Using the CHA2DS2-VASc Score for Refining Stroke Risk Stratification in ‘Low-Risk’ Asian Patients With Atrial Fibrillation

Background

A new scoring system, the anticoagulation and risk factors in atrial fibrillation (ATRIA) score, was proposed for risk stratification in patients with atrial fibrillation (AF). Whether the ATRIA scheme can adequately identify patients who are at low risk of ischemic stroke remains unknown.

Objectives

The goal of the present study was to compare the performance of ATRIA to that of CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65 to 74, female) scores for stroke prediction.

Methods

This study used the National Health Insurance research database in Taiwan. A total of 186,570 AF patients without antithrombotic therapy were selected as the study cohort. The clinical endpoint was the occurrence of ischemic stroke.

Results

During the follow-up of 3.4 ± 3.7 years, 23,723 patients (12.7%) experienced ischemic stroke. The CHA₂DS₂-VASc score performed better than ATRIA score in predicting ischemic stroke as assessed by c-indexes (0.698 vs. 0.627, respectively; p < 0.0001). The CHA₂DS₂-VASc score also improved the net reclassification index by 11.7% compared with ATRIA score (p < 0.0001). Among 73,242 patients categorized as low-risk on the basis of an ATRIA score of 0 to 5, the CHA₂DS₂-VASc scores ranged from 0 to 7, and annual stroke rates ranged from 1.06% to 13.33% at 1-year follow-up and from 1.15% to 8.00% at 15-year follow-up. The c-index of CHA₂DS₂-VASc score (0.629) was significantly higher than that of the ATRIA score (0.593) in this “low-risk” category (p < 0.0001).

Conclusions

Patients categorized as low-risk by use of the ATRIA score were not necessarily low-risk, and the annual stroke rates can be as high as 2.95% at 1-year follow-up and 2.84% at 15-year follow-up. In contrast, patients with a CHA₂DS₂-VASc score of 0 had a truly low risk of ischemic stroke, with an annual stroke rate of approximately 1%.     

Clinical Impact of Atrial Fibrillation in Patients With the HeartMate II Left Ventricular Assist Device

Background

Atrial fibrillation (AF) is common in patients with the HeartMate II (HMII) left ventricular assist device (LVAD), but the impact of AF on clinical outcomes is uncertain.

Objectives

This study sought to determine the effect of AF on outcomes in patients with the HMII LVAD.

Methods

Records of 106 patients who underwent HMII implantation at a single center were reviewed. The associations of paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PeAF) with survival, heart failure (HF) hospitalization, bleeding, and thromboembolism were examined using Kaplan-Meier survival analysis and Cox proportional hazards regression.

Results

Mean age was 56.6 ± 11.4 years, 87.7% of the implants were intended as a bridge to transplantation, and median length of support was 217 days (range: 1 to 952 days). AF was present in 55 patients (51.9%); 36 patients (34.0%) had PAF and 19 (17.9%) had PeAF. Twenty-one patients (19.8%) died, and 18 (17.0%) were hospitalized for HF. There were 0.75 major bleeding events and 0.28 thromboembolic events per patient year of follow-up. PAF was not associated with increased mortality, HF hospitalization, bleeding, or thromboembolism. PeAF, however, was an independent predictor of the composite endpoint of death or HF hospitalization (hazard ratio: 3.54; 95% confidence interval: 1.52 to 8.25; p < 0.01). Although there was no increase in bleeding or thromboembolism, patients with AF had thromboembolic events at higher international normalized ratios (INRs).

Conclusions

Although PAF is not associated with worse outcomes in patients with the HMII LVAD, PeAF may be associated with increased mortality and HF hospitalization. Patients with AF also may have thromboembolic events at higher INR levels.     

乙型肝炎肝硬化失代偿期患者并发心房颤动l例报告

女性患者,58岁,农民。于2009年发现乙型肝炎,期间病情稳定,于2011年10月因劳累,病情加重,当地医院确诊“肝硬化失代偿期”住院治疗1个月后康复,期间未予抗病毒治疗,出院后定期复查肝功能、电解质及B超等检查。于2012年3月19日因“腹胀伴尿少1个月”住本院治疗,入院查体：体温36．8℃,心率60次／min,呼吸17次／min,血压（BP）110／80mmrig。神清,呼吸平,精神可,皮肤巩膜轻度黄染,肝掌（一）,蜘蛛痣（一）,气管居中,双侧甲状腺无肿大,颈静脉无充盈。胸廓对称,双肺呼吸音低,未闻及明显干湿哕音。心律齐,各瓣膜听诊区未闻及病理性杂音,腹部膨隆,中上腹轻压痛,无反跳痛,肝脾触诊不满意,移动性浊音（＋）,双下肢轻度浮肿。于3月20H查肝功能：TBil49．7mmol／L,ATJT60U／L,AST137U／L,白球比（A／G）25／30g／L;凝血酶原时间（PT）18．7S;电解质：钾2．5mmol／L,钠139mmol／L,氯100mmol／L;血常规：白细胞3．5×10^9／L,红细胞3．15×10^12／L,血红蛋白108g／L,血小板53×10^9／L;HBVM“小三阳”,HBVDNA：5．07×10^6IU／ml,甲胎蛋白（＋）;腹部B超：肝硬化、脾肿大、肝囊肿、腹腔盆腔积液;腹部cr：肝硬化腹水伴门静脉高压、脾肿大、肝内多发小囊肿、两侧少量胸腔积液;胸片：右侧少量胸腔积液、两侧膈面抬高;心电图：窦性心律、左胸导联低电压。入院诊断为：（1）乙型肝炎肝硬化失代偿期;（2）低钾血症;（3）自发性腹膜炎。     

缬沙坦联合胺碘酮对持续性心房颤动复律及复律后窦性心律维持率的影响

目的观察缬沙坦联合胺碘酮对持续性心房颤动复律及复律后窦性心律维持率的影响。方法选择持续性心房颤动患者96例,随机分为两组,治疗组49例,给予缬沙坦及胺碘酮治疗,对照组47例给予安慰剂及胺碘酮治疗。随访1年,观察两组心房颤动转复率和转复后3、12个月时心房颤动复发率,以及转复时及转复后12个月左心房内径（LAD）、左心室射血分数（LVEF）变化。结果心房颤动转复率治疗组（87．8％）与对照组（85．1％）差异无统计学意义（P〉0．05）。心房颤动复发率转复后3个月及12个月治疗组（14．0％、2312％）均小于对照组（32．5％、54．5％）（P〈0．05或0．01）,转律后12个月LAD治疗组[（44．3±065）mm）]较对照组[（469±0．54）mm]变小（P〈0＋05）,LVEF治疗组[（56．8±8．64）％]较对照组[（52．3±908）％]升高（P〈0．05）。结论缬沙坦联合胺碘酮治疗持续性心房颤动在减少心房颤动的复发率以及改善心功能方面优于单独使用胺碘酮。     

Effect of auricular point pressing therapy on postoperative pain of fracture: A protocol for systematic review and meta-analysis

Background:In clinical practices, postoperative fracture patients are often treated with analgesics. As one of the alternative therapies for nondrug analgesia, auricular point pressing has advantages of simple operation, easy to use, no injury and adverse reactions, and great potential for development. In this study, the effect of auricular point pressing therapy on postoperative pain of fracture was objectively evaluated through the method of meta-analysis, so as to provide evidence for clinical applications.Methods:PubMed, Web of Science, Cochrane Library, EMBASE, Wan fang Database, Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, and Chinese Biomedical Literature Database were systematically searched and randomized controlled trials on auricular point pressing in the treatment of postoperative pain after fracture were includes. After independent literature screening, data extraction and quality evaluation by 2 researchers, the original data was retrieved, merged, and analyzed. RevMan 5.3 software was adopted for meta-analysisResults:This study could provide high-quality evidence to evaluate the effect of auricular point pressing therapy on postoperative pain of fracture.Conclusion:This systematic review explored whether auricular point pressing therapy is effective on the intervention of postoperative pain after fracture.OSF Registration Number:DOI 10.17605/OSF.IO/AZ4JQ.     

New-onset atrial fibrillation and outcomes following isolated coronary artery bypass surgery: A systematic review and meta-analysis

Prior meta-analyses have shown that new-onset atrial fibrillation (NOAF) occurs in up to 40% of patients following cardiac surgery and is associated with substantial major adverse cardiovascular events. The stroke and mortality implications of NOAF in isolated CABG without concomitant valve surgery is not known. We thought that NOAF would be associated with increased risk of stroke and mortality, even in patients undergoing isolated CABG. A blinded review of studies from MEDLINE, CENTRAL, and Web of Science was done by two independent investigators. Stroke, 30-day/hospital mortality, long-term cardiovascular mortality, and long-term (>1 year) all-cause mortality were analyzed. We used Review Manager Version 5.3 to perform pooled analysis of outcomes. Of 4461 studies identified, 19 studies (n = 129 628) met inclusion criteria. NOAF incidence ranged from 15% to 36%. NOAF was associated with increased risk of stroke (unadjusted OR 2.15 [1.82, 2.53] [P < .00001]; adjusted OR 1.88 [1.02, 3.46] [P = .04]). NOAF was associated with increased 30-day/hospital mortality (OR 2.35 [1.67, 3.32] [P < .00001]) and long-term cardiovascular mortality (OR 2.04 [1.35, 3.09] [P = .0007]) NOAF was associated with increased long-term all-cause mortality (unadjusted OR 1.79 [1.63, 1.96] [P < .00001]; adjusted OR 1.58 [1.24, 2.00] [P = .0002]). We found that the incidence of NOAF following isolated CABG is high and is associated with increased stroke rate and mortality. Early recognition and management of NOAF could improve outcomes.