings suggest that, in contrast with a previous hypothesis, the phenomenon of slow dye progression may not always be due to a microvascular cause. Epicardial artery disease, as suggested by the marked coronary artery ectasia, may be linked to the slow dye progression and predispose to coronary artery thrombosis.

Epicardial coronary artery diameter (ECAD), coronary blood flow velocity (CBFV), and coronary flow velocity reserve (CFVR) were analyzed at baseline and after a 500 micrograms i.c. bolus of diltiazem in nonstenotic coronary arteries of awake humans. Furthermore, patients (n = 25) were first randomized to pretreatment either with placebo (n = 12) or isosorbide dinitrate (0.5 micrograms/kg/min infusion) (n = 13). Diltiazem resulted in a significant increase in epicardial diameter (+10%; p = 0.001) and in coronary blood flow (CBF) (+30%; p = 0.0001). Whereas basal CBFV only slightly increased (+7%; NS), there was a significant fall in CFVR (-11%; p = 0.001). The increase in coronary diameter and CBF after administration of i.c. diltiazem was comparable in placebo- and nitrate-pretreated patients. The decrease in CFVR, however, was restricted to the placebo-pretreated patients (-21%; p = 0.0004). Apparently, diltiazem attenuated the CFVR but only in the absence of nitrates. Thus, diltiazem i.c. appears to enhance myocardial oxygen supply without deleterious effects on the distal coronary perfusion pressure.

The severity of the infarct-related residual coronary stenosis after spontaneous or therapeutic thrombolysis was quantitatively assessed in 91 patients with an acute myocardial infarction who were allocated to treatment in the acute stage with either a thrombolytic agent (100 mg of recombinant tissue-type plasminogen activator given over 3 h, 49 patients) or a placebo (42 patients). Heparin and aspirin were given to both groups until angiography was performed. Digital subtracted images of the infarct-related coronary vessel were obtained 10 to 14 days after hospital admission and were subsequently analyzed with the use of a computer-assisted coronary stenosis measurement system. Neither treatment group differed significantly in age, gender or location of the culprit coronary lesion. Median values (90% range) in the thrombolysis and control groups were, respectively, 1.95 (0.9 to 5.3) mm versus 1.7 (0.9 to 3.4) mm for stenosis length; 1.4 (0.8 to 2.7) mm versus 1.4 (0.9 to 1.8) mm for minimal luminal diameter; 57% (36% to 75%) versus 58% (44% to 71%) for diameter obstruction; 82% (59% to 95%) versus 82% (68% to 92%) for geometric area obstruction; and 78% (58% to 91%) versus 79% (66% to 90%) for densitometric area obstruction. The difference between the two groups was not statistically significant for any of these measurements. Thus, in this study no significant differences in anatomy or severity of residual coronary stenosis could be demonstrated at 10 to 14 days after an acute myocardial infarction in patients with a recanalized infarct-related vessel, whether or not thrombolytic therapy was given on admission. These results indicate that with effective antithrombotic treatment, gradual endogenous fibrinolysis or more rapid lysis induced by the infusion of a thrombolytic agent results in a similar infarct-related coronary lesion at the time of hospital discharge.

We report a case of aneurysm of the abdominal aorta with spontaneous rupture in a 64-year-old man with emphysema and chronic alcoholism. Campylobacter fetus subspecies fetus was repeatedly recovered from the blood and from specimens of the excised aneurysm. The patient died in spite of early diagnosis, intravenous erythromycin and surgical intervention. The bacteriology and epidemiology of campylobacteriosis in man is briefly discussed and eight other published cases of aneurysm, infected with the same organism, are tabulated. C. fetus ssp. fetus should be added to the list of bacteria having a tropism for vascular endothelium.