Increased level of resistin predicts development of atrial fibrillation

BackgroundResistin is a peptide hormone that is secreted from lipid cells and is linked to type-2 diabetes, obesity, and inflammation. Being an important adipocytokine, resistin was proven to play an important role in cardiovascular disease. We compared resistin levels in patients with and without atrial fibrillation (AF) to demonstrate the relationship between plasma resistin levels and AF.MethodOne hundred patients with AF and 58 control patients who were matched in terms of age, gender, and risk factors were included in the trial. Their clinical risk factors, biometric measurements, echocardiographic work up, biochemical parameters including resistin and high-sensitivity C-reactive protein (hs-CRP) levels were compared.ResultsIn patients with AF, plasma resistin levels (7.34 ± 1.63 ng/mL vs 6.67 ± 1.14 ng/mL; p = 0.003) and hs-CRP levels (3.01 ± 1.54 mg/L vs 2.16 ± 1.28 mg/L; p = 0.001) were higher than control group. In subgroup analysis, resistin levels were significantly higher in patients with paroxysmal (7.59 ± 1.57 ng/mL; p = 0.032) and persistent AF (7.73 ± 1.60 ng/mL; p = 0.006), but not in patients with permanent AF subgroups (6.86 ± 1.61 ng/mL; p = 0.92) compared to controls. However, hs-CRP levels were significantly higher only in permanent AF patients compared to control group (3.26 ± 1.46 mg/L vs 2.16 ± 1.28 mg/L; p = 0.02). In multivariate regression analysis using model adjusted for age, gender, body mas index, hypertension, diabetes mellitus, and creatinine levels, plasma resistin levels [odds ratio (OR): 1.30; 95% confidence interval (CI): 1.01–1.70; p = 0.04] and hs-CRP levels (OR: 1.44; 95% CI: 1.12–1.86; p = 0.004) were the only independent predictors of AF.ConclusionThe elevated levels of plasma resistin were related to paroxysmal AF group and persistent AF group, but not to permanent AF group.     

Estimated glomerular filtration rate and proteinuria are associated with persistent form of atrial fibrillation: Analysis in Japanese patients

BackgroundSeveral reports have identified that decline in renal function and presence of proteinuria are closely associated with incidence of atrial fibrillation (AF). However, it is still unclear whether these kidney-related markers are associated with the progression of AF from paroxysmal to persistent form.Methods and resultsAmong the new patients who visited the Cardiovascular Institute Hospital between 2004 and 2010 (Shinken Database 2004–2010, n = 15,227), both estimated glomerular filtration rate (eGFR) and proteinuria were measured in 1074 AF patients (paroxysmal/persistent 579/495, respectively), who were divided into tertiles of eGFR (the borderlines were 60.07 and 73.67 ml [min^?1] 1.73 [m^?2], respectively), and then further divided into the two categories with/without proteinuria. The average value of eGFR was lower (63.1 ml [min^?1] 1.73 [m^?2] vs. 68.8 ml [min^?1] 1.73 [m^?2], p < 0.001) and the detection rate of proteinuria was higher (13.7% vs. 8.5%, p = 0.006) in patients with persistent AF than in those with paroxysmal AF, respectively. In the multivariate analysis without parameters of echocardiography [left ventricular ejection fraction (LVEF) and left atrial dimension (LAD)], both eGFR and proteinuria were independently associated with persistent AF, but the association was abolished when the model included LAD and LVEF.ConclusionsIn the present analysis with cross-sectional design, both eGFR and proteinuria were apparently linked to the persistent form of AF, but their role in the pathogenesis does not seem to exceed the atrial stretch and remodeling, represented by LAD and LVEF.     

Association between red cell distribution width and thromboembolic events in patients with atrial fibrillation

BackgroundWe investigated whether an increase in the value of red cell distribution width (RDW) was associated with thromboembolic outcomes in patients with atrial fibrillation (AF).MethodsWe performed a retrospective analysis of 5082 consecutive patients with non-valvular AF. Thromboembolic events (N = 723, 14.2%) were recorded and analysed according to RDW value.ResultsThe peak RDW value during follow-up was higher in patients with thromboembolic events than in those without thromboembolic events (15.1% vs. 14.2%, p < 0.001). The RDW value showed similar power in predicting thromboembolic outcomes compared with the factor of age. The risk of thromboembolic events was higher in patients with a peak RDW ≥ 13.9% than in patients with a peak RDW < 13.9% (hazard ratio 1.63, p < 0.001), and increased with each quartile increase of RDW. In a subgroup of 739 patients with congestive heart failure (CHF), there were 112 (15.2%) thromboembolic events. The peak RDW value of patients with CHF with thromboembolic events was also significantly higher (16.4% vs. 15.6%, p = 0.019) compared to that of those without thromboembolic events.ConclusionAn increased RDW value during follow-up could be associated with thromboembolic events in patients with non-valvular AF. The suggested cut-off values for RDW used to predict an increased thromboembolic risk in were ≥ 13.9% in patients with AF in general, ≥ 15% in patients with co-existing AF and CHF.     

High-sensitivity troponin T is a prognostic marker for patients with aortic stenosis after valve replacement surgery

BackgroundAortic stenosis (AS) is recognized as a cause of sudden cardiac death. Recently, the measurement of high-sensitivity troponin T (hs-TnT) has become possible. Several studies have clarified that hs-TnT is a marker to indicate mortality of cardiovascular diseases.ObjectivesTo examine whether hs-TnT can be used as a prognostic marker to predict the operative outcome of AS.MethodsWe enrolled 60 patients with AS (mean age = 68.7 ± 9.6 years, male/female = 30/30). Cardiac catheterization and echocardiography were performed to evaluate the severity of AS. Aortic valve replacement surgery was performed in all patients. We defined major adverse cardiac events (MACE) as composite events of heart failure, fatal arrhythmia, and all causes of death.ResultsWe followed up the patients for 922 ± 800 days. Mean left ventricular ejection fraction was 60.0 ± 1.8%. Mean aortic valve area was 0.61 ± 0.03 cm². MACE occurred in 11 patients (18%), including 5 sudden cardiac deaths. We divided the patients into three groups based on the percentile of the plasma levels of hs-TnT. Kaplan–Meier curve revealed a statistically significant difference in MACE rate among the groups (log-rank test, χ² = 13.0, p = 0.002). We conducted a Cox proportional hazard analysis with a model including age, sex, estimated glomerular filtration rate, and hs-TnT tertile as explanatory variables to predict MACE. We found that hs-TnT tertile to be a significant factor to predict MACE (hazard ratio: 3.71, p = 0.03).Conclusionshs-TnT can be a prognostic marker for patients with AS after valve replacement surgery.     

Left ventricular structure and diastolic function by cardiac magnetic resonance imaging in hypertrophic cardiomyopathy

ObjectiveDiastolic dysfunction is common in hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HHD), but its relationships with left ventricular (LV) parameters have not been well studied. Our objective was to assess the relationship of various measures of diastolic function, and maximum left ventricular wall thickness (MLVWT) and left ventricular mass index (LVMI) in HCM, HHD and normal controls using cardiac magnetic resonance imaging (CMR). We also assessed LV parameters and diastolic function in relation to late gadolinium enhancement (LGE) and right ventricular (RV) hypertrophy in HCM.Methods41 patients with HCM, 21 patients with HHD and 20 controls were studied. Peak filling rate (PFR), time to peak filling (TPF), MLVWT and LVMI were measured using CMR. LGE and RV morphology were assessed in HCM patients.ResultsMLVWT correlated with TPF in HCM (r = 0.38; p = 0.02), HHD (r = 0.58; p = 0.01) and controls (r = 0.54; p = 0.01); correlation between MLVWT and TPF was weaker in HCM than HHD. LVMI did not correlate with diastolic function. In HCM, LGE extent correlated with MLVWT (τ = 0.41; p = 0.002) and with TPF (τ = 0.29; p = 0.02). The HCM patients with RV hypertrophy had higher MLVWT (p < 0.001) and TPF (p = 0.03) than patients without RV hypertrophy.ConclusionMLVWT correlates with diastolic function (TPF) in HCM, HHD and controls. LVMI did not show significant correlation with TPF. The diastolic dysfunction in HCM is not entirely explained by wall thickening. LGE and RV involvement are associated with worse LV diastolic function, suggesting that these may be markers of more severe underlying myocardial disarray and fibrosis that contribute to diastolic dysfunction.     

Prediction of cardiovascular events in pre-dialysis chronic kidney disease patients with normal SPECT myocardial perfusion imaging

PurposePatients with normal stress myocardial perfusion imaging (MPI) results generally have an excellent prognosis with <1% cardiovascular events/year. Chronic kidney disease (CKD) is an established risk factor for cardiovascular events. However, the estimated glomerular filtration rate (eGFR) varies considerably among patients with CKD. We evaluated the prognostic value of eGFR for patients with CKD who did not undergo hemodialysis and had no evidence of coronary artery disease (CAD).Methods and subjectsPatients with CKD (n = 108; 58 males; mean age: 74 years) with no CAD [no previous CAD and normal stress MPI results; summed stress score (SSS) <4] and with no history of hemodialysis were followed-up (mean duration: 24 months). CKD was defined by eGFR of <60 ml/min/1.73 m² and/or persistent proteinuria. Cardiovascular events included cardiac death, non-fatal myocardial infarction, and unstable angina.ResultsCardiovascular events were observed in 8 patients with CKD (7%). The following were determined as significant predictors of these events: age (hazard ratio = 1.14; p = 0.019), hemoglobin levels (hazard ratio = 0.69; p = 0.021), eGFR (hazard ratio = 0.94; p = 0.008), SSS (hazard ratio = 2.31; p = 0.012), and summed difference score (hazard ratio = 2.33; p = 0.014).ConclusionsPatients with CKD and with no previous CAD and normal stress MPI results (SSS < 4) may not exhibit an excellent cardiovascular prognosis. Further, a lower eGFR and stress MPI results may be the predictors of cardiovascular events. Thus, patients with a lower eGFR and/or normal stress MPI results (SSS < 4) may require continuous follow-up.     

Prediction of atrial fibrillation after ischemic stroke using P-wave signal averaged electrocardiography

BackgroundAtrial fibrillation (AF) is highly prevalent in patients with ischemic stroke, but the diagnosis is often difficult.MethodsThis study consisted of 68 stroke patients in sinus rhythm without history of AF. All patients underwent P-wave signal-averaged electrocardiography (P-SAECG), echocardiography, 24-h Holter monitoring, and measurement of plasma B-type natriuretic peptide (BNP) concentrations at admission.ResultsAn abnormal P-SAECG was found in 34 of 68 stroke patients. In the follow-up period of 11 ± 4 months, AF developed in 17 patients (AF group). The remaining 51 patients were classified as the non-AF group. The prevalence of atrial late potentials (ALP) on P-SAECG, and the number of premature atrial contractions (PACs) were significantly higher in the AF group than those in the non-AF group (88.2% vs 37.3%; p < 0.001, 149 ± 120 vs 79 ± 69; p = 0.030, respectively). However, there were no significant differences in age, left atrial dimension, or BNP concentrations between both groups. Cox proportional hazards analysis revealed that the presence of ALP (risk ratio 11.15; p = 0.002) and frequent PACs (more than 100/24 h) (risk ratio 4.53; p = 0.007) had significant correlation to the occurrence of AF.ConclusionsALP may be a novel predictor of AF in stroke patients. P-SAECG should be considered in stroke of undetermined etiology.     

Elevated left ventricular filling pressure estimated by E/E′ ratio after exercise predicts development of new-onset atrial fibrillation independently of left atrial enlargement among elderly patients without obvious myocardial ischemia

ObjectiveTo determine whether elevated left ventricular (LV) filling pressure estimated by raised Doppler E velocity to tissue Doppler E′ velocity ratio (E/E′) after exercise is associated with increased risk of new-onset atrial fibrillation (AF) in non-ischemic elderly patients.BackgroundPrognostic importance of exercise induced LV diastolic dysfunction remains uncertain.Patients and methodsWe studied 147 elderly patients (73 ± 5 years) who underwent treadmill stress echocardiography. Patients with exercise induced LV wall motion abnormality were not included. Doppler and tissue Doppler measurements were done before treadmill exercise and immediately after the post-stress image acquisition, and E/E′ ratio was measured. Raised E/E′ was defined as E/E′ ≥ 15, and left atrial (LA) enlargement was defined as LA volume index ≥ 34 ml/m². Using Cox proportional hazards regression analysis, predictor of new-onset AF was determined. Using Kaplan–Meier analysis, we evaluated association between raised post-exercise E/E′ or LA enlargement with new-onset AF.ResultsDuring the follow-up period (median = 67 months), there were 25 new-onset AF. Cox proportional hazards regression analysis demonstrated that male gender [hazard ratio (HR) 3.294; p = 0.0117], LA enlargement (HR 3.576; p = 0.0017), and raised post-exercise E/E′ (HR 3147; p = 0.0068) were the best predictors of new-onset AF. Kaplan–Meier survival plot demonstrated that patients with both LA enlargement and raised post-exercise E/E′ developed new-onset AF most frequently. There was no significant difference in outcome between patients with isolated raised post-exercise E/E′ or isolated LA enlargement.ConclusionsRaised E/E′ ratio after exercise provides significant prognostic information for predicting new-onset AF in non-ischemic elderly patients. This prognostic value of raised post-exercise E/E′ is independent of and incremental to the LA enlargement.     

Evaluation of early direct current cardioversion for maintenance of sinus rhythm in rheumatic atrial fibrillation following successful balloon mitral valvotomy

BackgroundPatients with rheumatic mitral stenosis (MS) and atrial fibrillation (AF) are at risk for thromboembolism and restoration of sinus rhythm (SR) may be the preferred strategy. Percutaneous balloon mitral valvotomy (PBMV) improves hemodynamics, but may not be enough to restore SR.MethodsProspective randomized study aimed at evaluating efficacy of early direct current cardioversion (DCCV) following successful PBMV in patients with long-standing AF. Group 1 (n = 20) had patients of rheumatic MS with AF who underwent successful PBMV. Group 2 (n = 15) patients were DC cardioverted and administered oral Amiodarone for 6 weeks. Primary endpoint was maintenance of SR after 6 months. Secondary endpoints were functional capacity, number of embolic episodes, adverse drug effects, and all-cause mortality.ResultsIn Group 2, all patients underwent successful cardioversion. At a mean follow-up of 7.6 months, 95% in Group 1 were in AF. In Group 2, 87% patients were in SR and 13% had reverted to AF. Difference in rate of SR was 0.82 (95% CI 0.2, 1.01) (p = 0.001), with relative risk of 7.1 (1.95, 25.9, 95% CI, p = 0.001) for patients to be in AF who underwent only successful PBMV, i.e. Group 1. There was significant improvement in quality of life (SF36) score in Group 2 (p = 0.001), with no deaths, stroke, or adverse drug effects in either group.ConclusionIn patients with rheumatic MS and AF, early DCCV and a short-duration oral Amiodarone, following successful PBMV, may be a reasonable strategy to attain long-term SR.     

Assessment of clinical factors associated with a successful catheter ablation outcome in younger patients with atrial fibrillation

BackgroundCatheter ablation is now an alternative approach to antiarrhythmic drug therapy for patients with symptomatic atrial fibrillation (AF). We focused on younger patients in whom the prevalence of AF is low, and we sought clinical factors associated with unsuccessful ablation outcomes.Methods and resultsAmong 1983 consecutive symptomatic patients who underwent AF ablation procedures, 95 patients (4.8%), age ≤ 40 years, were prospectively included. Of them, 64 had paroxysmal AF, and the remaining 31 had persistent AF. All patients underwent pulmonary vein isolation and cavotricuspid isthmus ablation. When AF recurred, redo ablations were performed if the patients desired. The mean number of ablation procedures was 1.3 ± 0.6 times per patient. During the follow-up of 40 [27.8–49.6] months, sinus rhythm was maintained in 86 patients (90.5%) without any antiarrhythmic drugs, but not in the remaining 9 patients (9.5%). Low body mass index (BMI) and persistent AF were associated with unsuccessful ablation procedures. In multivariate logistic regression analysis, a low BMI had the most significant value, with an odds ratio of 7.33 (p = 0.022). The receiver operating characteristic curve demonstrated a BMI cut point of 22.1 kg/m², with an area under the curve of 0.773.ConclusionIn symptomatic younger AF patients, a low BMI was an independent clinical factor for unsuccessful AF ablation outcomes.     

Arrhythmia recurrence in patients following cardiac surgery with concomitant therapy of atrial fibrillation – Experience of our cardiac center

IntroductionSurgical treatment of atrial fibrillation (AF) is a common and time-proven treatment method for this type of arrhythmias both as a separate procedure and as a procedure related to cardiac surgery for another indication (concomitant procedure). Patients experience arrhythmia recurrence despite highly efficient surgical treatment. These arrhythmias are often resistant to pharmacological treatment (due to an extensive fibrous substrate); therefore, electroanatomical mapping accompanying catheter ablation is significantly more effective. The arrhythmogenic fibrous substrate is a result of both a primary cardiac disease (an underlying disease causing atrial dilation) and surgical intervention (incision, cannula insertion sites, MAZE lines with a renewed spread of electrical signal in these blocks).Method and patientsElectroanatomical mapping and ablation were performed in 92 patients with arrhythmia recurrence following concomitant surgical treatment for AF between January 2010 and November 2015. The Cox maze procedure was performed using a disposable cryoablation catheter. The heart rhythm in patients following radiofrequency ablation procedure was monitored in half-year intervals (24-h Holter ECG, 7-day loop recorder, in some patients also by means of implanted pacemakers or implantable loop recorders). The average left atrial size (PLAX) was 50 mm, 59% of patients underwent mitral valve surgery, 54% of patients had tricuspid valve surgery, 16% were operated for congenital developmental disorders, in 17% of patients, repeated cardiac surgery was performed. The above-mentioned facts show that these are patients with an extensive arrhythmogenic substrate.ResultsThe Cox maze procedure resulted in an extensive fibrous arrhythmogenic substrate in the atrium (arrhythmia recurrence following the maze procedure is more often regular atrial tachycardias while AF is predominant among arrhythmias for which the maze procedure was indicated). All patients had a follow-up visit after 12 months, 80% of patients presented for a follow-up visit after 24 months. Early recurrence after ablation (within 3 months following the procedure) was found in 21% of patients. Early recurrence after ablation was statistically significantly related to arrhythmia recurrence within 12 months (p = 0.003) and arrhythmia recurrence within 24 months (p = 0.003). 73% of patients had no recurrent AF or atrial tachycardia (AT) after 12 months and 53% after 24 months. A total of 146 arrhythmias were ablated, i.e. 1/3 of patients had more than 1 arrhythmia. These were persistent AF found in 24% of patients, paroxysmal AF seen in 13% of patients and regular AT detected in 53% of patients. More than one half of regular AT originated in LA (as perimitral atrial flutter in most cases). Remaining arrhythmias originated from the right atrium (as typical atrial flutter in half of the cases). 57% of patients had a renewed spread of signal in the mitral isthmus (ablation of the coronary sinus was necessary in 1/3 of patients). No domination in the number of reconnections was found for any of the pulmonary veins. The finding of a significantly reduced signal amplitude in the entire LA was associated with a higher risk of acute ablation failure (p = 0.001). Acute ablation failure was associated with a higher risk of arrhythmia recurrence after 12 months (p = 0.07). There was a trend of a higher AT incidence originating from the RA in patients who underwent surgery for a congenital heart defect (p = 0.06). The diagnosis of arterial hypertension was associated with a higher risk of arrhythmia recurrence (p = 0.13). The finding of persistent AF on ECG (compared to other findings, i.e. paroxysmal AF and regular AT) before ablation did not increase the risk of recurrence after ablation.ConclusionIn patients after cardiac surgery, catheterization performed to treat arrhythmia recurrence is a effective method of subsequent treatment, despite an extensive arrhythmogenic substrate. A rather large number of AT cases originate from the right atrium, in particular in patients after surgery for congenital heart defects. Patients with a significantly reduced signal in the larger part of the atrium due to an extensive arrhythmogenic substrate present the most complicated cases.     

Intolerance to physiologic pacing following upgrade of long term ventricular pacing: A drawback of routine upgrade

BackgroundUpgrade from VVI(R) to physiologic pacing offers benefit to patients with pacemaker syndrome (PMS). However, in asymptomatic patients with long term ventricular pacing little is known regarding potential early hazards related to the acute changes in hemodynamics following upgrade.MethodsData of 28 patients who underwent upgrade of VVI(R) pacing were retrospectively analyzed. Mean time of ventricular pacing to upgrade was 6.3 ± 2.7 years. Indications of upgrade included PMS (considered as necessary indication) in 9 patients, and unnecessary indications in 19 patients. Pacing was upgraded to DDD in 26 patients, VDD in 1 patient, and multisite pacing in 1 patient. Three-month follow up data were reviewed. Intolerance to upgrade was defined as worsening of (or new onset) symptoms, hospital admissions or deaths following uncomplicated upgrade procedures.ResultsEleven patients (39.3%) were intolerant to upgrade. Intolerance to upgrade included palpitations/dyspnea in 3 patients, hospitalization and death in 8 patients (1 patient with pulmonary congestion related to underlying mitral stenosis and 6 patients with newly diagnosed myocardial ischemia were hospitalized; two of whom died from acute ischemia, and 1 patient had out of hospital sudden death). Patients with intolerance to upgrade were older than other patients (p < 0.001), with more frequent unnecessary upgrades (p = 0.049), more rise in HR (p < 0.001), and more preexisting undiagnosed myocardial ischemia (p = 0.001). Univariate logistic regression analysis showed that age (p = 0.009) and HR increase (p = 0.004) were significant predictors for intolerance to upgrade.ConclusionsUnnecessary pacing upgrade may not be tolerated. Pacing upgrade is recommended to be individualized for selected patients.     

Right bundle branch block and ventricular septal fibrosis in patients with hypertrophic cardiomyopathy

BackgroundRight bundle branch block (RBBB) is associated with ventricular septal fibrosis in patients with hypertrophic cardiomyopathy (HCM) after alcohol septal ablation, but little data are available in HCM patients without a history of septal ablation.MethodsMagnetic resonance late gadolinium enhancement (LGE) was performed in 59 HCM patients with no history of alcohol septal ablation. The location and extent of LGE were examined in relation to electrocardiographic features including RBBB.ResultsLGE volume was higher in 7 HCM patients with RBBB (7.3 ± 7.4 g/cm) than in patients without RBBB (2.9 ± 7.4 g/cm, p = 0.016). LGE volume was positively correlated to QRS duration of RBBB (correlation coefficient = 0.93, p = 0.023). The diagnostic value of RBBB was highly specific for the detection of LGE in the ventricular septum, with sensitivity 21% and specificity 94%.ConclusionsThe presence of RBBB may be a simple marker for detecting ventricular septal fibrosis in HCM patients who had no history of alcohol septal ablation. Further studies are necessary to confirm our findings.     

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

IntroductionThe incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.MethodsWe conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.ResultsIn this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p < 0.001, unadjusted OR 6.03 (2.22–16.37), p < 0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02–1.11), p = 0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60–0.98), p = 0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37–22.72), p = 0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32–5.33), p = 0.006) were independent predictors of mortality.ConclusionAKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.     

Time to antibiotics administration and outcome in community-acquired pneumonia: Secondary analysis of a randomized controlled trial

BackgroundThe association between early antibiotic administration and outcomes remains controversial in patients hospitalized for community-acquired pneumonia.MethodsWe performed a secondary analysis of a randomized controlled trial comparing two antibiotic treatment strategies for patients hospitalized for moderately severe CAP. The univariate and multivariate associations between time to antibiotic administration (TTA) and time to clinical stability were assessed using a Cox proportional hazard model. Secondary outcomes were death, intensive care unit admission and hospital readmission up to 90 days.Results371 patients (mean age 76 years, CURB-65 score ≥ 2 in 52%) were included. Mean TTA was 4.35 h (SD 3.48), with 58.5% of patients receiving the first antibiotic dose within 4 h.In multivariate analysis, number of symptoms and signs (HR 0.876, 95% CI 0.784–0.979, p = 0.020), age (HR 0.986, 95% CI 0.975–0.996, p = 0.007), initial heart rate (HR 0.992, 95% CI 0.986–0.999, p = 0.023), and platelets count (HR 0.998, 95% CI 0.996–0.999, p = 0.004) were associated with a reduced probability of reaching clinical stability. The association between TTA and time to clinical stability was not significant (HR 1.009, 95% CI 0.977–1.042, p = 0.574). We found no association between TTA and the risk of intensive care unit admission, death or readmission up to 90 days after the initial admission.ConclusionIn patients hospitalized for moderately severe CAP, a shorter time to antibiotic administration was not associated with a favorable outcome. These findings support the current recommendations that do not assign a specific time frame for antibiotics administration.     

Thoracoscopic radiofrequency ablation for lone atrial fibrillation: Box-lesion technique

BackgroundWe report the feasibility and outcomes of box-lesion ablation technique to treat stand-alone atrial fibrillation (AF).MethodsThere were 31 patients with a mean age of 63.3 ± 8.4 years who underwent bilateral totally thoracoscopic ablation of symptomatic paroxysmal AF (n = 8; 25.8%) and long-standing persistent AF (n = 23; 75.2%). The box-lesion procedure included bilateral pulmonary vein and left atrial posterior wall ablation using irrigated bipolar radiofrequency with documentation of conduction block.ResultsThere were no intra- or perioperative ablation-related complications. There was no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 152.1 ± 36.7 min and the postoperative average length of stay was 6.26 ± 1.24 days. At discharge, 29 patients (93.5%) were in sinus rhythm. Median follow-up time was 20.4 ± 8.3 months. At three months postsurgery, 20 patients of 30 (66.6%) were free from AF without the need of antiarrhythmic drugs. Six patients (20%) underwent catheter reablation. Twenty-three patients (76.6%) were in sinus rhythm at one year after the last performed ablation (surgical ablation or catheter reablation).ConclusionThe thoracoscopic box-lesion ablation procedure is a safe, effective, and minimally invasive method for the treatment of isolated (lone) AF. This procedure provided excellent short-term freedom from AF.     

Bi-directional block is superior to non-inducibility in predicting freedom from atrial fibrillation after pulmonary vein isolation

BackgroundThere is variability in the endpoints used with the different approaches to pulmonary vein (PV) isolation. Elimination of PVP recorded inside the targeted PV antrum indicates inlet block and is considered the 1st indicator of a successful PV isolation, however this may not be sufficient to predict non recurrence of AF.AimTo compare the efficacy of two end points, pulmonary vein (PV) entrance block with non-inducibility (NI) Vs achieving PV bi-directional (BD) block in terms of freedom of AF after PV isolation (PVI) for paroxysmal/persistent atrial fibrillation (AF).MethodWe included 58 consecutive patients (pts) who underwent PVI for symptomatic AF. In all pts, the end point of ablation was abolishing PV potentials (PVP) in the PVs followed by testing for bidirectional block (defined by both loss of PVP and failure to conduct to the LA by pacing at 10 mA and from 10 bipolar pairs of electrodes on a circular catheter positioned at the entrance of the PV) and/or NI of AF (by burst atrial pacing).ResultsBidirectional block was achieved in 40 patients (69%) while Non inducibility was achieved in 36 (58.5%) patients with an overlap of achieving both endpoints in 18 (31%) patients. Over a follow up period of 17 ± 11 months, 34 pts (85%) in group I Vs 22 (62%) in group II were free of AF. Correlation showed significant relation between BD block (OR = 8.07, P = 0.004) Vs NI of AF post-PVI (OR = 2.8, P = 0.095) in predicting freedom from AF at follow up.ConclusionAchieving BD block improves results and may predict maintenance of sinus rhythm more than NI of AF after PVI. It can be used as an electrophysiological endpoint alternative to or in conjunction with non inducibility in AF ablation procedures.     

Brecha de sexo en la miocardiopatía hipertrófica

Introduction and objectivesKey sex differences have been explored in multiple cardiac conditions. However, sex impact in hypertrophic cardiomyopathy outcome is unclear. We aimed to characterize sex impact in overall and cardiovascular (CV) mortality in a nationwide hypertrophic cardiomyopathy registry.MethodsWe analyzed 1042 adult patients, 429 (41%) women, from a national registry of hypertrophic cardiomyopathy, with mean age at diagnosis 53 ± 16 years and a mean follow-up of 65 ± 75 months. At baseline, women were older (56 ± 16 vs 51 ± 15 years; P < .001), more symptomatic (56.4%, vs 51.7%; P < .001) and had more heart failure (42.0% vs 24.2%. P < .001), diastolic dysfunction (75.2% vs 64.1% P = .001), moderate/severe mitral regurgitation (33.4% vs 21.7%; P = .003), and higher B-type natriuretic peptide levels (920 [366-2412] mg/dL vs 487 [170-1087] mg/dL; P < .001). Women underwent fewer stress tests and cardiac magnetic resonance.ResultsKaplan-Meier survival curves showed higher overall (8.4% vs 5.0%; P = .026) and CV mortality (5.5% vs 2.2%; P = .004) in women. Cox proportional hazard regression showed that female sex was an independent predictor of overall (HR, 2.05; 95%CI, 1.11–3.78; P = .021) and CV mortality (HR, 3.16; 95%CI, 1.25–7.99; P = .015). Women had more heart failure-related death (2.6% vs 0.8%, P = .024). Despite similar sudden cardiac death (SCD) risk, women received fewer implantable cardioverter-defibrillators (10.9% vs 15.6%; P = .032) and, in patients without cardioverter-defibrillators, SCD occurred more commonly in women (1.8% vs 0.4%; P = .031).ConclusionsIn this nationwide registry, female sex was an independent predictor of overall and CV-related death, with more heart failure-related death. Despite similar SCD risk, women were undertreated with implantable cardioverter-defibrillators. These data highlight the need for an improved clinical approach in women with HCM.