AimsThe mechanistic basis of the symptoms and signs of myocardial ischaemia in patients without obstructive coronary artery disease (CAD) and evidence of coronary microvascular dysfunction (CMD) is unclear. The aim of this study was to mechanistically test short-term late sodium current inhibition (ranolazine) in such subjects on angina, myocardial perfusion reserve index, and diastolic filling.Materials and resultsRandomized, double-blind, placebo-controlled, crossover, mechanistic trial in subjects with evidence of CMD [invasive coronary reactivity testing or non-invasive cardiac magnetic resonance imaging myocardial perfusion reserve index (MPRI)]. Short-term oral ranolazine 500–1000 mg twice daily for 2 weeks vs. placebo. Angina measured by Seattle Angina Questionnaire (SAQ) and SAQ-7 (co-primaries), diary angina (secondary), stress MPRI, diastolic filling, quality of life (QoL). Of 128 (96% women) subjects, no treatment differences in the outcomes were observed. Peak heart rate was lower during pharmacological stress during ranolazine (−3.55 b.p.m., P < 0.001). The change in SAQ-7 directly correlated with the change in MPRI (correlation 0.25, P = 0.005). The change in MPRI predicted the change in SAQ QoL, adjusted for body mass index (BMI), prior myocardial infarction, and site (P = 0.0032). Low coronary flow reserve (CFR <2.5) subjects improved MPRI (P < 0.0137), SAQ angina frequency (P = 0.027), and SAQ-7 (P = 0.041).ConclusionsIn this mechanistic trial among symptomatic subjects, no obstructive CAD, short-term late sodium current inhibition was not generally effective for SAQ angina. Angina and myocardial perfusion reserve changes were related, supporting the notion that strategies to improve ischaemia should be tested in these subjects.Trial registrationclinicaltrials.gov Identifier: NCT01342029.

Despite the landmark release of recent transcatheter aortic valve replacement data, the gold standard of surgical therapy is here to stay. Surgery remains vital in patient populations with low coronary height raising risk of coronary occlusion, aneurysmal ascending aorta, isolated aortic regurgitation, noncalcific disease, bicuspid valves, and multivessel coronary disease, or other structural abnormality requiring cardiac surgery.Consideration of these issues highlights the ongoing importance of multidisciplinary consideration of individual patient cases, careful review of imaging, and preservation of a robust surgical program to complement transcatheter development. As the landscape of valvular heart disease management continues to evolve, the surgeon's role is changing, but by no means diminished and their engagement in heart team decision making remains paramount. K E Y W O R D Saorta and great vessels, cardiovascular pathology, cardiovascular research, surgical history To the Editor In March of this year, randomized trial data was released demonstrating noninferiority of transcatheter aortic valve replacement (TAVR) to surgical therapy in low-risk patients. 1,2 As expected, approval of both balloon expandable and self-expanding TAVR systems for the full spectrum of risk categorization was issued by the FDA. In effect, it is anticipated that practice patterns will shift further towards a transcatheter approach, as the default strategy in patients with senile calcific trileaflet aortic stenosis who are candidates for bioprosthetic valves. However, with appropriate use of imaging and interdisciplinary collaboration, surgical valve replacement will remain an important approach to optimize long-term outcomes in certain patient cohorts -primarily due to anatomic characteristics for which TAVR is suboptimal. This group of patients was largely excluded from randomized trials and includes patients with low coronary height raising risk of coronary occlusion, aneurysmal ascending aorta, isolated aortic regurgitation, noncalcific disease, bicuspid valves, and multivessel coronary disease, or other structural abnormality requiring cardiac surgery. Although there is ongoing clinical study on transcatheter approaches in these patient cohorts, as a community, the utility of surgical therapy for these issues is accepted as the standard of care.With low-risk expansion, a third subset of patients emerges that requires particular attention: those who are anatomic candidates for TAVR but for whom surgery will likely yield the best, most durable longterm outcomes. This primarily includes younger patients and those with small annulus size. Consideration of patient age will become increasingly important as younger patients become eligible for TAVR despite lack of applicable durability data. Long-term TAVR outcomes (6-10 years) have been limited to first generation valves. In studies with newer generation valves, the majority of patients die of extracardiac causes before structural valve degeneration (SVD) can occur. 3 This will chan...

In the current state of interventional cardiology, the ability to offer advanced therapies to patients who historically were not surgical candidates has grown exponentially in the last few decades. As therapies have expanded in complex coronary and structural interventions, the nuances of treating certain populations have emerged. In particular, the role of sex-based anatomic and outcome differences has been increasingly recognized. As guidelines for cardiovascular prevention and treatment for certain conditions may vary by sex, therapeutic interventions in the structural and percutaneous coronary areas may also vary. In this review, we aim to discuss these differences, the current literature available on these topics, and areas of focus for the future.

Background: CCTA offers an exceptional negative predictive value when evaluating patients with suspected coronary disease. Many non-cardiology clinicians remain unaware of this test option and patients for which CCTA is appropriate. We hypothesized that a redesign of the noninvasive imaging ordering menu in our electronic health system, paired with didactic education, could increase ordering of CCTA. Methods: We designed a new ordering menu to guide noninvasive cardiac testing. A series of yes/no questions guided clinicians through a decision tree about which test modality would be best for a given patient: CCTA, myocardial perfusion scintigraphy (MPS), or exercise treadmill test (ETT). This menu change was paired with education in the form of flyers, PowerPoint-guided lectures, and question-answer sessions. We measured the volume of each test modality (CCTA, ETT, and MPS) ordered for 6 months prior and 4 months after our intervention in two-week intervals, mapped on a runchart. We compared the median number of tests for each modality before and after the intervention. We surveyed clinicians’ opinions about ordering CCTA before and after the intervention and also asked their opinions about the change in a post-intervention survey. Results: Before the intervention, the median numbers of CCTA, ETT, and MPS ordered per two-week interval were 8.5, 10, and 60, respectively. Post-intervention, CCTA, ETT, and MPS were ordered 14, 10, and 60 times per two-week period, respectively. We saw a 67% increase in ordering of CCTA post-intervention (p=0.001, 95% CI: 3.0-12.0) while there were no significant changes in ordering patterns for ETT or MPS. Based on the surveys, 38% of clinicians were not comfortable ordering cardiac CTA prior to our intervention which decreased to 32% of clinicians after our intervention (p=0.64). 36% of providers reported that they liked the new ordering menu, while 52% were neutral, and 12% of providers expressed their dislike. Conclusion: A simple change in the ordering menu for noninvasive cardiology testing resulted in a substantial increase in CCTA ordering. A large majority of clinicians felt either neutral or positive towards the changes. We did not observe an offsetting decrease in other test modality ordering raising the question as to whether clinicians changed their test choice or increased the amount of testing being performed.