Chronic heart failure due to left ventricular systolic dysfunction has a high morbidity and mortality. Angiotensin converting enzyme inhibitors reduce symptomatic deterioration, hospitalisation, and death. Most patients with suspected heart failure present first to general practitioners. Recent studies have emphasised the difficulty of diagnosing heart failure in the community. Fewer than half of patients treated for heart failure by general practitioners CommentThis study shows that left ventricular systolic dysfunction is unlikely to be present if the electrocardiogram is normal (or shows only minor abnormalities). Conversely, there is usually a major electrocardiographic abnormality in the presence of left ventricular systolic dysfunction. The electrocardiogram is not a substitute for echocardiography, as an abnormal electrocardiogram does not accurately predict the presence of left ventricular systolic dysfunction. A patient with an abnormal electrocardiogram has about a one in three chance of significant left ventricular systolic dysfunction. Sensitivity 90/96=94%; specificity 269/438=61%; positive predictive value 90/259=35%; negative predictive value 269/275=98%. tNormal or minor abnormality (atrial enlargement, bradycardia, tachycardia, broadening of QRS complex, poor R wave progression, right axis deviation, myocardial ischaemia, first degree atrioventricular block, nonspecific ST-T wave changes).

Background-The optimal strategy for treating coronary bifurcation lesions remains a subject of debate. With bare-metal stents, single-stent approaches appear to be superior to systematic 2-stent strategies. Drug-eluting stents, however, have low rates of restenosis and might offer improved outcomes with complex stenting techniques. Methods and Results-Patients with significant coronary bifurcation lesions were randomized to either a simple or complex stenting strategy with drug-eluting stents. In the simple strategy, the main vessel was stented, followed by optional kissing balloon dilatation/T-stent. In the complex strategy, both vessels were systematically stented (culotte or crush techniques) with mandatory kissing balloon dilatation. Five hundred patients 64Ϯ10 years old were randomized; 77% were male. Eighty-two percent of lesions were true bifurcations (Ͼ50% narrowing in both vessels). In the simple group (nϭ250), 66 patients (26%) had kissing balloons in addition to main-vessel stenting, and 7 (3%) had T stenting. In the complex group (nϭ250), 89% of culotte (nϭ75) and 72% of crush (nϭ169) cases were completed successfully with final kissing balloon inflations. The primary end point (a composite at 9 months of death, myocardial infarction, and target-vessel failure) occurred in 8.0% of the simple group versus 15.2% of the complex group (hazard ratio 2.02, 95% confidence interval 1.17 to 3.47, Pϭ0.009). Myocardial infarction occurred in 3.6% versus 11.2%, respectively (Pϭ0.001), and in-hospital major adverse cardiovascular events occurred in 2.0% versus 8.0% (Pϭ0.002), respectively. Procedure duration and x-ray dose favored the simple approach. Conclusions-When coronary bifurcation lesions are treated, a systematic 2-stent technique results in higher rates of in-hospital and 9-month major adverse cardiovascular events. This difference is largely driven by periprocedural myocardial infarction. Procedure duration is longer, and x-ray dose is higher. The provisional technique should remain the preferred strategy in the majority of cases. Clinical Trial Registration Information-URL: http://www.clinicaltrials.gov. Unique identifier: NCT 00351260.

In both age groups, the MVG was lower in both systole and diastole in patients with HCM than in athletes, hypertensive patients or normal subjects. The MVG measured in early diastole in a group of subjects 18 to 45 years old would appear to be an accurate variable used to discriminate between HCM and hypertrophy in athletes.

The frequency of known causative factors of cerebral infarction was studied in 244 cases of first ever stroke due to cerebral infarction proved by computed tomography or at necropsy who were registered in the first two years of a prospective community based study. Risk In this unselected series of patients with first ever stroke due to cerebral infarction most of the strokes were presumed to be due to either atheromatous arterial disease or embolism from the heart, and only 4% (95% confidence interval 2 to 7%) were probably due to non-atheromatous non-embolic causes. This has implications for research into strokes and allocation of public health expenditure. IntroductionDoctors who care for patients with cerebral infarction are all too aware that most cases are the consequence of atheromatous vascular disease or heart disease; yet there is a long list of rare but potentially treatable conditions that they may have at least to consider in each new patient.' Extensively investigating every patient with stroke, particularly the elderly, is not, however, always appropriate. In deciding on a clinically sensible approach to a typical patient a knowledge of the relative frequency of each of the major causative factors and a sense of proportion about what is important would be helpful.Studying the relative importance of different potential causative factors in a single sample of patients with stroke may, however, be difficult. A hospital based series of patients is prone to selection bias as