[A man with a crease in his earlobe]. / Een man met een groef in zijn oorlel.

A 68-year-old man consulted his GP with a crease in his earlobe, running diagonally from the tragus over the earlobe backwards. This is the Frank's sign, which is a risk factor for the presence and prognosis of cardiovascular pathology, such as coronary sclerosis, cerebrovascular accident and peripheral arterial disease.

[Mitral valve insufficiency; undertreated or not?] / Mitralisklepinsufficiëntie.

Dziadzko et al. describe the poor prognosis and low performance of surgery (15%) in a large cohort of patients with isolated moderate to severe mitral regurgitation (MR). They report a prevalence of moderate-severe MR 'in the community'. This is misleading as these patients were referred for echocardiography. Second, the authors stated there was 'important undertreatment' of MR as only 15% underwent surgery. Moderate MR was present in 70% and according to the 2006 guidelines, surgery for moderate MR is a class III recommendation. Finally, the authors report that few patients received 'the only treatment available (surgery)' and call for action. However, from the beginning of this century, treatment options have been extended by means of cardiac resynchronization therapy and the Mitraclip procedure. As nowadays these options account for up to 10% of non-pharmacological interventions of the mitral valve, not considering these modalities in the paper limits its value.

Variation in minimum desired cardiovascular disease-free longevity benefit from statin and antihypertensive medications: a cross-sectional study of patient and primary care physician perspectives.

OBJECTIVE: Expressing therapy benefit from a lifetime perspective, instead of only a 10-year perspective, is both more intuitive and of growing importance in doctor-patient communication. In cardiovascular disease (CVD) prevention, lifetime estimates are increasingly accessible via online decision tools. However, it is unclear what gain in life expectancy is considered meaningful by those who would use the estimates in clinical practice. We therefore quantified lifetime and 10-year benefit thresholds at which physicians and patients perceive statin and antihypertensive therapy as meaningful, and compared the thresholds with clinically attainable benefit. DESIGN: Cross-sectional study. SETTINGS: (1) continuing medical education conference in December 2016 for primary care physicians;(2) information session in April 2017 for patients. PARTICIPANTS: 400 primary care physicians and 523 patients in the Netherlands. OUTCOME: Months gain of CVD-free life expectancy at which lifelong statin therapy is perceived as meaningful, and months gain at which 10 years of statin and antihypertensive therapy is perceived as meaningful. Physicians were framed as users for lifelong and prescribers for 10-year therapy. RESULTS: Meaningful benefit was reported as median (IQR). Meaningful lifetime statin benefit was 24 months (IQR 23-36) in physicians (as users) and 42 months (IQR 12-42) in patients willing to consider therapy. Meaningful 10-year statin benefit was 12 months (IQR 10-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Meaningful 10-year antihypertensive benefit was 12 months (IQR 8-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Women desired greater benefit than men. Age, CVD status and co-medication had minimal effects on outcomes. CONCLUSION: Both physicians and patients report a large variation in meaningful longevity benefit. Desired benefit differs between physicians and patients and exceeds what is clinically attainable. Clinicians should recognise these discrepancies when prescribing therapy and implement individualised medicine and shared decision-making. Decision tools could provide information on realistic therapy benefit.