Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A systematic review and meta‐analysis

BackgroundAtrial fibrillation (AF) is the most common cardiac rhythm disturbance and leads to morbidity and mortality. Peripheral artery disease (PAD) is associated with atherosclerotic risk factors and always classified as a vascular disease and deemed to be a bad complication of AF. In patients with AF, the risk and prognostic value of PAD have not been estimated comprehensively.HypothesisPAD is associated with all‐cause mortality, cardiovascular (CV) mortality, and other outcomes in patients with AF.MethodsWe searched PubMed, Embase, and Cochrane Library databases for prospective studies published before April 2021 that provided outcomes data on PAD in confirmed patients with AF. Heterogeneity was estimated using the I ² statistic. The fixed‐effects model was used for low to moderate heterogeneity studies, and the random‐effects model was used for high heterogeneity studies.ResultsEight prospective studies (Newcastle‐Ottawa score range, 7–8) with 39 654 patients were enrolled. We found a significant association between PAD and all‐cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.25–1.62; p < .001), CV mortality (HR, 1.64; 95% CI, 1.32–2.05; p < .001) and MACE (HR, 1.75; 95% CI, 1.38–2.22; p < .001) in patients with AF. No significant relationship was found in major bleeding (HR, 1.22; 95% CI, 0.95–1.57; p = 0.118), myocardial infarction (MI) (HR, 2.07; 95% CI, 1.17–3.67; p = .038), and stroke (HR, 1.14; 95% CI, 0.87–1.50, p = 0.351).ConclusionsPAD is associated with an increased risk of all‐cause mortality, CV mortality, and MACE in patients with AF. However, no significant association was found with major bleeding, MI, and stroke.     

Comparison of prognosis and outcomes of catheter ablation versus drug therapy in patients with atrial fibrillation and stable coronary artery disease: A prospective propensity‐score matched cohort study

BackgroundAtrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist.HypothesisTo investigate the prognosis of catheter ablation versus drug therapy in patients with AF and SCAD.MethodsIn total, 25 512 patients with AF in the Chinese AF Registry between 2011 and 2019 were screened for SCAD. 815 patients with AF and SCAD underwent catheter ablation therapy were matched with patients by drug therapy in a 1:1 ratio. Primary end point was composite of thromboembolism, coronary events, major bleeding, and all‐cause death. The secondary endpoints were each component of the primary endpoint and AF recurrence.ResultsOver a median follow‐up of 45 ± 23 months, the patients in the catheter ablation group had a higher AF recurrence‐free rate (53.50% vs. 18.41%, p < .01). In multivariate analysis, there was no significant difference between the strategy of catheter ablation and drug therapy in primary composite end point (adjusted HR 074, 95%CI 0.54–1.002, p = .0519). However, catheter ablation was associated with fewer all‐cause death independently (adjusted HR 0.36, 95%CI 0.22–0.59, p < .01). In subgroup analysis, catheter ablation was an independent risk factor for all‐cause death in the high‐stroke risk group (adjusted HR 0.39, 95%CI 0.23–0.64, p < .01), not in the low‐medium risk group (adjusted HR 0.17, 95%CI 0.01–2.04, p = .17).ConclusionsIn the patients with AF and SCAD, catheter ablation was not independently associated with the primary composite endpoint compared with drug therapy. However, catheter ablation was an independent protective factor of all‐cause death     

Survival benefit of overweight patients undergoing MitraClip® procedure in comparison to normal‐weight patients

BackgroundThe number of MitraClip® implantations increased significantly in recent years. Data regarding the impact of weight class on survival are sparse.HypothesisWe hypothesized that weight class influences survival of patients treated with MitraClip® implantation.MethodsWe investigated in‐hospital, 1‐year, 3‐year, and long‐term survival of patients successfully treated with isolated MitraClip® implantation for mitral valve regurgitation (MR) (June 2010–March 2018). Patients were categorized by weight classes, and the impact of weight classes on survival was analyzed.ResultsOf 617 patients (aged 79.2 years; 47.3% females) treated with MitraClip® implantation (June 2010–March 2018), 12 patients were underweight (2.2%), 220 normal weight (40.1%), 237 overweight (43.2%), and 64 obesity class I (11.7%), 12 class II (2.2%), and 4 class III (0.7%). Preprocedural Logistic EuroScore (21.1 points [IQR 14.0–37.1]; 26.0 [18.5–38.5]; 26.0 [18.4–39.9]; 24.8 [16.8–33.8]; 33.0 [25.9–49.2]; 31.6 [13.1–47.6]; p = .291) was comparable between groups. Weight class had no impact on in‐hospital death (0.0%; 4.1%; 1.5%; 0.0%; 7.7%; 0.0%; p = .189), 1‐year survival (75.0%; 72.0%; 76.9%; 75.0%; 75.0%; 33.3%; p = .542), and 3‐year survival (40.0%; 36.8%; 38.2%; 48.6%; 20.0%; 33.3%; p = .661). Compared to normal weight, underweight (hazard ratio [HR]: 1.35 [95% confidence interval [CI]: 0.65–2.79], p = .419), obesity‐class I (HR: 0.93 [95% CI: 0.65–1.34], p = .705), class II (HR: 0.39 [95% CI: 0.12–1.24], p = .112), and class III (HR: 1.28 [95% CI: 0.32–5.21], p = .726) did not affect long‐term survival. In contrast, overweight was associated with better survival (HR: 1.32 [95% CI: 1.04–1.68], p = .023).ConclusionOverweight affected the long‐term survival of patients undergoing MitraClip® implantation beneficially compared to normal weight.     

Prognostic implications of ST‐segment elevation in lead aVR in patients with acute coronary syndrome: A meta‐analysis

BackgroundST‐segment elevation (STE) in lead aVR is a useful tool in recognizing patients with left main or left anterior descending coronary obstruction during acute coronary syndrome (ACS). The prognostic implication of STE in lead aVR on outcomes has not been established.MethodsWe performed a systematic search for clinical studies about STE in lead aVR in four databases including PubMed, EMBASE, Cochrane Library, and Web of Science. Primary outcome was in‐hospital mortality. Secondary outcomes included in‐hospital (re)infarction, in‐hospital heart failure, and 90‐day mortality.ResultsWe included 7 studies with a total of 7,700 patients. The all‐cause in‐hospital mortality of patients with STE in lead aVR during ACS was significantly higher than that of patients without STE (OR: 4.37, 95% CI 1.63 to 11.68, p = .003). Patients with greater STE (>0.1 mV) in lead aVR had a higher in‐hospital mortality when compared to lower STE (0.05–0.1 mV) (OR: 2.00, 95% CI 1.11–3.60, p = .02), However, STE in aVR was not independently associated with in‐hospital mortality in ACS patients (OR: 2.72, 95% CI 0.85–8.63, p = .09). The incidence of in‐hospital myocardial (re)infarction (OR: 2.77, 95% CI 1.30–5.94, p = .009), in‐hospital heart failure (OR: 2.62, 95% CI 1.06–6.50, p = .04), and 90‐day mortality (OR: 10.19, 95% CI 5.27–19.71, p < .00001) was also noted to be higher in patients STE in lead aVR.ConclusionsThis contemporary meta‐analysis shows STE in lead aVR is a poor prognostic marker in patients with ACS with higher in‐hospital mortality, reinfarction, heart failure and 90‐day mortality. Greater magnitude of STE portends worse prognosis. Further studies are needed to establish an independent predictive role of STE in aVR for these adverse outcomes.     

Association of non‐invasive electrocardiographic risk factors with left ventricular systolic function in post‐myocardial infarction patients with mildly reduced or preserved ejection fraction: Insights from the PRESERVE‐EF study

BackgroundElectrocardiographic non‐invasive risk factors (NIRFs) have an important role in the arrhythmic risk stratification of post‐myocardial infarction (post‐MI) patients with preserved or mildly reduced left ventricular ejection fraction (LVEF). However, their specific relation to left ventricular systolic function remains unclear. We aimed to evaluate the association between NIRFs and LVEF in the patients included in the PRESERVE‐EF trial.MethodsWe studied 575 post‐MI ischemia‐free patients with LVEF≥40% (mean age: 57.0 ± 10.4 years, 86.2% men). The following NIRFs were evaluated: premature ventricular complexes, non‐sustained ventricular tachycardia (NSVT), late potentials (LPs), prolonged QTc, increased T‐wave alternans, reduced heart rate variability, and abnormal deceleration capacity with abnormal turbulence.ResultsThere was a statistically significant relationship between LPs (Chi‐squared = 4.975; p < .05), nsVT (Chi‐squared = 5.749, p < .05), PVCs (r= −.136; p < .01), and the LVEF. The multivariate linear regression analysis showed that LPs (p = .001) and NSVT (p < .001) were significant predictors of the LVEF. The results of the multivariate logistic regression analysis indicated that LPs (OR: 1.76; 95% CI: 1.02–3.05; p = .004) and NSVT (OR: 2.44; 95% CI: 1.18–5.04; p = .001) were independent predictors of the mildly reduced LVEF: 40%–49% versus the preserved LVEF: ≥50%.ConclusionLate potentials and NSVT are independently related to reduced LVEF while they are independent predictors of mildly reduced LVEF versus the preserved LVEF. These findings may have important implications for the arrhythmic risk stratification of post‐MI patients with mildly reduced or preserved LVEF.     

Left atrial appendage size is a marker of atrial fibrillation recurrence after radiofrequency catheter ablation in patients with persistent atrial fibrillation

IntroductionThere are no consistently confirmed predictors of atrial fibrillation (AF) recurrence after catheter ablation. Therefore, we aimed to study whether left atrial appendage volume (LAAV) and function influence the long‐term recurrence of AF after catheter ablation, depending on AF type.MethodsAF patients who underwent point‐by‐point radiofrequency catheter ablation after cardiac computed tomography (CT) were included in this analysis. LAAV and LAA orifice area were measured by CT. Uni‐ and multivariable Cox proportional hazard regression models were performed to determine the predictors of AF recurrence.ResultsIn total, 561 AF patients (61.9 ± 10.2 years, 34.9% females) were included in the study. Recurrence of AF was detected in 40.8% of the cases (34.6% in patients with paroxysmal and 53.5% in those with persistent AF) with a median recurrence‐free time of 22.7 (9.3–43.1) months. Patients with persistent AF had significantly higher body surface area‐indexed LAV, LAAV, and LAA orifice area and lower LAA flow velocity, than those with paroxysmal AF. After adjustment left ventricular ejection fraction (LVEF) <50% (HR = 2.17; 95% CI = 1.38–3.43; p < .001) and LAAV (HR = 1.06; 95% CI = 1.01–1.12; p = .029) were independently associated with AF recurrence in persistent AF, while no independent predictors could be identified in paroxysmal AF.ConclusionThe current study demonstrates that beyond left ventricular systolic dysfunction, LAA enlargement is associated with higher rate of AF recurrence after catheter ablation in persistent AF, but not in patients with paroxysmal AF.     

Atrial fibrillation bleeding risk and prediction while treated with direct oral anticoagulants in warfarin‐naïve or warfarin‐experienced patients

BackgroundIn patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOAC), bleeding risk scores provide only modest discrimination for major or intracranial bleeding. However, warfarin experience may impact HAS‐BLED  (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly) score performance in patients evaluated for DOACs, as HAS‐BLED was derived and validated in warfarin cohorts.MethodsWe performed a retrospective cohort study of patients prescribed DOAC for AF in the Veterans Health Administration between 2010 and 2017. We determined modified HAS‐BLED score discrimination and calibration for bleeding, for patients treated with DOAC, stratified by prior warfarin exposure. We also determined the association between DOAC–warfarin‐naïve status to bleeding (nonintracranial and intracranial) with DOAC–warfarin‐experienced patients as reference.ResultsThe DOAC analysis cohort included 100, 492 patients with AF (age [mean ± SD]: 72.9 ± 9.6 years; 1.7% female; 90.1% White), of which 26, 760 patients (26.6%) and 73, 732 patients (73.4%) were warfarin experienced or naïve, respectively. HAS‐BLED discrimination for bleeds was modest for patients treated with DOAC, regardless of prior warfarin experience (concordance statistics: 0.53–0.59). For DOAC–warfarin‐naïve patients, as compared to DOAC–warfarin‐experienced patients, adjusted risk of intracranial bleeding was lower, while risk of nonintracranial bleeding was higher ( intracranial bleeding propensity adjusted with inverse probability of treatment weights [IPTWs]: hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.78–0.95, p = .0040) (nonintracranial bleeding propensity adjusted with IPTW: HR: 1.15, 95% CI: 1.11–1.19, p < .0001).ConclusionPatients’ modified HAS‐BLED score at the time of DOAC initiation, regardless of prior warfarin use, provided only modest discrimination for intracranial and nonintracranial bleeds. These data argue against maintaining DOAC eligible patients on warfarin therapy regardless of modified HAS‐BLED score.     

QRS fragmentation is associated with increased risk of ventricular arrhythmias in high‐risk patients; Data from the SMASH 1 Study

IntroductionQRS fragmentation (fQRS), defined as the presence of additional spikes within the QRS complex, has been associated with myocardial conduction abnormalities and arrhythmogenicity.ObjectiveWe aimed to assess whether fQRS is associated with incident ventricular arrhythmias (VA) in high‐risk patients treated with implantable cardioverter‐defibrillator (ICD) for primary and secondary prevention.MethodsIn a prospective observational multicenter study, we included 495 patients treated with ICD. fQRS was analyzed according to previously validated criteria, by two physicians blinded for outcome data. Incident VA were obtained from ICD recordings.ResultsECG recordings interpretable for fQRS were available in 459 patients (93%), aged 66 ± 12 years with left ventricular ejection fraction 40% ± 13%. fQRS was present in 52 patients (11%) with comparable baseline characteristics to patients without fQRS, except higher age, higher prevalence of coronary artery disease (CAD), lower prevalence of cardiomyopathy, and more frequently a secondary prevention ICD indication. Among patients with native QRS, those with fQRS had similar QRS duration and axis to those without fQRS. During 3.1 ± 0.7 years follow‐up, 126 patients (28%) had ≥1 VA . fQRS was associated with increased risk of VA (HR 3.41 [95% CI 2.27–5.13], p < .001), which persisted after adjusting for age, gender, sex, BMI, CAD, heart failure, renal function, ICD indication, QRS duration, QRS axis, Q waves, and bundle branch block. fQRS was more strongly associated with VA in patients with a primary (HR 6.05 [95% CI 3.16–11.60]) versus secondary (HR 2.39 [95% CI 1.41–4.04]) ICD indication (p‐for‐interaction = .047).ConclusionsfQRS is associated with threefold increased risk of VA in high‐risk patients, independent of established risk factors.     

High‐density lipoprotein cholesterol levels are associated with major adverse cardiovascular events in male but not female patients with hypertension

BackgroundThe relationship between high‐density lipoprotein cholesterol (HDL‐C) levels and major adverse cardiovascular events (MACEs) in hypertensive patients of different sexes is unclear.HypothesisSex differences in the relationship between HDL‐C levels and the risk of MACEs among hypertensive patients.MethodsWe performed a post‐hoc analysis of data obtained from the Systolic Blood Pressure Intervention Trial (SPRINT) and explored sex‐based differences in the relationship between HDL‐C levels and MACEs among hypertensive patients using Cox proportional hazards regression.ResultsA total of 9323 hypertensive patients (6016 [64.53%] men and 3307 [35.47%] women) were assessed using SPRINT data. MACEs occurred in 395 (6.57%) men and 166 (5.02%) women after a mean follow‐up of 3.26 years. When HDL‐C levels were used as a continuous covariate, each 10 mg/dl increase in HDL‐C levels decreased the risk of MACEs in men (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.70–0.88; p < .0001). However, HDL‐C levels were not associated with MACEs in female hypertensive patients (HR, 1.02; 95% CI, 0.89–1.16; p = .7869). Compared with those in the first quartile, MACEs in the fourth quartile had the lowest risk among male patients (HR, 0.58; 95% CI, 0.41–0.82; p = .0023). Female patients in the fourth quartile of HDL‐C levels had an HR of 1.09 for MACEs (95% CI, 0.62–1.93; p = .7678). HDL‐C levels were not associated with the risk of MACEs among females.ConclusionAmong elderly hypertensive patients, higher HDL‐C levels were associated with a lower MACE incidence in men but not in women. Unique identifier: {"type":"clinical-trial","attrs":{"text":"NCT01206062","term_id":"NCT01206062"}}NCT01206062.     

T‐wave heterogeneity in standard resting 12‐lead ECGs is associated with 90‐day cardiac mortality in women following emergency department admission: A nested case–control study

BackgroundWe investigated whether T‐wave heterogeneity (TWH) can identify patients who are at risk for near‐term cardiac mortality.MethodsA nested case–control analysis was performed in the 888 patients admitted to the Emergency Department (ED) of our medical center in July through September 2018 who had ≥2 serial troponin measurement tests within 6 hr for acute coronary syndrome evaluation to rule‐in or rule‐out the presence of acute myocardial infarction. Patients who died from cardiac causes during 90 days after ED admission were considered cases (n = 20; 10 women) and were matched 1:4 on sex and age with patients who survived during this period (n = 80, 40 women). TWH, that is, interlead splay of T waves, was automatically assessed from precordial leads by second central moment analysis.ResultsTWH_V4‐6 was significantly elevated at ED admission in 12‐lead resting ECGs of female patients who died of cardiac causes during the following 90 days compared to female survivors (100 ± 14.9 vs. 40 ± 3.6 µV, p < .0001). TWH_V4‐6 generated areas under the receiver‐operating characteristic (ROC) curve (AUC) of 0.933 in women (p < .0001) and 0.573 in men (p = .4). In women, the ROC‐guided 48‐µV TWH_V4‐6 cut point for near‐term cardiac mortality produced an adjusted odds ratio of 121.37 (95% CI: 2.89–6,699.84; p = .02) with 100% sensitivity and 82.5% specificity. In Kaplan–Meier survival analysis, TWH_V4‐6 ≥ 48 µV predicted cardiac mortality in women during 90‐day follow‐up with a hazard ratio of 27.84 (95% CI: 7.29–106.36, p < .0001).ConclusionElevated TWH_V4‐6 is associated with near‐term cardiac mortality among women evaluated for acute coronary syndrome.     

Percutaneous coronary intervention in insulin‐treated diabetic patients: A meta‐analysis

BackgroundThis meta‐analysis of randomized controlled trials (RCTs) compared long‐term adverse clinical outcomes of percutaneous coronary intervention (PCI) in insulin‐treated diabetes mellitus (ITDM) and non‐ITDM patients.MethodsThis is a meta‐analysis study. The PubMed and Embase databases were searched for articles on long‐term adverse clinical outcomes of PCI in ITDM and non‐ITDM patients. The risk ratios (RR) and 95% confidence intervals (CI) were calculated.ResultsA total of 11 related RCTs involving 8853 DM patients were included. Compared with non‐ITDM patients, ITDM patients had significantly higher all‐cause mortality (ACM) (RR = 1.52, 95% CI: 1.25–1.85, p _{heterogeneity} = .689, I ² = 0%), major adverse cardiac and cerebrovascular events (MACCE) (RR = 1.35, 95% CI: 1.18–1.55, p _{heterogeneity} = .57, I ² = 0%), myocardial infarction (MI) (RR = 1.41, 95% CI: 1.16–1.72, p _{heterogeneity} = .962, I ² = 0%), and stent thrombosis (ST) (RR = 1.75, 95% CI: 1.23–2.48, p _{heterogeneity} = .159, I ² = 32.4%). No significant difference was found in the target lesion revascularization (TLR) and target vessel revascularization (TVR) between the ITDM and non‐ITDM groups.ConclusionsThe results showed that ITDM patients had significantly higher ACM, MACCE, MI, and ST, compared with non‐ITDM patients.     

Meta‐analysis of cryoballoon ablation versus antiarrhythmic drugs as initial therapy for symptomatic atrial fibrillation

BackgroundThe optimal first‐line approach for patients with symptomatic atrial fibrillation (AF) remains unclear. We compared the efficacy and safety of cryoballoon ablation (CBA) and antiarrhythmic drugs (AADs) in the initial management of symptomatic AF.HypothesisCBA is superior to AAD as initial therapy for symptomatic AF.MethodsWe searched the EMBASE, PubMed, and Cochrane Library databases for randomized controlled trials (RCTs) that compared CBA with AAD as first‐line treatment for AF from the date of database establishment until March 18, 2021. The risk ratio (RR) with a 95% confidence interval (CI) was used as a measure of treatment effect.ResultsThree RCTs that enrolled 724 patients in total were included in this meta‐analysis. Majority of the patients were relatively young and had paroxysmal AF. CBA was associated with a significant reduction in the recurrence of atrial arrhythmia compared with AAD therapy, with low heterogeneity (RR, 0.59; 95% CI, 0.49–0.71; p < .00001; I ²  = 0%). There was a significant difference in the rate of symptomatic atrial arrhythmia recurrence (RR, 0.44; 95% CI, 0.29–0.65; p < .0001; I ²  = 0%); however, the rate of serious adverse events was similar between the two treatment groups (RR: 1.18; 95% CI: 0.71–1.97, p = .53; I ² = 0%). Transient phrenic nerve palsy occurred in four patients after the CBA procedure.ConclusionThe current meta‐analysis suggests that CBA is more effective than AAD as initial therapy in patients with symptomatic paroxysmal AF. Serious iatrogenic adverse events are uncommon in CBAs.     

Anxiety and prognosis of patients with myocardial infarction: A meta‐analysis

Although anxiety is highly prevalent after myocardial infarction (MI), but the association between anxiety and MI is not well established. This study aimed to provide an updated and comprehensive evaluation of the association between anxiety and short‐term and long‐term prognoses in patients with MI. Anxiety is associated with poor short‐term and long‐term prognoses in patients with MI. We performed a systematic search in the PubMed and Cochrane databases (January 2000–October 2020). The study endpoints were complications, all‐cause mortality, cardiac mortality, and/or major adverse cardiac events (MACEs). Pooled data were synthesized using Stata SE12.0 and expressed as risk ratios (RRs) and 95% confidence intervals (CIs). We included 9373 patients with MI from 16 published studies. Pooled analyses indicated a correlation between high anxiety and poor clinical outcomes (RR: 1.19, 95% CI: 1.13–1.26, p < .001), poor short‐term complications (RR: 1.23, 95% CI: 1.09–1.38, p = .001), and poor long‐term prognosis (RR: 1.27, 95% CI: 1.13–1.44, p < .001). Anxiety was also specifically associated with long‐term mortality (RR: 1.16, 95% CI: 1.01–1.33, p = .033) and long‐term MACEs (RR: 1.54, 95% CI: 1.26–1.90, p < .001). This study provided strong evidence that increased anxiety was associated with poor prognosis in patients with MI. Further analysis revealed that MI patients with anxiety had a 23% increased risk of short‐term complications and a 27% increased risk of adverse long‐term prognosis compared to those without anxiety.     

6‐year change in high sensitivity cardiac troponin T and the risk of atrial fibrillation in the Atherosclerosis Risk in Communities cohort

BackgroundCirculating high sensitivity cardiac troponin T (hs‐cTnT) is associated with incidence of atrial fibrillation (AF), but the association of changes in hs‐cTnT over time on incident AF has not been explored.HypothesisSix‐year increase in circulating hs‐cTnT will be associated with increased risk of AF and will contribute to improved prediction of incident AF.MethodsWe conducted a prospective cohort analysis of 8431 participants from the Atherosclerosis Risk in Communities (ARIC) study. hs‐cTnT change was categorized at visit 2 and 4 as undetectable (<5 ng/L), detectable (≥5 ng/L, <14 ng/L), or elevated (≥14 ng/L). We used Cox regression to examine the association between the combination of hs‐cTnT categories at two visits and incident AF. We also assessed the impact of adding absolute hs‐cTnT change on risk discrimination for AF by C‐statistics and net reclassification improvement (NRI).ResultsOver a mean follow‐up of 16.5 years, 1629 incident AF cases were diagnosed. Among participants with undetectable hs‐cTnT at visit 2, the multivariable HR of AF was 1.28 (95% CI 1.12–1.48) among those with detectable or elevated hs‐cTnT at visit 4 compared to those in which hs‐cTnT remained undetectable. Among those with detectable hs‐cTnT at visit 2, compared to those who remained in the detectable hs‐cTnT group, reduction to undetectable at visit 4 was associated with lower risk of AF (HR 0.74, 95% CI 0.59–0.94), while increment to elevated was associated with higher AF risk (HR 1.30, 95% CI 1.01–1.68). Adding hs‐cTnT change to our main model with baseline hs‐cTnT did not result in significant improvement in the C‐statistic or substantial NRI.ConclusionSix‐year increase in circulating hs‐cTnT was associated with elevated risk of incident AF.     

Association between gestational visit‐to‐visit blood pressure variability and adverse neonatal outcomes

The authors aimed to explore the association between visit‐to‐visit blood pressure variability (BPV) in pregnant women and adverse neonatal outcomes. The study included 52 891 pregnant women. BPV was calculated as standard deviation (SD) and coefficient of variation (CV) of systolic blood pressure (SBP) or diastolic blood pressure (DBP). All participants were divided into four groups by the quartiles of BPV. When comparing the highest quartiles to the lowest quartiles of DBP SD in all participants, the fully adjusted ORs were 1.19 (95% CI 1.11–1.27, p for trend < .001) for fetal distress, 1.32 (95% CI 1.14–1.54, p for trend < .001) for small for gestational age, 1.32 (95% CI 1.06–1.63, p for trend = .003) for 1‐min Apgar score ≤ 7. When comparing the highest quartiles to the lowest quartiles of DBP CV, ORs were 1.22 (95% CI 1.14–1.30, p for trend < .001) for fetal distress, 1.38 (95% CI 1.17–1.61, p for trend < .001) for small for gestational age, 1.43 (95% CI 1.14–1.79, p for trend < .001) for 1‐min Apgar score ≤ 7. ORs for preterm birth and 5‐min Apgar score ≤ 7 were not statistically significant. However, in participants with gestational hypertension or preeclampsia, ORs for preterm birth were 2.80 (95% CI 1.99–3.94, p for trend < .001) in DBP SD and 3.25 (95% CI 2.24–4.72, p for trend < .001) in DBP CV when extreme quartiles were compared. In conclusion, higher visit‐to‐visit BPV was associated with adverse neonatal outcomes.     

Coronary artery calcium and cystatin C for risk stratification of MACCEs and all‐cause death in symptomatic patients

ObjectivesThe aim of this study was to examine the independent and joint associations of baseline coronary artery calcium score (CACS) and cystatin C (Cys‐C) with the risk of major adverse cardiac and cerebrovascular events (MACCEs) and all‐cause death in symptomatic populations.MethodsThe study included 7140 patients with symptom of chest pain who underwent cardiac computerized tomography examinations to measure CACS. All of them had serum Cys‐C results. Endpoints were set for MACCEs and all‐cause death events.ResultsA total of 7140 participants were followed for a median of 1106 days. A total of 305 patients had experienced MACCEs and 191 patients had experienced all‐cause death. CACS ≥ 100 and Cys‐C ≥ 0.995 mg/L were independently associated with an increased risk of MACCEs (adjusted hazard ratio [HR]: 1.46; 95% confidence interval [CI]: 1.15–1.85; p = .002 and adjusted HR: 1.57; 95% CI: 1.24–2.00; p < .001, respectively). Compared with CACS < 100 and Cys‐C < 0.995 mg/L patients, CACS ≥ 100 and Cys‐C ≥ 0.995 mg/L patients had the highest risk of MACCEs and all‐cause death (adjusted HR: 2.33; 95% CI: 1.64–3.29; p < .001 and adjusted HR: 2.85; 95% CI: 1.79–4.55; p < .001, respectively). Even in patients with CACS < 100, Cys‐C ≥ 0.995 mg/L was also associated with a higher risk of MACCEs and all‐cause death than Cys‐C < 0.995 mg/L (adjusted HR: 1.76; p = .003 and adjusted HR: 2.02; p = .007, respectively).ConclusionsThe combined stratification of CACS and Cys‐C showed an incremental risk of MACCEs and all‐cause death, reflecting complementary prognostic value. Our results support the combination of the two indicators for risk stratification and event prediction.     

Nocturnal heart rate rising is a risk factor for poor renal outcomes in patients with chronic kidney disease and hypertension

The association of heart rate (HR) dipping pattern with renal outcomes in chronic kidney disease (CKD) patients with hypertension has never been investigated. In order to demonstrate if HR dipping pattern is a risk factor for renal outcomes, cardiovascular (CV) diseases, and mortality in hypertensive patients with CKD, we conducted the prospective longitudinal observational study. Patients were divided into three groups according to their nocturnal HR: HR dippers (night–day HR ratio ≤ 0.9), HR non‐dippers (0.9 < night–day HR ratio ≤ 1.0), and HR risers (night–day HR ratio > 1.0). The primary outcome was renal endpoint, a composite outcome of progression to end‐stage renal disease (ESRD) or estimated glomerular filtration rate (eGFR) decline ≥ 50%; the secondary outcomes included poor renal outcomes, CV events, and death. A total of 34 (11.3%) patients reached renal endpoint after a follow‐up of 34 ± 17 months. Both HR non‐dippers and HR risers were predictive to renal endpoint (hazard ratio 2.58, 95% confidence interval (CI) 1.04‐ 6.4, P = .04; hazard ratio 3.95, 95% CI 1.33‐ 11.79, P = .01, respectively), while only HR risers was shown to be correlated with a decline in eGFR≥ 50% (hazard ratio 5.28, 95% CI 1.45–19.16, P < .05), and decline in eGFR (β ‐0.17, 95% CI ‐0.33‐ ‐0.01, P = .04). No predictive value was found for HR dipping pattern to mortality and CV events. In conclusion, our study provided the first evidence that HR non‐dippers, especially risers were a risk factor for poor renal outcomes in hypertensive patients with CKD.     

Impact of revascularization in patients with post‐infarction left ventricular aneurysm and ventricular tachyarrhythmia

BackgroundVentricular arrhythmia is a leading cause of cardiac death among patients with post‐infarction left ventricular aneurysm (PI‐LVA). The effect of coronary revascularization in PI‐LVA patients with ventricular tachyarrhythmia remains unknown. This study aims to investigate the impact of revascularization therapy on clinical outcomes in these patients.MethodsA total of 238 PI‐LVA patients were enrolled, and 59 patients were presented with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Patients were classified into 4 groups by treatment strategies (medical or revascularization) and the presence of VT/VF: group 1 (n = 57): VT/VF− and revascularization−; group 2 (n = 122): VT/VF− and revascularization+; group 3 (n = 34): VT/VF+ and revascularization+; and group 4 (n = 25): VT/VF+ and revascularization‐. The clinical outcomes were compared, and the primary endpoint was cardiac death or heart transplantation.ResultsPatients were followed up for 45 ± 16 months, and 41 patients (17.2%) reached the primary endpoint. Kaplan–Meier analysis showed that in VT/VF− patients, revascularization associated with higher cardiac survival compared with medical therapy (log‐rank p = .002), but in VT/VF+ patients, revascularization did not predict better cardiac outcome (log‐rank p = .901). Cox regression analysis revealed PET‐EF (HR 4.41, 95% CI: 1.72–11.36, p = .002) and moderate/severe mitral regurgitation (HR 2.32, 95% CI: 1.02–5.30, p = .046) as independent predictors of adverse cardiac outcome in patients with VT/VF.ConclusionPI‐LVA patients with VT/VF are at high risk of adverse cardiac outcome, and coronary revascularization does not mitigate this risk, although revascularization was associated with higher cardiac survival in PI‐LVA patients without VT/VF.     

Nighttime ambulatory pulse pressure predicts cardiovascular and all‐cause mortality among middle‐aged participants in the 21‐year follow‐up

Office pulse pressure (PP) is a predictor for cardiovascular (CV) events and mortality. Our aim was to evaluate ambulatory PP as a long‐term risk factor in a random cohort of middle‐aged participants. The Opera study took place in years 1991–1993, with a 24‐h ambulatory blood pressure measurement (ABPM) performed to 900 participants. The end‐points were non‐fatal and fatal CV events, and deaths of all‐causes. Follow‐up period, until the first event or until the end of the year 2014, was 21.1 years (mean). Of 900 participants, 22.6% died (29.6% of men/15.6% of women, p<.001). A CV event was experienced by 208 participants (23.1%), 68.3% of them were male (p<.001). High nighttime ambulatory PP predicted independently CV mortality (hazard ratio [HR] 2.60; 95% confidence interval [CI 95%] 1.08–6.31, p=.034) and all‐cause mortality in the whole population (HR 1.72; Cl 95% 1.06–2.78, p=.028). In males, both 24‐h PP and nighttime PP associated with CV mortality and all‐cause mortality (24‐h PP HR for CV mortality 2.98; CI 95% 1.11–8.04, p=.031 and all‐cause mortality HR 2.40; CI 95% 1.32–4.37, p=.004). Accordingly, nighttime PP; HR for CV mortality 3.13; CI 95% 1.14–8.56, p=.026, and for all‐cause mortality HR 2.26; CI 95% 1.29–3.96, p=.004. Cox regression analyses were adjusted by sex, CV risk factors, and appropriate ambulatory mean systolic BP. In our study, high ambulatory nighttime PP was detected as a long‐term risk factor for CV and all‐cause mortality in middle‐aged individuals.     

Automatically assessed P‐wave predicts cardiac events independently of left atrial enlargement in patients with cardiovascular risks: The Japan Morning Surge‐Home Blood Pressure Study

A prolonged P‐wave in electrocardiography (ECG) reflects atrial remodeling and predicts the development of atrial fibrillation (AF). The authors enrolled 810 subjects in the Japan Morning Surge Home Blood Pressure (J‐HOP) study who had ≥1 cardiovascular (CV) risk factor. The duration of P‐wave was automatically analyzed by standard 12‐lead electrocardiogram. Left atrial (LA) enlargement and left ventricular hypertrophy (LVH) were measured on echocardiography. The primary end points were fatal/nonfatal cardiac events: myocardial infarction, sudden death, and hospitalization for heart failure. The maximum P‐wave duration (Pmax) from the 12 leads was selected for analysis. The authors compared four prolonged P‐wave cutoffs (Pmax = 120, 130, 140, 150 ms) and cardiac events. LA diameter and left ventricular mass index (LVMI) were significantly associated with Pmax (r = 0.08, P = .02 and r = 0.17, P < .001, respectively). When the cutoff level was Pmax 120 or 130 ms, prolonged P‐wave was not associated with cardiac events (P = .45 and P = .10), but when a prolonged P‐wave was defined as Pmax ≥ 140 ms (n = 50) or Pmax ≥ 150 ms (n = 19), the patients in those groups had significantly higher incidence of cardiac events than others (P < .001 and P = .03). A Cox proportional hazards model including age, gender, body mass index, smoking, regular drinker, hypertension, dyslipidemia, diabetes, office systolic blood pressure, heart rate, LA enlargement, and LVH revealed that prolonged P‐wave defined as Pmax ≥ 140 ms was independently associated with cardiac events (hazard ratio: 4.23; 95% confidence interval: 1.30–13.77; P = .02). In conclusion, the automatically assessed prolonged P‐wave was associated with cardiac events independently of LA enlargement and LVH in Japanese patients with CV risks.