Background We aimed to evaluate whether genotype-guided warfarin dosing is superior to conventional clinical dosing for the outcomes of interest in Chinese patients. Methods - All patients with nonvalvular AF were randomly divided into two groups, genetic group and control group. We included genotypes for CYP2C9 and VKORC1 in the gene group，then doctors and pharmacists used the warfarin dosing algorithm and clinical information to determine patients’ initial dose, while in control group doses were determined by experince. The international normalized ratio (INR) measurement and standard protocols were used for further dose adjustment in both groups. The primary outcome measure was the percentage of time in the therapeutic range (%TTR) of the INR during follow up after initiation of warfarin treatment. Results The average TTR was (68.36 ± 20.57) % vs (48.52 ± 21.56) %, P<0.001) in the gene group compared with the control group. At the end of follow-up, the genetic group had a significant lower risk of cumulative incidences of ischemic stroke events in the adjusted model [relative risk (RR) 0.38 (95% CI 0.18 to 0.80), log-rank test P =0.008] than control group. There was no significant difference in the risk ratios (RR) for cumulative incidence of total bleeding events, minor bleeding events, gastrointestinal bleeding and intracerebral bleeding events between the two groups(P>0.05). Conclusion Genotype-guided dosing could improve the average TTR, improve the safety of treatment, achieve a higher level of TTR in the early anticoagulation period and reduce the risk of ischemic stroke events significantly.

Anomalous origin of coronary arteries is usually asymptomatic and a rare disease. However, some cases can cause severe life-threatening events such as myocardial infarction and syncope. Management of coronary anomalies continues to be a controversial topic in clinic, for which requires a high index of suspicion for timely diagnosis and management. We report a case of a 15-year-old symptomatic boy who presented with cardiogenic syncope and was diagnosed with a rare congenital “coronary artery sandwich anomaly” (CASA), acute subendocardial myocardial infarction and cardiac failure requiring extracorporeal membrane oxygenation(ECMO) for stabilization. Speckle tracking echocardiography examination showed decreased segmental ventricular wall motion and the left ventricular global longitudinal strain was -9.3%. Cardiac computed tomography (CT) showed that an anomalous origin of the left coronary artery arose from the right coronary sinus, with acute angle takeoff and inter-arterial course between aorta and pulmonary artery. Cardiac Magnetic Resonance Imaging(MRI) image showed: diffuse abnormal intima enhancement in the left ventricle, the left ventricle was enlarged and systolic function was decreased. The best treatment was coronary artery unroofing operation. However, the patient was with poor cardiac function and was managed with conservative treatment instead of operation. This case demonstrated that the left CASA with acute angle takeoff and inter-arterial course between the aorta and pulmonary artery is extremely rare but severe potentially life-threatening presentation which should be managed with a promptly and careful treatment. In this case, speckle tracking echocardiography, cardiac CT and MRI have played important roles in diagnosis and therapy of the disease.

A 16-year-old male patient was admitted to the emergency department because of “continuous palpitations and shortness of breath”. He developed cardiogenic shock, electrocardiogram (ECG) showed persistent atrial tachycardia (AT), left ventricle was enlarged, the lowest left ventricular ejection fraction (LVEF) was only 19%, the highest N-terminal-forebrain natriuretic peptide was 5830pg/ml. He was treated with extracorporeal membrane oxygenation-based comprehensive treatment, but various antiarrhythmic drugs were no therapeutic effective. Considering he was atrial tachycardia-induced cardiomyopathy (TIC) with heart failure induced by circadian rhythm disturbance, we performed radiofrequency catheter ablation and adjust his work-and-rest system. AT was terminated after ablation. Three months after the operation, there was no recurrence of palpitations, ECG showed normal, LV function and heart size recovered. This report describes a case of atrial TIC associated with systolic dysfunction treated with RFCA successfully. In the future, we should pay more attention to changes in the circadian rhythm of atrial arrhythmia which may help clinical diagnosis and treatment.

Background We aimed to evaluate whether genotype-guided warfarin dosing is superior to conventional clinical dosing for the outcomes of interest in Chinese patients. Methods - All patients with nonvalvular AF were randomly divided into two groups, genetic group and control group. We included genotypes for CYP2C9 and VKORC1 in the gene group，then doctors and pharmacists used the warfarin dosing algorithm and clinical information to determine patients’ initial dose, while in control group doses were determined by experince. The international normalized ratio (INR) measurement and standard protocols were used for further dose adjustment in both groups. The primary outcome measure was the percentage of time in the therapeutic range (%TTR) of the INR during follow up after initiation of warfarin treatment. Results The average TTR was (68.36 ± 20.57) % vs (48.52 ± 21.56) %, P<0.001) in the gene group compared with the control group. At the end of follow-up, the genetic group had a significant lower risk of cumulative incidences of ischemic stroke events in the adjusted model [relative risk (RR) 0.38 (95% CI 0.18 to 0.80), log-rank test P =0.008] than control group. There was no significant difference in the risk ratios (RR) for cumulative incidence of total bleeding events, minor bleeding events, gastrointestinal bleeding and intracerebral bleeding events between the two groups(P>0.05). Conclusion Genotype-guided dosing could improve the average TTR, improve the safety of treatment, achieve a higher level of TTR in the early anticoagulation period and reduce the risk of ischemic stroke