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Background: Smartphone applications may enable interventions to increase physical activity but this has limited evidence in randomized trials. Objectives: The MyHeart Counts Cardiovascular Health study (MHC) is a smartphone-based longitudinal research study aimed at elucidating the determinants of cardiovascular health. Among MHC participants, we performed a randomized controlled trial to investigate the response to four different physical activity coaching interventions on the primary outcome of change in daily step count. Secondary outcomes included life satisfaction, 6-minute walk distance, and sleep quality. Methods: The trial was completed entirely using personal smartphones: participants were digitally consented, the interventions were delivered via the device, and measurements of the primary and secondary outcomes were collected from smartphone sensors. Participants were enrolled from December 12, 2016 to June 6, 2018 and followed for up to 5 weeks. Participants completed the trial through the MyHeart Counts phone app in a free-living setting. All adults over 18 years of age with access to a smartphone (Apple iPhone, version 5S or later) were eligible to participate. After one week of baseline measurements, participants (n=2783) were randomized to a sequence of four, week-long interventions delivered in random order. Interventions consisted of either daily prompts to complete 10,000 steps (completed by n=853); hourly prompts to stand following a full hour of sitting (completed by n=879); instructions to read the guidelines from the American Heart Association website (completed by n=868); and e-coaching based upon the individual's personal activity patterns from the baseline week of data collection (completed by n=896). Results: 2783 participants consented to enroll in the coaching study, of whom 1075 completed the baseline week of data collection and at least one of the four interventions. 493 individuals completed the full set of assigned interventions. All four interventions were found effective at modestly increasing daily step count by a mean of 266 ±75 steps from a baseline mean of 2958±69 steps (p=0.003). Intervention-specific step increases were: 319±74 steps (p

Despite the evolution in pharmacology and devices, recurrent and persistent angina still represent a frequent issue in clinical practice. A 69-year-old Caucasian female patient has history of surgical aortic valve replacement with a bioprosthesis for severe aortic stenosis with subsequent transcatheter valve-in-valve implantation for bioprosthesis degeneration and single coronary artery bypass graft with left internal mammary artery on left anterior descending (LAD). After transcatheter aortic valve implantation, she started to complain angina [Canadian Cardiovascular Society (CCS) Class III], effectively treated with bisoprolol uptitration and ivabradine 5 b.i.d. addition. After 6 months, she had a non-ST segment elevated myocardial infarction with evidence of left main occlusion and good functioning aortic bioprosthesis. A retrograde drug-eluting balloon percutaneous coronary intervention (PCI) on LAD (in-stent restenosis) was performed. However, the patient continued to complain angina (CCS Class II–III), even after further ivabradine increase to 7.5 mg b.i.d. After 4 months, the patient underwent Reducer implantation. After 2 months, angina started to improve and the patient is currently angina free. In the last decades, PCI materials and stents greatly improved. Medical therapy (such as β-blockers) has been shown not only to improve symptoms but also to add a prognostic benefit in patients with reduced ejection fraction (EF). Ivabradine showed additional benefits in patients with angina and reduced EF. However, still a relevant portion of patients complain refractory angina. The COSIRA trial showed that a coronary sinus Reducer was associated with greater angina relief than the sham procedure and could be a further step in angina treatment.

A 64 year old female patient with a history of dyslipidaemia presented with Canadian Cardiovascular Society class II angina and stage 1 positive treadmill stress test. Coronary angiogram revealed 20% stenosis in distal left main coronary artery (LMCA), two 95% stenosis in proximal left anterior descending artery (LAD) and non-significant disease in left circumflex and right coronary arteries. LAD lesion was crossed with Rinato guidewire and first diagonal branch (D1) crossed with BMW guidewire. Both proximal and distal LAD lesions were predilated and stented with 2.75 × 38 mm Xience prime (Everolimus Eluting) stent. After the stent implantation, jailed guidewire used to protect the diagonal branch could not be removed. Traction, pull and push, balloon reinflation and deflation, back-and-fourth vibration were attempted to no avail. Finally guidewire fracture occurred and eventually entrapment leaving a part in D1, LAD and LMCA. By using an endovascular snare system we were able to remove the fractured guidewire successfully. This case highlights that endovascular snare system can safely and effectively be used for extraction of fractured retained guidewires inside the coronary arteries which prevents impending surgical intervention.

Background Catheter ablation improves symptoms and quality of life in patients with atrial fibrillation (AF); however, despite its benefit, women are less likely than men to undergo catheter ablation. Women with AF have been described to have more frequent and severe symptoms with a lower quality of life than men, and it is therefore unclear why women are less likely to undergo catheter ablation. We prospectively characterized gender differences in AF symptoms among men and women undergoing ablation at UNC using questionnaire data. Methods Functional capacity was assessed with the Duke Activity Status Index (DASI) and quality of life was assessed with the Canadian Cardiovascular Society Symptoms of AF score (CCS-SAF) and the AF Effect on Quality-of-Life Questionnaire Tool (AFEQT). Results Among 191 patients in the study, women were less likely to undergo catheter ablation and had higher rates of paroxysmal AF and higher CHADS2 -VASc scores than men. Women had a worse functional capacity with significantly lower DASI scores than men; quality of life was also worse among women, with higher CCS-SAF scores and lower AFEQT scores than men. After adjustment for AF type, there was a persistent gender difference for functional capacity and symptom measures. Conclusions At the time of catheter ablation, women with AF had a significantly lower functional status with worse symptoms and a lower quality of life than men. The role of this symptom difference on the gender gap in enrollment for catheter ablation is unclear and likely due to multiple patient and provider factors.

Background: There are no data on how fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are associated with the placebo-controlled efficacy of percutaneous coronary intervention (PCI) in stable single-vessel coronary artery disease. Methods: We report the association between prerandomization invasive physiology within ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina), a placebo-controlled trial of patients who have stable angina with angiographically severe single-vessel coronary disease clinically eligible for PCI. Patients underwent prerandomization research FFR and iFR assessment. The operator was blinded to these values. Assessment of response variables, treadmill exercise time, stress echocardiography score, symptom frequency, and angina severity were performed at prerandomization and blinded follow-up. Effects were calculated by analysis of covariance. The ability of FFR and iFR to predict placebo-controlled changes in response variables was tested by using regression modeling. Results: Invasive physiology data were available in 196 patients (103 PCI and 93 placebo). At prerandomization, the majority had Canadian Cardiovascular Society class II or III symptoms (150/196, 76.5%). Mean FFR and iFR were 0.69±0.16 and 0.76±0.22, respectively; 97% had ≥1 positive ischemia tests. The estimated effect of PCI on between-arm prerandomization-adjusted total exercise time was 20.7 s (95% confidence interval [CI], –4.0 to 45.5; P =0.100) with no interaction of FFR ( P interaction =0.318) or iFR ( P interaction =0.523). PCI improved stress echocardiography score more than placebo (1.07 segment units; 95% CI, 0.70–1.44; P P interaction P interaction P =0.072) with no detectable evidence of interaction with FFR ( P interaction =0.849) or iFR ( P interaction =0.783). However, PCI resulted in more patient-reported freedom from angina than placebo (49.5% versus 31.5%; odds ratio, 2.47; 95% CI, 1.30–4.72; P =0.006) but neither FFR ( P interaction =0.693) nor iFR ( P interaction =0.761) modified this effect. Conclusions: In patients with stable angina and severe single-vessel disease, the blinded effect of PCI was more clearly seen by stress echocardiography score and freedom from angina than change in treadmill exercise time. Moreover, the lower the FFR or iFR, the greater the magnitude of stress echocardiographic improvement caused by PCI. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02062593.

Aim The objective of this study was to define the patient demographics, periprocedural characteristics and mid to long term outcomes associated with rotational atherectomy in modern clinical practice in Ireland. Methods We performed a retrospective analysis of all patients who underwent rotational atherectomy in two Irish centres. Data on all patients was collected from the electronic patient records system. Baseline characteristics were collected for all patients. This included demographic and procedural characteristics. Demographic characteristics included age, co-morbidities, medications and presentation. Long term follow up was obtained at 3 and 12 months to assess clinical response. NYHA functional class and CCS angina scores were evaluated at 3 months and 12 months post procedure. 66 cases were identified over the study period and a database of patients was produced. Results 66% of patients were male. Mean age was 72±8.12 years (Range 54–86 years). 90.6% of our patients were hypertensive, 32.3% were diabetic. 28.33% had CKD and 96.88% had hypercholesterolaemia. 44% were current smokers, 35.6% never smokers and 20.33% ex-smokers. Mean weight was 79.66±17.67 kg (Range 42.6–124 kg) and mean creatinine was 104.77±70.03 (Range 56–398). 40.6% of patients had previous PCI, 31.25% had previous failed attempts at PCI and 15.625% had previously had coronary artery bypass grafting. 98.5% of patients were on Aspirin and 92.3% were on a second antiplatelet agent. Periprocedural complications were detailed for all procedures based on pre-specified criteria. The most common complications reported were coronary artery dissection (9.09%) and bleeding (9.2%). 2 patients required dialysis post procedure (3.03%), 1 patient required emergency CABG (1.5%) and 1 patient suffered cardiac death (1.5%). Coronary artery rupture and cardiac tamponade did not occur in any cases. We also analysed for any association between outcomes and categorical variables. These included burr size, femoral vs radial access and age (Over/Under 75). We found no statistically significant difference between complication rates between cases with burr size 1.25 mm and cases using burr size of over 1.25 mm (18.4% vs 10%, p=0.33). Similarly complication rates were not significantly different for radial versus femoral access (23.5% vs 23.9%, p=0.974) and age over/under 75 (17.8% vs 28%, p=0.900919) Patients were assessed at 3 months and 12 months to assess clinical status post rotational atherectomy. Canadian cardiovascular society grading of angina pectoris and New York heart association functional scores were utilised. Mean CCS score at 3 months was 0.26±0.77 (Range 0–3) and this persisted out until 12 months (0.25±0.657). NYHA score at 3 months was 0.5±0.993 and again, this persisted until 12 months (0.457±0.816), indicating that the clinical benefit of rotational atherectomy is maintained until 1 year post procedure. Conclusions Whilst less commonly used in modern day intervention, rotational atherectomy still has a role in the drug eluting stent era to modify heavily calcified plaque. The risk of MACEs remains higher than conventional PCI, reflecting the complexity of the disease and increased procedural technical difficulty.

Background Cell therapy with bone marrow (BM)-derived progenitors has emerged as a promising therapeutic for refractory angina (RA) patients. In the present study, we evaluated the safety and preliminary efficacy of transcatheter delivery of autologous BM-derived advanced therapy medicinal product CD133+ cells (ATMP-CD133) in RA patients, correlating perfusion outcome with cell function. Methods In the phase I “Endocavitary Injection of Bone Marrow Derived CD133+ Cells in Ischemic Refractory Cardiomyopathy” (RECARDIO) trial, a total of 10 patients with left ventricular (LV) dysfunction (ejection fraction ≤ 45%) and evidence of reversible ischemia, as assessed by single-photon emission computed tomography (SPECT), underwent BM aspiration and fluoroscopy-based percutaneous endomyocardial delivery of ATMP-CD133. Patients were evaluated at 6 and 12 months for safety and preliminary efficacy endpoints. ATMP-CD133 samples were used for in vitro correlations. Results Patients were treated safely with a mean number of 6.57 ± 3.45 × 106 ATMP-CD133. At 6-month follow-up, myocardial perfusion at SPECT was significantly ameliorated in terms of changes in summed stress (from 18.2 ± 8.6 to 13.8 ± 7.8, p = 0.05) and difference scores (from 12.0 ± 5.3 to 6.1 ± 4.0, p = 0.02) and number of segments with inducible ischemia (from 7.3 ± 2.2 to 4.0 ± 2.7, p = 0.003). Similarly, Canadian Cardiovascular Society and New York Heart Association classes significantly improved at follow-up vs baseline (p ≤ 0.001 and p = 0.007, respectively). Changes in summed stress score changes positively correlated with ATMP-CD133 release of proangiogenic cytokines HGF and PDGF-bb (r = 0.80, p = 0.009 and r = 0.77, p = 0.01, respectively) and negatively with the proinflammatory cytokines RANTES (r = − 0.79, p = 0.01) and IL-6 (r = − 0.76, p = 0.02). Conclusion Results of the RECARDIO trial suggested safety and efficacy in terms of clinical and perfusion outcomes in patients with RA and LV dysfunction. The observed link between myocardial perfusion improvements and ATMP-CD133 secretome may represent a proof of concept for further mechanistic investigations. Trial registration ClinicalTrials.gov, NCT02059681. Registered 11 February 2014.

It is unknown if anemia in the absence of transfusions is an independent risk factor for adverse outcomes in cardiac surgery, and if correction to higher hemoglobin targets impacts these outcomes. This is a retrospective review of 3848 cardiac surgery patients. Propensity matching was completed using 41 covariates. Intraoperative Anemia Analysis matched patients with or without anemia who did not receive intraoperative transfusions (n = 392/group), while Intraoperative Transfusion Analysis matched anemic patients treated conventionally with intraoperative transfusions to end cardiopulmonary bypass hemoglobin greater or less than 95 g/L (n = 261/group). Outcomes of death, renal failure, and 2 composite outcomes were assessed using paired analysis techniques. Study composite 1 consisted of prolonged ventilation, renal failure, myocardial infarction, stroke, or deep sternal wound infection, while composite 2 was the TRICS-III composite. In the Intraoperative Anemia Analysis, anemia was associated with mortality (P = 0.034), stroke (P = 0.021), renal failure (P = 0.015), and a significant increase in the composite measure (control 8.7% vs anemia 16.1%, P = 0.002). These findings were unchanged in patients who did not receive any postoperative transfusions. The Intraoperative Transfusion Analysis showed no difference in mortality or the composite outcome between groups. There was a significant increase in low cardiac output in the lower threshold group (P = 0.001). There were no differences in outcomes between those who did and did not receive postoperative transfusions (P > 0.05). Preoperative anemia in the absence of transfusions is a risk factor for morbidity and mortality after cardiac surgery, and there is no evidence that transfusion to higher end cardiopulmonary bypass hemoglobin levels impacted this risk.

Aims We analysed the impact of bundle branch block (BBB) and pacemaker (PM) implantation on symptoms and survival after alcohol septal ablation (ASA) in patients with hypertrophic cardiomyopathy (HCM). Methods and results Among 1416 HCM patients from the Euro-ASA registry, 58 (4%) patients had a PM and 64 (5%) patients had an implantable cardioverter-defibrillator (ICD) before ASA. At latest follow-up (5.0 ± 4.0 years) after ASA, 118 (8%) patients had an ICD and 229 (16%) patients had a PM. In patients without an implantable device prior to ASA 13% had a PM and 5% had an ICD implanted following ASA. New onset BBB was present in 44% (right BBB in 31%) of patients without previous BBB. At latest follow-up, we found no associations between BBB and New York Heart Association (NYHA) Class 3–4 [odds ratio (OR) 0.98, 95% confidence interval (CI) 0.63–1.51; P = 0.91] or Canadian Cardiovascular Society (CCS) Class 3–4 (OR 1.5, CI 0.32–6.7; P = 0.62), respectively, and no associations between PM and NYHA Class 3–4 (OR 1.2, CI 0.70–2.0; P = 0.52) or CCS 3–4 (OR 1.3, CI 0.24–6.6; P = 0.79), respectively. The survival after ASA was not reduced in patients with BBB [hazard ratio (HR) 0.73, CI 0.53–1.01; P = 0.06] or PM (HR 0.78, CI 0.52–1.17; P = 0.24). Conclusions Development of BBB or need for a PM after ASA in patients with obstructive HCM was not associated with inferior symptomatic outcome or reduced survival, thus concerns for the negative impact of impaired cardiac conduction on the clinical outcome after ASA were not confirmed.

Hypertensive disorders of pregnancy (HDP) comprise an independent, sex-specific risk factor for cardiovascular disease (CVD) in women. This study examined the utility of CVD risk models proposed in the 2016 Canadian Cardiovascular Society (CCS) lipid guidelines to identify women requiring further screening or lipid treatment following HDP.Using data collected from the postpartum Maternal Health Clinic (MHC) at Kingston General Hospital in Kingston, Ontario and the Preeclampsia New Emerging Team (PE-NET) cohort study, the study investigators used the models recommended by the CCS guidelines and the cardiometabolic model of life expectancy in each cohort to estimate CVD risk in women after HDP. (Canadian Task Force Classification II-2).Using the 10-Year Modified Framingham Risk Score, all women were classified by the 2016 CCS Guidelines as low risk, requiring no follow-up. The 30-Year and Lifetime Risk Scores resulted in significant reclassification of women at risk in the PE-NET control and HDP groups (P 0.001 and P 0.0001, respectively); 49.2% of women with HDP were classified as high risk, requiring follow-up, compared with 14.3% of control subjects. Using the cardiometabolic model, median life expectancy was significantly lower and expected onset of CVD was earlier in the HDP group compared with the control group (P 0.0001).The 2016 CCS lipid guidelines' risk classification recommendations significantly underestimated lifelong CVD risk in the HDP group compared with the control group. Women with HDP also had a significant decrease in cardiometabolic life expectancy and an earlier predicted age at onset of CVD. Early primary prevention in this at-risk population may improve CVD outcomes and reduce the future burden on the health care system.

Risk assessment for ischemic cardiac complications post noncardiac surgery is not an exact science. This often prompts physicians to order investigations for further risk stratification. As a diagnostic text coronary CT angiography (CCTA)* could prove to be a useful adjunct in preoperative risk assessment and its utility in this setting will be considered. CCTA has been used to assess preoperative risk in several clinical studies, including the recent CTA VISION trial. CTA VISION suggested, in the cohort examined, that CCTA could lead to an exaggeration of preoperative risk. Whether this is true in other populations will be considered. In this review, the results from CTA VISION and the recently published Canadian Cardiovascular Society guidelines will be considered in the context of previous literature and current international guidelines.

Objectives The aim of our systematic review was to investigate the efficacy of coronary sinus (CS) reducer device in patients with refractory angina. Background The CS reducer device provides a therapeutic option for patients with coronary artery disease who are not suitable for revascularization. Methods Two independent investigators (GB and GT) systematically searched the Medline and Cochrane library databases for studies describing the efficacy and safety of the CS reducer in patients with refractory angina from January 1, 2000 until May 12, 2018 using the following terms: "coronary sinus (reducer OR reducing) device." Efficacy was defined as ≥1 unit improvement in the Canadian cardiovascular society (CCS) score. Results Our search strategy provided six studies (five observational studies and one randomized clinical trial) with 196 patients. The CS reducer device was effective in 146/186 (78.5%) patients. CCS score improved from 3.2 at baseline to 1.9 after 8.6 months of follow-up. The efficacy of CS reducer device was also demonstrated as an improvement in Seattle Angina Questionnaire score, dobutamine echocardiography, thalium single-photon emission computed tomography perfusion studies, 6-min-walk test and myocardial perfusion reserve index. Implantation failed in 4 of 196 (2%) patients and 5 patients (2.5%) had a complication during 30-day follow-up. Conclusions The CS reducer is a promising treatment option for patients with refractory angina who are not candidates for revascularization. However, larger randomized control trials with long-term follow-up are needed to elucidate its role.

Background Alcohol septal ablation (ASA) is an established interventional treatment for hypertrophic obstructive cardiomyopathy (HOCM) patients with drug refractory symptoms. This study investigated the prognostic value of cardiopulmonary exercise test (CPET) in relation to the late clinical outcome. Methods Twenty-one (21) HOCM patients underwent CPET before and 3 months after ASA and were followed yearly thereafter. Clinical success was considered to be a decrease of ≥1 (New York Heart Association or Canadian Cardiovascular Society) functional class. Cardiopulmonary exercise test parameters [maximal oxygen uptake (PeakVO2), % predicted VO2 (PeakVO2%), oxygen uptake at anaerobic threshold (AT), maximal workload (W), % predicted W (W%), ventilation (VE), % predicted VE (VE%), ventilation to maximal carbon dioxide production slope (VE/VCO2), % predicted maximal heart rate (HR%), and maximal systolic blood pressure (SBP)] were compared before and 3 months after ASA. Results After follow-up of 29 ± 13 months, 16 patients had a good clinical results (clinical responders), while five did not improve (clinical non-responders). The CPET parameters did not change in non-responders, while clinical responders showed significant improvement in VO2, VO2%, W, VE/VCO2, VE, VE%, as well as an increase in HR% and SBP at 3 months. Conclusions The data confirmed a good association between the improvement in CPET parameters and the clinical results 3 months after ASA. This may therefore serve as an early marker of HOCM-ASA treatment success.

AIMS The aim of this study was to evaluate the clinical efficacy of Coronary Sinus Reducer implantation in alleviating angina symptoms and improving objective ischaemia parameters and indices of physical capacity. METHODS AND RESULTS Patients with refractory angina (Canadian Cardiovascular Society [CCS] class 3-4) were treated with the Reducer. Baseline and follow-up evaluation consisted of clinical assessment including completion of the Seattle Angina Questionnaire (SAQ) and CCS class evaluation, and objective assessment by treadmill exercise test, dobutamine echocardiography and six-minute walk test (6MWT). Overall, 48 patients (40 male) were enrolled. No periprocedural or long-term adverse events were recorded. CCS class diminished from a mean of 3.4±0.5 at baseline to 2.0±1 (p

Background: The coronary sinus (CS) Reducer is a novel device designed to aid in the management and to improve quality of life of patients with severe angina symptoms refractory to optimal medical and interventional therapies. This study aims to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina. Methods: One hundred forty-one consecutive patients were treated with CS Reducer implantation. The primary efficacy endpoint was reduction in angina symptoms from baseline as assessed by Canadian Cardiovascular Society (CCS) class status and Seattle Angina Questionnaire (SAQ) scores. The primary safety endpoint was successful Reducer device delivery and deployment in the absence of any device-related events. Results: Procedural success was achieved in 139 (98.6%) patients. Reducer implantation was not obtained in 2 (1.4%) patients because of unfavorable anatomy of the CS. There were no CS perforations, cardiac tamponade, peri-procedural death or myocardial infarction during a median follow-up of 14 months (range from 6- to 70-month). In patients undergoing Reducer implantation, mean CCS class improved from 3.05 ± 0.53 at baseline to 1.63 ± 0.98 at follow-up (p < 0.001). Overall, 113 (81%) patients experienced at least 1 CCS improvement, and 63 (45%) patients at least 2 CCS-class improvement. All SAQ items improved significantly (p < 0.001 for all) and translated into a significant reduction in the mean number of anti-ischemic drugs prescribed (2.37 ± 0.97 vs 2.17 ± 0.95; p = 0.003). Conclusions: In a real-world multi-center experience, implantation of the CS Reducer appears safe, and efficacious in reducing symptoms of angina and improving quality of life.

Introduction: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED) and is associated with an increased risk of ischemic stroke. Studies have shown that only oral anticoagulant (OAC) therapy reduces risk of AF related stroke. Our objective was to measure the prescribing practices for OACs for new onset AF at a tertiary ED and two surrounding community EDs, and identify rates of adverse effects within 90 days. The findings of this study will provide quality assurance information for the management of patients with new onset AF. This information has the potential to promote adherence to prescribing guidelines for AF in the ED and the reduction of common adverse events such as ischemic stroke. Methods: We conducted a retrospective chart review of 385 patients with new onset AF who presented to the ED between November 2014 to Mach 2018. We defined new onset as symptoms Results: 86 of 294 (29.5%) of patients who qualified under CHADS-65 received OACs appropriately. 64 of 66 (97.0%) of patients who did not qualify under CHADS-65 did not receive OACs appropriately. 5 patients overall returned within 90 days with ischemic stroke, 4 of those were not prescribed OACs, however this was not statistically significant (P = 0.999). Conclusion: This data suggests that physicians in the study are under-prescribing OACs relative to published guidelines. A larger study is necessary to elucidate the effect of ED OAC prescribing patterns on long-term patient outcome.

Aims The aim of this study was to assess the cost-effectiveness of eight common diagnostic work-up strategies for coronary heart disease (CHD) in patients with stable angina symptoms in Switzerland. Methods and results A decision analytical model was used to perform a cost-effectiveness comparison of eight common multitest strategies to diagnose CHD using combinations of four diagnostic techniques: exercise treadmill test (ETT), single-photon emission computed tomography (SPECT), cardiac magnetic resonance imaging (CMR), and coronary angiography (CA). We used a Markov state transition model to extrapolate the results over a life-time horizon, from a third-party payer perspective. We used a CHD prevalence rate of 39% in patients and a base-case scenario with 60-year-old male patients with intermediate symptom severity Canadian Cardiovascular Society grading of angina pectoris 2 and at least one cardiovascular (CV) risk factor but without a history of myocardial infarction and without need for revascularization. Among the eight work-up strategies, one strategy was dominant, i.e. least costly and most effective: ETT followed by CMR if the ETT result was inconclusive and then CA if the CMR result was positive or inconclusive. The CMR features a favourable balance between false-negative diagnoses, associated with an elevated risk of CV events, and false-positive diagnoses, leading to unnecessary CA and related mortality. Key parameters guiding the diagnostic strategy are the prevalence of CHD in patients with angina symptoms and the diagnostic costs of CA and CMR. Conclusion Cardiac magnetic resonance imaging appears to be a cost-effective work-up strategy compared with other regimens using SPECT or direct CA. Cardiac magnetic resonance imaging should be more widely recommended as a diagnostic procedure for patients with suspected angina symptoms.

Background: Heart rate is the important key factor for determining the cardiac output, myocardial oxygen demand and coronary blood flow. Reduction in heart rate is the main stay of treatment for preventing and treating IHD. Due to the interactions with other drugs and adverse effects of the conventional drugs, the management of IHD focused on novel targets. Ivabradine is a novel specific and selective if current inhibitor of SA node. The objective of the study was to efficacy and safety of ivabradine as an add-on to atenolol in patients with chronic stable ischemic heart disease. Methods: Interventional, open label, prospective clinical study was done over a period of 1 year. Single centered study conducted in 50 patients in the Outpatient Department of cardiology, Tirunelveli Medical College Hospital, Tirunelveli. Endpoints noted were reduction in resting heart rate using 12 lead ECG and improvement in Canadian cardiovascular society (CCS) class of angina grading. Results: Ivabradine in reducing the heart rate at the end of 1 month (86.60±9.16) and at the end of 3 months (81.82±8.37) compared with baseline (93.08±11.67). CCS class of grade of angina also improved at the end of one month and 3 months compared with baseline. Grade IV (3 - 0 - 0), grade III (7 - 3 - 1) and grade II (40 - 8 - 9). Conclusions: Ivabradine is safe and effective in preventing and treating further anginal attacks in patients with chronic stable ischemic heart disease already on atenolol therapy.

Intraventricular septum-hematoma is a rare complication following percutaneous coronary intervention (PCI). This complication may represent a challenge for accurate diagnosis and treatment. This case report is about a 60-year-old male patient being admitted with an acute coronary syndrome. Despite successful PCI with drug eluting stent implantation into the right coronary artery (RCA) the patient complained about recurrent angina pectoris according to Canadian Cardiovascular Society (CCS) class IV. Cardiac magnetic resonance imaging and transthoracic echocardiography revealed a massive 4.9×9.2 cm sized end-diastolic septum-hematoma, which compromised right ventricular cavity. Emergent recoronary angiography ruled out further contrast extravasation from the RCA. Conservative treatment was intended after discussion in the “heart-team.” The patient completely recovered with nearly complete resolution of the hematoma after 6 months.

Hypercholesterolemia is a major risk factor for cardiovascular diseases. The 2012-2013 survey of Canada's public health measures revealed that dyslipidemia was present in 38% of the respondents aged between 18 and 79 years. According to the American College of Cardiology, the American Heart Association, the Canadian Cardiovascular Society and the Canadian Working Group Consensus, statins remain the treatment of choice for dyslipidemia and the reduction of cardiovascular risk. However, concerns and questions persist regarding statins use and safety, potential and harmful muscular side-effects, interactions with exercise, and molecular mechanisms of myotoxicity. The goal of the present review is to provide a clear picture of the clinical situation and to investigate possible mechanisms of statin-induced myopathy. A better understanding of muscle pathology in statin users is absolutely essential to minimize their muscle symptoms and to provide a sound clinical basis for the management of cardiovascular risk.

Introduction In coronary artery disease (CAD), medical treatment is the main clinical strategy for controlling ischemia and angina symptoms while restoring a satisfactory level of usual activities and improving quality of life (QOL). This study's purpose was to evaluate in CAD patients the antianginal efficacy of 4-month treatment with ivabradine plus a β-blocker and to record patient compliance and the effect of treatment on QOL. Methods In this noninterventional study, 2403 patients with chronic stable angina were prospectively studied from 245 private cardiology offices. Data were recorded at baseline and at 1 and 4 months after inclusion. Patient quality of life was assessed using the EuroQol 5 dimensions (EQ-5D) questionnaire. Results From baseline to study completion, mean heart rate decreased from 81.5 ± 9.7 bpm to 63.9 ± 6.0 bpm (P

Objectives: Elevated heart rate can increase myocardial oxygen demand and reduce myocardial perfusion, provoking myocardial ischemia and angina symptoms. We evaluated adding ivabradine to the therapy of patients on metoprolol. Methods: ADDITIONS (prActical Daily efficacy anD safety of Procoralan® In combinaTION with betablockerS) was a multicenter, 4-month, noninterventional, prospective, open-label trial that involved stable-angina patients. Along with metoprolol, patients received ivabradine (5 or 7.5 mg, b.i.d.). We investigated the effect of ivabradine on heart rate, angina attacks, nitrate consumption, quality of life (QoL) and tolerability as well as the influence of baseline heart rate. Results: Heart rate fell by 19.7 ± 11.2 bpm, with an 8-fold decrease in weekly angina attacks (1.7 ± 2.2 to 0.2 ± 0.7) and nitrate consumption (2.4 ± 3.4 to 0.3 ± 0.9). Patient numbers in Canadian Cardiovascular Society class I more than doubled (i.e. from 29 to 65%) and QoL improved (the EQ-5D index and visual analog scale scores rose from 0.68 ± 0.27 to 0.84 ± 0.20 and 58.1 ± 18.4 to 72.2 ± 15.5 mm, respectively). The effect of ivabradine was greater in patients with a baseline heart rate ≥70 bpm (mean reduction in heart rate -21.2 ± 10.4 bpm, with a relative reduction in angina attacks and short-acting nitrate consumption of 87.1 and 87.2%, respectively). Conclusions: Ivabradine combined with metoprolol safely and effectively reduces heart rate, angina attacks and nitrate use, and improves QoL in stable-angina patients.

Background Multiple stents make standard coronary artery bypass techniques difficult. We describe our surgical approach, in patients undergoing coronary artery bypass grafting (CABG), in left anterior descending arteries (LAD) with multiple failed overlapping stents. Methods We retrospectively reviewed the data of six patients undergoing CABG with multiple failed overlapping stents in the LAD. All patients were operated on electively. After removal of the stents with an open endarterectomy, the long segmental arteriotomy of the LAD was reconstructed with a saphenous vein patch. Afterwards the left internal mammary artery was anastomosed to the vein patch. Results The mean age was 61.5 ± 7.9 years. Five patients (83.3%) were in Canadian Cardiovascular Society Class III or IV. Four patients (66.6%) had suffered a remote myocardial infarction (>1 month). The average hospital stay was 6.5 ± 1.1 days. Postoperative electrocardiograms showed no specific changes and no myocardial enzyme elevations were noted. Early postoperative angiography showed that all grafts including the endarterectomized LAD were patent. There was no mortality within the 30 days. Patients’ mean follow-up time was 35.6 ± 36.7 months. Conclusions CABG with open stent endarterectomy is a valuable alternative option for patients with “full-metal jacket“ diseased LAD that are not graftable using standard surgical techniques.

Direct oral anticoagulants are making anticoagulation simpler for patients with atrial fibrillation who need protection from strokes. However, clinicians still have an important role to play in pat...

In 2004, practice guidelines for the management of heart failure in children by Rosenthal and colleagues were published in conjunction with the International Society for Heart and Lung Transplantation. These guidelines have not been updated or reviewed since that time. In general, there has been considerable controversy as to the utility and purpose of clinical practice guidelines, but there is general recognition that the relentless progress of medicine leads to the progressive irrelevance of clinical practice guidelines that do not undergo periodic review and updating. Paediatrics and paediatric cardiology, in particular, have had comparatively minimal participation in the clinical practice guidelines realm. As a result, most clinical practice guidelines either specifically exclude paediatrics from consideration, as has been the case for the guidelines related to cardiac failure in adults, or else involve clinical practice guidelines committees that include one or two paediatric cardiologists and produce guidelines that cannot reasonably be considered a consensus paediatric opinion. These circumstances raise a legitimate question as to whether the International Society for Heart and Lung Transplantation paediatric heart failure guidelines should be re-reviewed.The time, effort, and expense involved in producing clinical practice guidelines should be considered before recommending an update to the International Society for Heart and Lung Transplantation Paediatric Heart Failure guidelines. There are specific areas of rapid change in the evaluation and management of heart failure in children that are undoubtedly worthy of updating. These domains include areas such as use of serum and imaging biomarkers, wearable and implantable monitoring devices, and acute heart failure management and mechanical circulatory support. At the time the International Society for Heart and Lung Transplantation guidelines were published, echocardiographic tissue Doppler, 3 dimensional imaging, and strain and strain rate were either novel or non-existent and have now moved into the main stream. Cardiac magnetic resonance imaging (MRI) had very limited availability, and since that time imaging and assessment of myocardial iron content, delayed gadolinium enhancement, and extracellular volume have moved into the mainstream. The only devices discussed in the International Society for Heart and Lung Transplantation guidelines were extracorporeal membrane oxygenators, pacemakers, and defibrillators. Since that time, ventricular assist devices have become mainstream. Despite the relative lack of randomised controlled trials in paediatric heart failure, advances continue to occur. These advances warrant implementation of an update and review process, something that is best done under the auspices of the national and international cardiology societies. A joint activity that includes the International Society for Heart and Lung Transplantation, American College of Cardiology/American Heart Association, the Association for European Paediatric and Congenital Cardiology (AEPC), European Society of Cardiology, Canadian Cardiovascular Society, and others will have more credibility than independent efforts by any of these organisations.

Background Enhanced external counterpulsation (EECP) is effective in the treatment of refractory angina, a condition suffered by 1.7 million Americans. Declining cardiovascular mortality and appropriate use criteria may further increase this number. Hypothesis EECP is hypothesized to be cost-effective in reducing hospitalizations in refractory angina patients. Methods The data used in this analysis were collected in phase II of the International EECP Patient Registry (IEPR-II). Data were collected on changes in Canadian Cardiovascular Society functional class, Duke Activity Status Index, and number of hospitalizations in the 6 months prior to EECP and in the 6- and 12-month intervals following EECP. Estimates of the changes in annual cost of all-cause hospitalization before and after EECP therapy were calculated by the product of the differences in hospitalization rates in the 6-month interval before and after EECP treatment and estimated hospitalization and physician charges after subtracting the average cost of EECP. Results Data for 1015 patients were analyzed. Hospitalization occurred in 55.2% of patients, an average of 1.7 ± 1.4 hospitalizations/patient, in the 6-month period before 35 hours of EECP; and in 24.4%, an average of 1.4 ± 1.0 hospitalizations/patient, during the 6- to 12-month period after EECP. The average hospitalization and physician charge in the US was $17 995, and the average EECP cost was $4880, yielding an annual cost savings/patient of $17 074. Conclusions Treatment of refractory angina patients with EECP resulted in improvement in angina and functional class accompanied by a sustained reduction in health care costs over 1 year of follow-up.

Dyslipidemia is a major risk factor for the development of atherosclerotic disease. Therefore, lifestyle interventions and pharmacological approaches to decrease cholesterol are widely used in cardiovascular disease prevention. The introduction and widespread use of 3-hydroxy-3 methylglutaryl coenzyme A inhibitors (statins) for individuals at risk of atherosclerotic disease has been an important advance in cardiovascular care. There can be no doubt that better control of dyslipidemia, even in subjects whose low-density lipoprotein cholesterol level is not particularly high, has reduced overall event rates. On a background of lifestyle interventions, statins are routinely used to decrease risk along with aspirin and interventions to control hypertension and diabetes. More than other risk factors, the approach to the identification and treatment of dyslipidemia has been heterogeneous and widely debated. The recent release of the 2013 American College of Cardiology/American Heart Association dyslipidemia guidelines has reignited the controversy over the best approach for risk stratification and treatment. In this article we review the importance of statin therapy for global cardiovascular risk reduction, compare the Canadian Cardiovascular Society dyslipidemia guidelines with other standards, and discuss the points of debate. Despite the seeming variety of recommendations, their common link is a systematic approach to risk stratification and treatment, which will continue to benefit our patients at risk.

The appearance of angina pectoris in patients after myocardial infarction has got a negative influence on their quality of life. The aim of the paper was to assess the influence of angina pectoris on the quality of life of patients one month and twelve months after myocardial infarction. Prospective cohort study involved 240 patients from the city of Nis, aged 30–79 years, who suffered from the first myocardial infarction in 2007. The quality of life was assessed with the Serbian version of these questionnaires: EuroQuol5Dimension and EuroQuolVAS. Angina pectoris was ranked according to the classification of Canadian Cardiovascular Society. Multivariate logistic regression analysis was used. A total of 240 patients (160 males and 80 females) filled in the questionnaires one month after the myocardial infarction. They were aged 61.37±8.87 years on average. All the patients had the significantly lower average scores in EuroQuolVAS compared with the scores twelve months after the myocardial infarction (60.50±12.03 vs 69.83±12.06, p

A 69-year-old man with established coronary artery disease and left ventricular dysfunction (ejection fraction, 40%) with typical Canadian Cardiovascular Society class III angina underwent percutaneous coronary intervention (PCI) for severe diffuse calcific disease in the right coronary artery ([

Cardiac surgery waitlist recommendations, which were developed based on expert opinion, poorly predict preoperative mortality. Studies reporting risk factors for waitlist mortality have not evaluated the risks including nonadherence to waitlist benchmarks.In patients who underwent cardiac surgery or died on the waitlist between 2005 and 2015, we used a Fine and Gray competing risk model to identify independent predictors of waitlist mortality in 12,106 patients scheduled for urgent, semiurgent, or nonurgent surgery. The predictive variables were compared with Canadian Cardiovascular Society (CCS) waitlist recommendations using the Akaike information criterion.A total of 101 (0.8%) patients died awaiting surgery. The median wait times and frequency waitlist deaths among emergent, urgent, semi-urgent, and nonurgent surgery were 0.6, 7.4, 69.0, 55.5 days (P0.001) and 6.3%, 0.8%, 0.3%, 0.6% (P0.001), respectively. Adherence to CCS waitlist recommendations was higher in patients who died on the waitlist (51.6% vs 70.8%, P = 0.001) and was not predictive of waitlist mortality (hazard ratio 1.48, 95% confidence interval 0.62-0.56). Independent predictors of waitlist mortality were age, aortic surgery, ejection fraction35%, urgent surgery, prior myocardial infarction, haemodynamic instability during cardiac catheterization, hypertension, and dyslipidemia. These variables were superior to current CCS guidelines (Akaike information criterion 1251 vs 1317, likelihood ratio test P0.001).CCS waitlist recommendations were poorly predictive of waitlist mortality and the majority of waitlist deaths occur within recommended benchmarks. We identified variables associated with waitlist mortality with improved clinical performance. Our findings suggest a need to re-evaluate cardiac surgical triage criteria using evidence-based data.

The burden of atherosclerotic cardiovascular disease (ASCVD) in high-income countries is mostly borne by the elderly. With increasing life expectancy, clear guidance on sensible use of statin therapy to prevent a first and potentially devastating ASCVD event is critically important to ensure a healthy aging population. Since 2013, 5 major North American and European guidelines on statin use in primary prevention of ASCVD have been released by the American College of Cardiology/American Heart Association, the UK National Institute for Health and Care Excellence, the Canadian Cardiovascular Society, U.S. Preventive Services Task Force, and the European Society of Cardiology/European Atherosclerosis Society. Guidance on using statin therapy in primary ASCVD prevention in the growing elderly population (>65 years of age) differs markedly. The authors discuss the discrepant recommendations, place them into the context of available evidence, and identify circumstances in which uncertainty may hamper the appropriate use of statins in the elderly.

Article, see p 10 Lipid testing plays a major role in cardiovascular risk stratification and management in clinical practice. Fasting samples have long been the standard for assessing low-density lipoprotein cholesterol (LDL-C) and triglycerides because fasting is believed to reduce variability and to allow more accurate derivation of the commonly used Friedewald-calculated LDL-C. In 2009, the Danish guidelines recommended nonfasting lipid testing across Denmark. In 2014, the US Department of Veterans Affairs, the Joint British Societies, and the National Clinical Guideline Center practice guidelines recommended nonfasting lipids for cardiovascular risk assessment. In 2016 to 2017, several additional clinical guidelines and expert consensus statements1–3 from Europe, Canada, and the United States have also recommended nonfasting lipid testing for most routine clinical evaluations (Figure). As more of the worldwide medical community moves toward obtaining nonfasting lipids for routine testing,3 the time is opportune for reassessing whether Friedewald LDL-C or other methods for determining LDL-C could result in improved accuracy of LDL-C, whether assessed nonfasting or fasting. Figure. Timeline of countries and the respective guidelines advocating nonfasting lipid tests as preferred or acceptable alternative to fasting lipids. AACE/ACE indicates American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease; CCSG, Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult; CHEP, Canadian Hypertension Education Program; EAS/EFLM, European Atherosclerotic Society/European Federation of Clinical Chemistry and Laboratory Medicine joint consensus statement; JBS, Joint British Societies guidelines on prevention of cardiovascular disease in clinical practice; NICE, National Institute for Health and Care Excellence cardiovascular disease: risk assessment and reduction, including lipid modification clinical guideline; and VA DOD, Veterans Affairs/Department of Defense clinical practice guideline for the management of dyslipidemia for cardiovascular risk reduction. In their …

Background: The REGENT-VSEL trial demonstrated a neutral effect of transendocardial injection of autologous bone marrow (BM)-derived CD133+ in regard to myocardial ischemia. The current sub-analysis of the REGENT VSEL trial aims to assess the effect stem cell therapy has on quality of life (QoL) in patients with refractory angina. Methods: Thirty-one patients (63.0 ± 6.4 years, 70% male) with recurrent CCS II–IV angina, despite optimal medical therapy, enrolled in the REGENT-VSEL single center, randomized, double-blinded, and placebo-controlled trial. Of the 31 patients, 16 individuals were randomly assigned to the active stem cell group and 15 individuals were randomly assigned to the placebo group on a 1:1 basis. The inducibility of ischemia, (≥ one myocardial segment) was confirmed for each patient using Tc-99m SPECT. QoL was measured using the Seattle Angina Questionnaire. Each patient completed the questionnaire prior to treatment and at the time of their outpatient follow-up visits at 1, 4, 6, and 12 months after cell/placebo treatment. Results: The main finding of the REGENT-VSEL trial sub-analysis was that transendocardial injection of autologous BM-derived CD133+ stem cells in patients with chronic refractory angina did not show significant improvement in QoL in comparison to the control group. Moreover, there was no significant difference between cell therapy and placebo in a number of patients showing improvement of at least 1 Canadian Cardiovascular Society class during the follow-up period. Conclusions: Intra-myocardial delivery of autologous CD133+ stem cells is safe and feasible but does not show a significant improvement in the QoL or angina pectoris symptoms in patients with chronic myocardial ischemia.

The perioperative management of a cardiac-patient candidate to non-cardiac surgery (NCS) remains a topic of considerable debate. In recent years, the overall tendency from professional societies has been to delineate how to identify and manage high-risk patients following the best evidence. However, significant concerns persist, especially in the care of intermediate-risk patients (also labeled at "acceptable" risk), who may not fit into the categories of "completely healthy" or "critically ill", but that might still encounter dramatic (and unexpected) perioperative events. The specific interest and main goal of this expert viewpoint pertains to the care of cardiac patients scheduled for NCS, addressing central questions of real-life clinical care that practicing anesthesiologists and cardiologists face daily, discussing recent American College of Cardiology/American Heart Association (ACC/AHA), European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA), and Canadian Cardiovascular Society (CCS) guidelines. The viewpoint aims to discuss few of the important topics pertaining perioperative assessment and management: type of NCS and perioperative cardiac events, risk prediction including testing, and perioperative management of cardiac therapy. The fact that cardiac adverse events have reduced in number mostly due to better preoperative management and prevention should not prompt a reduction in clinical evaluations. While debate remains pertaining the most appropriate way to evaluate patients for NCS within international societies, a comprehensive approach-evaluation best recognized to assess functional and heart status, should be maintained, keeping into consideration the surgical procedure and global health management.

Objective Despite revascularization and optimal medical treatment (OMT), patients with angina often have a reduced quality of life due to inadequate relief from symptoms. Recent studies have shown that the application of shock waves may reduce angina symptoms and improve quality of life, exercise capacity, and myocardial perfusion due to the stimulation of angiogenesis. However, there is limited evidence due to small, single-arm, single-center studies of low to moderate quality. The purpose of this study is to evaluate the impact of cardiac shock wave therapy (CSWT) on exercise tolerance and angina symptoms in patients with coronary artery disease and objective evidence of myocardial ischemia who cannot undergo traditional revascularization and experience angina despite OMT in comparison to sham procedure. Methods We designed a randomized, triple-blind, placebo-controlled, multicentre trial (NCT02339454) to assess the efficacy of CSWT in addition to OMT in patients with stable angina and myocardial ischemia documented by exercise treadmill test (ETT). All patients were treated with stable doses of standard medical treatment 4 weeks before screening. An increase in the total exercise duration on ETT by ≥90 s from the baseline at the end of the study was set as the primary endpoint. Secondary endpoints included angina class, Seattle angina questionnaire scores, symptoms, and ECG changes during stress test. Patients underwent nine sessions of CSWT or corresponding sham procedure applied to all segments of the left ventricle, within 9 weeks. Endpoint assessments were performed at 6-month follow-up. The imaging substudies assessed the potential of CSWT to reduce stress-induced myocardial ischemia detected by dobutamine stress echocardiography, cardiac single-photon emission computed tomography, and cardiac magnetic resonance imaging. Results At two centers, 72 of the 323 screened patients were randomized in two groups (ratio 1:1): active treatment and placebo control. Study patients were predominantly males (70.8%); the mean age of the patients was 68.4±8.3 years. Of these, 44 patients had angina Canadian Cardiovascular Society class III, and 66.7% of the patients had a history of myocardial infarction. Conclusion Using sham applicators, blinding study participants, investigators, and endpoints assessors to the study data as well as centralized randomization ensures rigorous methodology and low risk of bias in this large randomized controlled CSWT study.

Objective: To analyze the inflammation resulting from myocardial revascularization techniques with and without cardiopulmonary bypass, based on ultrasensitive C-reactive protein (US-CRP) behavior. Methods: A prospective non-randomized clinical study with 136 patients was performed. Sixty-nine patients were enrolled for Group 1 (on-pump coronary artery bypass - ONCAB) and 67 patients were assigned to Group 2 (off-pump coronary artery bypass - OPCAB). All study participants had blood samples collected for analysis of glucose, triglycerides, creatinine, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and creatinephosphokinase (CPK) in the preoperative period. The samples of creatinephosphokinase MB (CKMB), troponin I (TnI) and US-CRP were collected in the preoperative period and at 6, 12, 24, 36, 48 and 72 hours after surgery. We also analyzed the preoperative biological variables of each patient (age, smoking, diabetes mellitus, left coronary trunk lesion, body mass index, previous myocardial infarction, myocardial fibrosis). All angiographically documented patients with >70% proximal multiarterial stenosis and ischemia, documented by stress test or classification of stable angina (class II or III), according to the Canadian Cardiovascular Society, were included. Reoperations, combined surgeries, recent acute myocardial infarction, recent inflammatory disease, deep venous thrombosis or recent pulmonary thromboembolism, acute kidney injury or chronic kidney injury were not included. Results: Correlation values between the US-CRP curve and the ONCAB group, the treatment effect and the analyzed biological variables did not present expressive results. Laboratory variables were evaluated and did not correlate with the applied treatment (P>0.05). Conclusion: The changes in the US-CRP at each moment evaluated from the postoperative period did not show any significance in relation to the surgical technique applied.

Introduction Chronic total occlusion (CTO) is common in the presence of other significantly narrowed coronary arteries. The impact of total occlusion and its association with completeness of revascularization on patients with multivessel disease undergoing coronary artery bypass graft (CABG) remains largely unknown. Aim The aim of our study was to compare CABG operation characteristics, as well as 30-day mortality, incidence of post-operative major adverse cardiac and cerebrovascular events (MACCE) between patients with and without CTO in right coronary artery (RCA). Materials and Methods A total of 156 consecutive patients were included in the analysis. CTO of RCA or right posterior descending artery (RPD) was diagnosed in 57 patients (CTO-RCA group). Coronary stenosis without CTO in RCA was diagnosed in 99 patients (nonCTO-RCA group). Baseline characteristics were comparable in both groups. Results The majority of patients had class II (49.1% vs. 46%, p = 0.86) or class III (42.1% vs. 43%, p = 1.0) Canadian Cardiovascular Society grading system symptoms. Patients in the CTO-RCA group had in average 2.2 grafts implanted, as opposed to 2.4 grafts in patients in the nonCTO-RCA group (p = 0.003). Graft to the RCA was performed in 40.3% patients in the CTO-RCA group and in 81% patients in the nonCTO-RCA group (p = 0.001). The 30-day mortality from any cause or cardiac cause did not differ between groups (7% vs. 2%, p = 0.14 and 3.5% vs. 2%, p = 0.57 respectively). In a multivariate analysis CTO in RCA or RPD and peripheral artery disease were independent predictors of post-operative MACCE (7.9 (1.434–43.045) p = 0.02; 18.8 (3.451–101.833) p < 0.01, respectively). Conclusions Chronic total occlusion of RCA was found to be associated with smaller number of grafts performed during the CABG procedure. Although mortality between patients in the CTO-RCA and nonCTO-RCA groups did not differ, patients in the CTO-RCA group had higher incidence of post-operative MACCE.

The initial Canadian Cardiovascular Society (CCS) Guidelines on the Use of Antiplatelet Therapy1 covered chronic antiplatelet therapy for a number of diseases and patient subgroups. The 2012 Focused Update2 specifically addressed the issues of antiplatelet therapy for secondary prevention in the first year after acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and the interaction between clopidogrel and proton pump inhibitors (PPIs). The updating of these topics and the prominence of the newer antiplatelet agents in the guidelines make them of particular relevance to pharmacists. The intent of this publication is to highlight components of the guidelines that are most likely to affect the practice of pharmacists and provide practical information to assist pharmacists in managing patients on antiplatelet therapy.

Objective: Patients with the coronary slow flow phenomenon frequently experience angina episodes. The present study aimed to compare the efficacy of nicorandil versus nitroglycerin for alleviation of angina symptoms in slow flow patients. Methods: In a single-center, single-blind, parallel-design, comparator-controlled, randomized clinical trial (NCT02254252), 54 patients with slow flow and normal or near-normal coronary angiography who presented with frequent angina episodes were randomly assigned to 1-month treatment with nicorandil 10 mg, 2 times a day ( n = 27) or sustained-release glyceryltrinitrate 6.4 mg 2 times a day ( n =27). Frequency of angina episodes, pain intensity, and the Canadian Cardiovascular Society (CCS) grading of angina pectoris were assessed at baseline and after 1 month of treatment. Results: In all, 25 patients in the nicorandil arm and 24 patients in the nitroglycerin arm were analyzed. After 1 month, patients treated with nicorandil had fewer angina episodes (adjusted mean number of episodes per week, nicorandil versus nitroglycerin; 1.68 ± 0.15 vs 2.29 ± 0.15, P = .007, effect size = 14.6%). Patients also reported greater reductions in pain intensity with nicorandil versus nitroglycerin (adjusted mean of self-reported pain score; 3.03 ± 0.29 vs 3.89 ± 0.30, P = .046, effect size = 8.4%). A significantly higher proportion of patients in the nicorandil arm were categorized in CCS class I (76% vs 33.3%, P = .004) or class II (16.0% vs 45.8%, P = .032). Conclusion: In slow flow patients, nicorandil provides better symptomatic relief of angina than nitroglycerin.

Background The relationship between coronary heart disease (CHD) and cognitive function is not completely elucidated. We examined the association between severity of angina pectoris (AP) in mid-life and subsequent cognitive impairment among CHD patients. Methods Severity of AP according to the Canadian Cardiovascular Society angina classification was assessed in a subgroup of people with chronic CHD, who previously participated in a secondary prevention trial. Cognitive performance was evaluated 15±3 years later, using a validated set of computerized cognitive tests (Neurotrax Computerized Cognitive Battery; computing index scores summarizing performance in each cognitive domain and a global cognitive score). We compared the risk of cognitive deficits in participants with AP class >2 to those with AP≤2, adjusting for vascular risk factors, common carotid-intima media thickness (CC-IMT), and presence of carotid plaques. Result Among 535 participants (mean age at baseline 57.9±6.6 y; 95% males), AP class >2 was associated with subsequent poorer performance on tests of memory and attention compared to those with AP class ≤2 (β=-4.3±1.8; P=0.016 and β=-3.6±1.7; P=0.029, respectively) and with a higher risk of having impairment in these domains [odds ratio (95% confidence interval)=1.83 (1.11-3.02); P=0.019 and 2.36 (1.34-4.16); P=0.003, for memory and attention, respectively]. These results were similar after controlling for vascular risk factors; however, the association of AP with memory domain attenuated after adjustment for CC-IMT or presence of carotid plaques. Conclusions In people with preexisting CHD, severity of AP is associated with late-life poorer cognitive performance, independent of other vascular risk factors.

Background It can be challenging to convince asymptomatic to minimally symptomatic patients to pursue treatment of their atrial fibrillation (AF). We hypothesized that once in sinus rhythm, asymptomatic to minimally symptomatic patients would realize they were compensating for moderate symptoms, and that we could quantify this via the Canadian Cardiovascular Society Severity of AF (CCS-SAF) score. Methods All patients in our study come from the Symptom Mitigation in Atrial Fibrillation (SMART) study. Upon enrollment all patients were assigned a CCS-SAF score. Patients receiving a CCS-SAF score of 0 or 1 that elected to pursue intervention were contacted by phone and asked about their symptoms post-intervention as compared to pre-intervention. Paired t-test was used for analysis. Results Out of 800 patients in the SMART study to date, 48 patients have qualified for our phone survey and presented for follow-up in our clinic. In our cohort, the revised pre-intervention CCS-SAF score was 1.69 ± 1.36 and the post-intervention CCS-SAF score was 0.52 ± 0.80. Thirty-seven patients reported symptom improvement; those who improved were on average 72.4% improved from baseline. Conclusions We conclude asymptomatic to minimally symptomatic AF patients benefit from therapy and should be offered intervention despite lack of symptoms.

Background Oral anticoagulation (OAC) is highly effective for stroke prevention in nonvalvular atrial fibrillation. We explored rates of stroke/thromboembolism/transient ischemic attack among the "OAC not recommended" patient group defined according to the 2014 Canadian Cardiovascular Society (CCS) algorithm (based on the C ongestive Heart Failure, H ypertension, A ge, D iabetes, S troke/Transient Ischemic Attack [CHADS 2 ] score) who would have been offered OAC using the European Society of Cardiology (ESC) guidelines approach (based on the C ongestive Heart Failure, H ypertension, A ge [≥75 years], D iabetes, S troke/Transient Ischemic Attack, V ascular Disease, A ge [65-74 years], S ex [Female]; CHA 2 DS 2 -VASc score). Methods We identified 22,582 nonanticoagulated patients age 2 score of 0 who were stratified according to the CHA 2 DS 2 -VASc score, except female sex, which would be an indication for OAC according to the ESC guidelines. Event rates for each risk strata were compared using Cox proportional hazard ratios. Results The overall rate of the combined end point of ischemic stroke/systemic embolism/transient ischemic attack was 4.32 per 100 person-years (95% confidence interval [CI], 3.26-5.74) at 1 year, among the patients who would have had an indication for OAC therapy according to ESC guidelines and "OAC not recommended" according to CCS algorithm. This corresponded to an adjusted hazard ratio of 3.08 (95% CI, 2.21-4.29) relative to the subgroup with no indication for OAC according to the ESC guidelines. A subgroup of patients with previous vascular disease and CHADS 2 score of 0 (ie, recommended only aspirin treatment according to the CCS algorithm) had an event rate of 4.84 (95% CI, 3.53-6.62) per 100 person-years at 1-year follow-up. Conclusions Based on the 2014 CCS algorithm, the "OAC not recommended" subgroup can have a high 1-year stroke rate overall, showing that such patients are not "low risk." Use of the ESC guideline approach (based on the CHA 2 DS 2 -VASc) offers refinement of stroke risk stratification in such patients.

Cognitive and procedural skills required of cardiologists have increased in the past 10 years. What is unknown is whether residents consistently meet recommended volumes during training and what their own subjective assessments of their competency are after training. The purpose of this study was to (1) determine whether current training provides residents with opportunities to develop skills to function independently and (2) identify whether residents perceive gaps in their skills. We surveyed current and recent graduates of adult cardiology programs in Canada. One hundred ten responses from 425 surveys were received. Procedural and diagnostic test interpretation volumes were recorded, as were the optimum number the respondents believed were important to complete to function independently. These volumes were compared with the 2008 American College of Cardiology Core Cardiology Training Symposium (COCATS 3) and the Canadian Cardiovascular Society (CCS) recommendations for training. The proportion of residents meeting recommended volumes for diagnostic test interpretation ranged from 7% (Holter monitors) to 91% (echocardiograms). For procedures, the range was from 71% (echocardiography) to 100% (cardioversion). The ratio of residents' perceived minimum numbers believed to be required for proficiency for diagnostic test interpretation to those recommended ranged from 14% (electrocardiograms) to 116% (echocardiograms), and for procedures, the ratio was 66% (temporary pacemaker placement) to 116% (echocardiography). Recent graduates' perception of minimum required numbers to achieve competency is underestimated compared with COCATS 3 and CCS recommendations. Few graduates achieved the recommended volume targets suggested for diagnostic test interpretation.

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.

Guidelines Committee GLD Health Care Centre, Department of Medicine, University of British Columbia, Vancouver, British Columbia Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada Montreal Heart Institute, Department of Medicine, Universit e de Montr eal, Montreal, Quebec, Canada Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada Alberta Health Services, Calgary, Alberta, Canada f Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada

The use of thrombus aspiration (TA) prior to primary percutaneous coronary intervention (PPCI) has undergone a radical change in intervention guidelines. The clinical implications, however, are still under scrutiny. This study investigated the clinical effects and outcome of TA before PPCI in patients with ST-segment elevation myocardial infarction (STEMI). Overall 1027 patients with STEMI were analyzed in this retrospective, propensity score-adjusted, multicenter study. The primary endpoints were in-hospital and long-term mortality. There were 418 patients in the TA group and 609 in the conventional PPCI group. The in-hospital mortality rate was significantly higher in the TA group (8.7 vs. 5.0%; P = 0.03). During long-term follow-up [median follow-up duration 689 days (IQR 405–959)] the mortality rates were similar (TA 14.3%, conventional PPCI 15.0%; P = 0.85). Survival analysis for the complete observation period revealed no significant benefit of TA [hazard ratio (HR) 1.12; 97.5% CI 0.90–0.71; P = 0.63]. There were also no significant differences between the groups in the following secondary endpoints: composite of cardiovascular death and non-fatal reinfarction at discharge (P = 0.39), post-PPCI thrombolysis in myocardial infarction flow-grade-3 (P = 0.14), left ventricular ejection fraction (P = 0.47), and non-fatal reinfarction during follow-up (P = 0.17). Rehospitalization rate (1.82 vs. 10.3%; P