Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands.

OBJECTIVE: Cardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS. DESIGN: A web-based survey containing clinical vignettes. SETTING AND PARTICIPANTS: Registered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes 'without' a risk score present, while group 2 completed vignettes 'with' a risk score present. RESULTS: 129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores. CONCLUSIONS: When deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.

Coronary artery assessment by multidetector computed tomography in patients with prosthetic heart valves.

OBJECTIVES: Patients with prosthetic heart valves may require assessment for coronary artery disease. We assessed whether valve artefacts hamper coronary artery assessment by multidetector CT. METHODS: ECG-gated or -triggered CT angiograms were selected from our PACS archive based on the presence of prosthetic heart valves. The best systolic and diastolic axial reconstructions were selected for coronary assessment. Each present coronary segment was scored for the presence of valve-related artefacts prohibiting coronary artery assessment. Scoring was performed in consensus by two observers. RESULTS: Eighty-two CT angiograms were performed on a 64-slice (n = 27) or 256-slice (n = 55) multidetector CT. Eighty-nine valves and five annuloplasty rings were present. Forty-three out of 1160 (3.7%) present coronary artery segments were non-diagnostic due to valve artefacts (14/82 patients). Valve artefacts were located in right coronary artery (15/43; 35%), left anterior descending artery (2/43; 5%), circumflex artery (14/43; 32%) and marginal obtuse (12/43; 28%) segments. All cobalt-chrome containing valves caused artefacts prohibiting coronary assessment. Biological and titanium-containing valves did not cause artefacts except for three specific valve types. CONCLUSIONS: Most commonly implanted prosthetic heart valves do not hamper coronary assessment on multidetector CT. Cobalt-chrome containing prosthetic heart valves preclude complete coronary artery assessment because of severe valve artefacts. KEY POINTS: • Most commonly implanted prosthetic heart valves do not hamper coronary artery assessment • Prosthetic heart valve composition determines the occurrence of prosthetic heart valve-related artefacts • Björk-Shiley and Sorin tilting disc valves preclude diagnostic coronary artery segment assessment.

[Intoxication with Monkshood (Aconitum napellus)]. / Intoxicatie met blauwe monnikskap (Aconitum napellus).

Three patients presented with an intoxication caused by Aconitum napellus, commonly known as Aconite, Monkshood or Wolfsbane. The first patient, a woman aged 24, was resuscitated after accidental ingestion of plant material 'from nature'. She experienced severe ventricular tachyarrhythmias. After discharge she returned with identical symptoms, which were now interpreted as intentional intoxication in a suicide attempt. She was referred to the Psychiatry department. The second patient was a 2-year-old boy who had cutaneous exposure to Aconite. Except for some red spots around his mouth there were no other symptoms. The third patient was a 34-year-old woman who ate Monkshood, which she mistook for parsley. Alarmed by the bitter taste she contacted the hospital. She was treated with stomach lavage which removed most of the ingested plant material, and with activated charcoal. She had no symptoms during observation in the hospital. Aconite alkaloids are known to cause ventricular arrhythmia by a prolonged activation of sodium channels. Because there is no antidote, treatment is largely supportive but serious arrhythmias and respiratory arrest need to be anticipated.