BackgroundThe instantaneous wave-free ratio (iFR) is a novel method to assess the ischemic potential of coronary artery stenoses. Clinical trial data have shown that iFR has acceptable diagnostic agreement with fractional flow reserve (FFR), the reference standard for the functional assessment of coronary stenoses. This study compares iFR measurements with FFR measurements in a real world, single-center setting.Methods and resultsInstantaneous wave-free ratio and FFR were measured in 50 coronary artery lesions in 42 patients, with FFR ≤ 0.8 classified as functionally significant. An iFR-only technique, using a treatment cut-off value, iFR ≤ 0.89, provided a classification agreement of 84% with FFR ≤ 0.80. Use of a hybrid iFR–FFR technique, incorporating FFR measurement for lesions within the iFR gray zone of 0.86–0.93, would improve classification agreement with FFR to 94%, with diagnosis achieved without the need for hyperemia in 57% patients.ConclusionThis study in a real-world setting demonstrated good classification agreement between iFR and FFR. Use of a hybrid iFR–FFR technique would achieve high diagnostic accuracy while minimizing adenosine use, compared with routine FFR.

No abstract

The axillary vein is an accepted route for gaining central venous access, particularly for pacing and implantable cardioverter defibrillator leads, with ultrasound guidance a useful way of facilitating venous puncture. We report a series of cases demonstrating the important complication of inadvertent arterial injury with this technique.

No abstract

Coronary artery vasospasm is the sudden narrowing of an artery caused by rapid prolonged contraction. It reduces blood supply to the heart and can present with typical cardiac chest pain symptoms. Vasospasm can lead to fatal arrhythmic complications such as ventricular fibrillation. Our case report describes an example of this occurring in a 53-year-old female, and the management plan that ensued. We look at the importance of accurate and prompt diagnosis of vasospasm and how this can have implications for treatment options. One of the available treatments for vasospasm is placement of an implantable cardioverter defibrillator (ICD). This delivers a shock in the event of future life-threatening arrhythmia, with the aim of preventing cardiac arrest. ICD placement, however, is not always a suitable option. This case report discusses the various challenges that arose while making the decision for ICD placement and gives insight into the best available treatment options for coronary artery vasospasm. We also highlight early warning signs that predict life-threatening vasospastic events and how this can be diagnosed and treated appropriately.

Background: Treatment decisions in myocardial infarction (MI) are currently stratified by ST elevation (ST-elevation myocardial infarction [STEMI]) or lack of ST elevation (non-ST elevation myocardial infarction [NSTEMI]) on the electrocardiogram.This arose from the assumption that ST elevation indicated acute coronary artery occlusion (OMI). However, one-quarter of all NSTEMI cases are an OMI, and have a higher mortality. The purpose of this study was to identify features that could help identify OMI.Methods: Prospectively collected data from patients undergoing percutaneous coronary intervention (PCI) was analyzed. Data included presentation characteristics, comorbidities, treatments, and outcomes. Latent class analysis was undertaken, to determine patterns of presentation and history associated with OMI.Results: A total of 1412 patients underwent PCI for acute MI, and 263 were diagnosed as OMI. Compared to nonocclusive MI, OMI patients are more likely to have fewer comorbidities but no difference in cerebrovascular disease and increased acute mortality (4.2% vs. 1.1%; p < .001). Of OMI, 29.5% had delays to their treatment such as immediate reperfusion therapy. With latent class analysis, while clusters of similar patients are observed in the data set, the data available did not usefully identify patients with OMI compared to non-OMI. Conclusion:Features between OMI and STEMI are broadly very similar. However, there was no difference in age and risk of cerebrovascular disease in the OMI/non-OMI group. There are no reliable characteristics therefore for identifying OMI versus non-OMI. Delays to treatment also suggest that OMI patients are still missing out on

Local provision of percutaneous coronary intervention increases stenting rates and reduces length of hospital stay in remote regional centre

No abstract