P167 ECG ABNORMALITIES AND DOUBLE CORONARY FISTULA

Coronary artery fistula (CAF) is defined as anomalous communication between coronary arteries and cardiac chamber or a major thoracic vessel. CAF are a rare coronary anomaly, mostly congenital, first described by Krause in 1856. In literature the incidence in general population is approximately 0,002%. Detection of CAF during coronary angiography is usually accidental. In 50% of cases CAF originate from right coronary artery, in 30% they originate from LAD, while in the rest of the percentage CAF originate from left circumflex artery. CAF drain into low–pressure chamber (right ventricle or right atrium, superior Vena Cava or pulmonary artery). We can distinguish CAF into little or medium sized, usually with silent clinical course, and large sized CAF, with variable clinical signs, depending on the extent of the shunt and on the hemodynamic overload of the receiving chamber. We describe the case of a 57 y.o woman with hypertension, admitted for femur fracture. ECG showed bifasic T waves in the anterior leads, already described in a previous ECG. Normal systolic function and no valvular defect were found on the echocardiogram. Patient was asymptomatic. Coronary angiography documented normal coronary arteries, with a double coronary fistula: the first from a septal branch of posterior descending and the second one from distal branches of the first diagonal. Even if CAF have often a favorable clinical course with no relevant consequences for the patient, it’s crucial to obtain more information about their functional implication and their anatomic connections. Indeed, rare cases of sudden cardiac death have been described in patients with CAF involved in myocardial ischemia based on the theft syndrome mechanism. Echocardiographic evaluation of the patient to detect associated congenital abnormalities, pressure overload of the receiving chambers and the extent of the shunt on the coronary angiography are crucial for the proper management of CAF. In the case described above we decided to optimize therapy adding beta–blocker (to reduce the overload caused by the two coronary fistula).

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The use of a telematic connection for the follow-up of hypertensive patients improves the cardiovascular prognosis

BACKGROUND

Inadequate blood pressure (BP) control could be due to incorrect management of hypertensives caused by the lack of interaction between general practitioners (GP) and hypertension specialists.

OBJECTIVES

To test the effectiveness on BP and total cardiovascular risk (TCVR) control of an internet-based digital network connecting specialists and GPs.

METHODS

We created a network among the Hypertension Clinic, Federico II University (Naples, Italy), 23 hospital-based hypertension clinics and 60 GPs from the area (CampaniaSalute Network, CS). Randomized GPs enrolled in CS could update online records of patients (n = 1979). As a control, we included 2045 patients referred to the specialist clinics by GPs from outside the network. All patients completed a 2-year follow-up.

RESULTS

CS provided a larger reduction in BP [systolic/diastolic BP (SBP/DBP): 7.3 +/- 0.4/5.4 +/- 0.3 versus 4.1 +/- 0.4/3.1 +/- 0.26 mmHg, CS versus control; P < 0.001 for both] and percentage of patients with BP < 140/90 mmHg (CS versus control: baseline, 33 versus 34%, NS; end of follow-up, 51 versus 47%, chi = 13.371; P < 0.001). A European Society of Hypertension-European Society of Cardiology (ESH/ESC) TCVR score was calculated [from 1 (average) to 5 (very high TCVR)]. The CS group showed a reduction in the mean TCVR score (CS: from 3.5 +/- 0.02 to 3.2 +/- 0, P < 0.01, ANOVA; control group: 3.5 +/- 0.03 to 3.4 +/- 0.03, NS) and, accordingly, fatal and non-fatal major cardiovascular events (MACE) were less frequent (2.9 versus 4.3%; chi = 5.047, P < 0.02). CS predicts fewer MACE in multiple binary regression analysis (beta:-7.27, P < 0.008) reducing the risk for MACE compared to control [odds ratio (OR): 0.838; 95% confidence interval (CI): 0.73-0.96].

CONCLUSION

Our results support the idea that telemedicine can achieve better control of BP and TCVR.