Wacin Buddhari

Challenges and solutions in medically managed ACS in the Asia-Pacific region: Expert recommendations from the Asia-Pacific ACS Medical Management Working Group

Acute coronary syndromes (ACS) remain a leading cause of mortality and morbidity in the Asia-Pacific (APAC) region. International guidelines advocate invasive procedures in all but low-risk ACS patients; however, a high proportion of ACS patients in the APAC region receive solely medical management due to a combination of unique geographical, socioeconomic, and population-specific barriers. The APAC ACS Medical Management Working Group recently convened to discuss the ACS medical management landscape in the APAC region. Local and international ACS guidelines and the global and APAC clinical evidence-base for medical management of ACS were reviewed. Challenges in the provision of optimal care for these patients were identified and broadly categorized into issues related to (1) accessibility/systems of care, (2) risk stratification, (3) education, (4) optimization of pharmacotherapy, and (5) cost/affordability. While ACS guidelines clearly represent a valuable standard of care, the group concluded that these challenges can be best met by establishing cardiac networks and individual hospital models/clinical pathways taking into account local risk factors (including socioeconomic status), affordability and availability of pharmacotherapies/invasive facilities, and the nature of local healthcare systems. Potential solutions central to the optimization of ACS medical management in the APAC region are outlined with specific recommendations.

Myocardial revascularization with the posterior tibial artery.

A large number of coronary artery bypass grafts are performed in Thailand. Some patients develop restenosed coronary arteries or stenosed graft conduits. Great saphenous veins, internal thoracic arteries, radial arteries, and right gastroepiploic arteries are used for redo coronary artery bypass grafting. But even with many conduits to choose from, sometimes graft conduits are not available. We report a case of redo coronary artery bypass grafting where the posterior tibial artery was harvested for the graft conduit. Clinical outcome and angiographic results are reported at 1 year postoperation.

Images in CardiologyScimitar Sign in a Patient With an Atrial Septal Defect: A Comprehensive Noninvasive Assessment With Transthoracic Echocardiography and Computed Tomography

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 30-year-old woman was referred for a percutaneous atrial septal defect (ASD) closure. She was acyanotic. She had a systolic ejection murmur and a wide-fixed split S2. The chest radiograph showed cardiomegaly; pulmonary

Scimitar Sign in a Patient With an Atrial Septal Defect: A Comprehensive Noninvasive Assessment With Transthoracic Echocardiography and Computed Tomography

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 30-year-old woman was referred for a percutaneous atrial septal defect (ASD) closure. She was acyanotic. She had a systolic ejection murmur and a wide-fixed split S2. The chest radiograph showed cardiomegaly; pulmonary

Low-density lipoprotein cholesterol target attainment in patients with stable or acute coronary heart disease in the Asia-Pacific region: results from the Dyslipidemia International Study II

Background As mortality due to cardiovascular disease increases throughout the world, accurate data on risk factors such as hyperlipidemia are required. This is lacking in the Asia-Pacific region. Design The observational Dyslipidemia International Study (DYSIS) II was established to quantify the extent of hyperlipidemia in adults with acute and stable coronary heart disease globally. Methods Patients with stable coronary heart disease or hospitalised with an acute coronary syndrome were enrolled across nine Asia-Pacific countries from July 2013 to October 2014. Lipid-lowering therapy and low-density lipoprotein cholesterol target attainment (<70 mg/dL) were assessed. The acute coronary syndrome cohort was followed up 4 months post-discharge. Results Of the 4592 patients enrolled, 2794 had stable coronary heart disease and 1798 were admitted with an acute coronary syndrome. In the coronary heart disease cohort, the mean low-density lipoprotein cholesterol level was 86.9 mg/dL, with 91.7% using lipid-lowering therapy and 31% achieving low-density lipoprotein cholesterol of less than 70 mg/dL. In the acute coronary syndrome cohort at admission, the corresponding values were 103.2 mg/dL, 63.4% and 23.0%, respectively. Target attainment was significantly higher in lipid-lowering therapy-treated than non-treated patients in each cohort (32.6% vs. 12.9% and 31.1% vs. 9.0%, respectively). Mean atorvastatin-equivalent dosages were low (20 ± 15 and 22 ± 18 mg/day, respectively), with little use of non-statin adjuvants (13.0% and 6.8%, respectively). Low-density lipoprotein cholesterol target attainment had improved by follow-up for the acute coronary syndrome patients, but remained low (41.7%). Conclusions Many patients in Asia at very high risk of recurrent cardiovascular events had a low-density lipoprotein cholesterol level above the recommended target. Although lipid-lowering therapy was common, it was not used to its full potential.

Unusual atrial myxoma with neovascularization associated with fistula to right atrium

A 80-year-old woman was evaluated for the first-detected atrial fibrillation found from regular health check. Transthoracic echocardiography revealed a 30 40 mm, pedunculated, inhomogeneous left atrial mass attached to the interatrial septum (Panel A, asterisk) with indeterminate blood flow inside. (Supplementary material online, Video S1). Short axis T2-weighted with fat suppression cardiac magnetic resonance showed the mass attached to the fossa ovalis with strongly hyperintense signal (Panel B) and isointense to myocardium on noncontrast T1 weighted image (Panel C). Perfusion image nicely demonstrated the rapid contrast uptake via the cluster of tortuous vascular channels within the tumour (Panel D, asterisk, Supplementary material online, Video S2). A fistula to the right atrium (RA) was suspected due to the presence of contrast leakage from tumour into the RA cavity. Preoperative coronary angiography confirmed the large, tortuous feeding artery to the mass arising from the left circumflex artery (Panel E, asterisk, Supplementary material online, Video S3) with fistula to RA (calculated pulmonary-systemic shunt ratio 1.2:1). She successfully underwent elective tumour removal with fistula closure. Gross specimen of bisected tumour showed a large, well-formed, 8-mm diameter intratumoural vessel (Panel F, arrow) with diffuse area of internal haemorrhage. Histology confirmed the diagnosis of myxoma with abundant, delicate blood vessel formation. To the best of our knowledge, this is the first case of hypervascularized myxoma associated with fistula to RA, which highlights the role of multimodality imaging in preoperative assessment. These findings are of importance to successfully contemplate the surgical technique.