Vascular disease and stroke risk in atrial fibrillation: a nationwide cohort study

BackgroundVascular disease (including myocardial infarction and peripheral artery disease) has been proposed as a less well-validated risk factor for stroke in patients with atrial fibrillation. We investigated whether vascular disease is an independent risk factor of stroke/thromboembolism in atrial fibrillation and whether adding vascular disease improves Congestive heart failure, Hypertension, Age 75 years, Diabetes, previous Stroke (CHADS₂) risk stratification.MethodsBy using nationwide Danish registers, we identified all patients discharged with atrial fibrillation and not treated with vitamin K antagonist or heparin between 1997 and 2008. The rate of stroke/thromboembolism in patients with atrial fibrillation with and without vascular disease was determined, and the risk associated with vascular disease was estimated in Cox regression analyses. The value of adding vascular disease to the CHADS₂ score was evaluated by Net Reclassification Improvement and Integrated Discrimination Improvement.ResultsWe included 87,202 patients with non-valvular atrial fibrillation; of these, 15,212 (17.4%) had vascular disease, 11,750 (77.2%) had myocardial infarction, 2503 (16.5%) had peripheral artery disease, and 959 (6.3%) had both. In patients with a CHADS₂ score = 0, the rate of stroke/thromboembolism at 1-year follow-up was 2.31 (1.63-3.26) and 1.52 (1.34-1.73) per 100 person-years in patients with and without vascular disease, respectively. Vascular disease increased the risk of stroke/thromboembolism in both univariate (hazard ratio [HR] 1.26; confidence interval [CI], 1.18-1.35) and multivariate (HR, 1.12; CI, 1.05-1.21) analyses. The risk of stroke/thromboembolism associated with peripheral artery disease alone (HR, 1.93; CI, 1.70-2.19) was greater than the risk with myocardial infarction alone (HR, 1.12; CI, 1.04-1.21), and vascular disease significantly improved the predictive ability of the CHADS₂ score (Net Reclassification Improvement 0.032, P < .001).ConclusionsVascular disease is an independent predictor of stroke/thromboembolism in atrial fibrillation and improves the predictive ability of the CHADS₂ score.     

Low cardiovascular event rate and high atrial fibrillation recurrence rate one year after electrical cardioversion

BackgroundElectrical cardioversion is widely used to restore sinus rhythm in patients with atrial fibrillation. However, the long term clinical event and sinus rhythm maintenance rates following electrical cardioversion still remains unclear. This study evaluated one year incidence and risk factors for cardiovascular events and atrial fibrillation recurrence in a single center clinical practice.MethodsIn a prospective study 188 patients with atrial fibrillation who underwent electrical cardioversion were enrolled. Patients and their primary care physicians were followed up one year after cardioversion and patient clinical and arrhythmic event rate was evaluated. Data obtained from patients and general practitioners were combined and the results were analyzed with PSPP 0.8.5 software.ResultsElectrical cardioversion success rate was 90.4%. Within a year after cardioversion one patient (0.6%) suffered myocardial infarction, three patients (1.9%) had a stroke/transitory ischemic attack (TIA), three patients (1.6%) died and three patients (1.9%) had a bleeding event that required hospitalization. The presence of diabetes mellitus was the only factor with a tendency to increase the risk of combined event of myocardial infarction, stroke/TIA and bleeding (P = 0.096). At follow up 30.0% of patients reported having atrial fibrillation and within a year 62.2% had suffered at least one atrial fibrillation paroxysm. The proportion of patients who underwent additional cardioversions after the initial hospitalization was 32.5%. The factors that significantly increased the risk of atrial fibrillation recurrence were history of stroke/TIA (P = 0.014) and increased left atrial volume index on echocardiography (P = 0.039). Greater left atrial diameter had a tendency toward an increased risk (P = 0.087).ConclusionsCardiovascular event rate one year after electrical cardioversion was low. Electrical cardioversion had a high immediate success rate, however, maintenance of stable sinus rhythm in the long term was low.     

Impact of the CHA2DS2-VASc score on anticoagulation recommendations for atrial fibrillation

BackgroundThe Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke (CHADS₂) score is used to predict the need for oral anticoagulation for stroke prophylaxis in patients with atrial fibrillation. The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category (CHA₂DS₂-VASc) schema has been proposed as an improvement. Our objective is to determine how adoption of the CHA₂DS₂-VASc score alters anticoagulation recommendations.MethodsBetween 2004 and 2008, 1664 patients were seen at the University of Virginia Atrial Fibrillation Center. We calculated the CHADS₂ and CHA₂DS₂-VASc scores for each patient. The 2006 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for atrial fibrillation management were used to determine anticoagulation recommendations based on the CHADS₂ score, and the 2010 European Society of Cardiology guidelines were used to determine anticoagulation recommendations based on the CHA₂DS₂-VASc score.ResultsThe average age was 62 ± 13 years, and 34% were women. Average CHADS₂ and CHA₂DS₂-VASc scores were 1.1 ± 1.1 and 1.8 ± 1.5, respectively (P <.0001). The CHADS₂ score classified 33% as requiring oral anticoagulation. The CHA₂DS₂-VASc score classified 53% as requiring oral anticoagulation. For women, 31% had a CHADS₂ score ≥ 2, but 81% had a CHA₂DS₂-VASc score ≥ 2 (P =  .0001). Also, 32% of women with a CHADS₂ score of zero had a CHA₂DS₂-VASc score ≥ 2. For men, 25% had a CHADS₂ score ≥ 2, but 39% had a CHA₂DS₂-VASc score ≥ 2 (P <.0001).ConclusionCompared with the CHADS₂ score, the CHA₂DS₂-VASc score more clearly defines anticoagulation recommendations. Many patients, particularly older women, are redistributed from the low- to high-risk categories.     

Rivaroxaban Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation and Severe Kidney Disease or Undergoing Hemodialysis

BackgroundPatients with nonvalvular atrial fibrillation with stage 4 or 5 chronic kidney disease or undergoing hemodialysis were excluded from phase III randomized trials of nonvitamin K antagonist oral anticoagulants (NOACs). We sought to evaluate the effectiveness and safety of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation and stage 4 or 5 chronic kidney disease or undergoing hemodialysis in routine practice.MethodsUsing MarketScan data from January 2012 to December 2017, we identified patients on oral anticoagulant (OAC) with naïve nonvalvular atrial fibrillation and stage 4 or 5 chronic kidney disease or undergoing hemodialysis and with ≥ 12 months of insurance coverage before OAC initiation. Differences in baseline covariates between the rivaroxaban and warfarin cohorts were adjusted using inverse probability-of-treatment weights based on propensity scores calculated using generalized boosted models and 10,000 regression trees (absolute standardized differences < 0.1 achieved for all covariates after adjustment). Patients were followed until a stroke/systemic embolism or major bleeding event, OAC discontinuation/switch, insurance disenrollment, or end of data availability. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing the OAC cohorts were calculated using Cox regression.ResultsWe identified 1896 rivaroxaban (38.7% received a dose < 20 mg/d) and 4848 warfarin users. Eighty-eight percent of included patients had stage 5 chronic kidney disease or were undergoing hemodialysis. Rivaroxaban did not significantly reduce stroke or systemic embolism (HR = 0.55, 95% CI = 0.27-1.10) or ischemic stroke (HR = 0.67, 95% CI = 0.30-1.50) alone, but it was associated with a significant 32% (95% CI = 1-53%) reduction in major bleeding risk compared with warfarin.ConclusionAmong patients with nonvalvular atrial fibrillation and stage 4 or 5 chronic kidney disease or undergoing hemodialysis, rivaroxaban appears associated with significantly less major bleeding compared to warfarin.     

Warfarin Use and Outcomes in Patients with Atrial Fibrillation Complicating Acute Coronary Syndromes

Background

We examined warfarin use at discharge (according to Congestive heart failure, Hypertension, Age > 75 years, Diabetes, Prior Stroke/transient ischemic attack score and bleeding risk) and its association with 6-month death or myocardial infarction in patients with post-acute coronary syndrome atrial fibrillation.

Methods

Of the 23,208 patients enrolled in the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy, Platelet IIb/IIIa Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network A, and Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors trials, 4.0% (917 patients) had atrial fibrillation as an in-hospital complication and were discharged alive. Cox proportional hazards models were performed to assess 6-month outcomes after discharge.

Results

Overall, 13.5% of patients with an acute coronary syndrome complicated by atrial fibrillation received warfarin at discharge. Warfarin use among patients with atrial fibrillation had no relation with estimated stroke risk; similar rates were observed across Congestive heart failure, Hypertension, Age > 75 years, Diabetes, Prior Stroke/transient ischemic attack (CHADS₂) scores (0, 13%; 1, 14%; ≥ 2, 13%) and across different bleeding risk categories (low risk, 11.9%; intermediate risk, 13.3%; high risk, 11.1%). Among patients with in-hospital atrial fibrillation, warfarin use at discharge was independently associated with a lower risk of death or myocardial infarction within 6 months of discharge (hazard ratio 0.39; 95% confidence interval, 0.15-0.98).

Conclusion

Warfarin is associated with better 6-month outcomes among patients with atrial fibrillation complicating an acute coronary syndrome, but its use is not related to CHADS₂ score or bleeding risk.     

Difficulties encountered by the very elderly with atrial fibrillation on warfarin attending an outpatient anticoagulant monitoring service

IntroductionWarfarin is effective in reducing the stroke risk in atrial fibrillation in the very elderly. This survey aimed to define characteristics and problems of patients aged ≥ 80 with atrial fibrillation attending an outpatient anticoagulant monitoring service (AMS) in a university hospital.MethodsAll patients aged  ≥ 80 from October 2007 to March 2008 were included.ResultsOne hundred and sixty-eight patients, average age 85.8 ± 3.1 years, were included in the study. Average age of commencement was 81.3 ± 4.5 years. Average length of time on warfarin was 4.8 ± 3.3 years. Fifty-three percent of patients managed their own warfarin and took instructions for dosing. In their entire period on warfarin, 61% of patients had problems including bleeding, bruising, falls, medication interactions and erratic International Normalized Ratio (INR) readings. Seven percent of patients had INR readings of > 8.0, necessitating emergency department assessment for reversal with vitamin K. The AMS staff had difficulty contacting 13% of patients with elevated INRs and missed appointments in 11%. In the 6 months, only 45% remained within target INR range of 2.5 ± 0.75 in 90–100% of 10 consecutive readings. Sixteen percent were within target INR in ≤ 60% of readings. Seven percent of patients died, one from a subdural haemorrhage postfall. Fifteen percent were admitted to hospital.DiscussionThe findings illustrate significant difficulties encountered by this elderly, vulnerable age group in proven effective treatment in atrial fibrillation. Changes need to be made to increase resources for monitoring in the community, including home visits, portable INR monitors and point-of-contact dose adjustment. Patients should be assessed carefully for risk to benefit ratio.     

Profile of Czech AF 2012. Profile of atrial fibrillation patients receiving antithrombotic therapy

The profile of Czech AF 2012 is an epidemiological survey conducted by 197 Czech internal medicine and cardiology specialists who aimed to provide a comprehensive view of patients with non-valvular atrial fibrillation and their treatment in the Czech Republic. Each specialist had to include 5 consecutive patients.It involved 982 patients with an average age of 69.9 ± 10.04 years. The population of men was slightly higher (n = 543, 55.3%), especially in the under 65 years age group; women were the majority in the age group above 75 years (44.3% of men, 55.7% of women).One quarter (25.1%) of patients were diagnosed with atrial fibrillation for less than 2 years; 23.2% for 2–5 years; 13.5% for 6–10 years, and 8.6% for more than 10 years. 20.7% of patients had paroxysmal atrial fibrillation; 58.5% indicated permanent atrial fibrillation, i.e. lasting more than one year. 58.7% of patients received medication to regulate heart rhythm; 44.0% had another antiarrhythmic medication. 13.8% of patients used their medication once a day; 55.1% twice a day, and 29.6% three times a day. 38.7% of patients were after cardioversion, 7.9% were after ablation. 91.5% of patients received warfarin alone or as dual (1.4%) therapy. Only 8.7% of patients had medium or severe kidney impairment. Only 7.5% of patients used acetylsalicylic acid, 0.2% used dual antiplatelet treatment.Only 3.0% of patients had CHADS2 = 0; 55.8% were at a medium risk (CHADS2 = 1–2), and 41.2% at a high risk (CHADS2 > 2). 22.1% had one associated condition; 27.5% had two associated conditions; 19.8% had three associated conditions; 28.7% had four or more associated conditions; and only 2.0% indicated no associated condition or gave no answer. The most common associated condition was hypertension (90.2%), followed by ischemic heart disease (50.9%) and diabetes mellitus (41.8%).95 patients (9.7%) had a history of embolism while receiving antithrombotic therapy. 102 patients (10.4%) had a clinically significant bleeding event while on antithrombotic therapy, 51 patients needed hospitalization.The average frequency of INR measurements was 10.2 per year (10.4 by cardiologists, 10.1 by internal medicine specialists). 61.6% were within the INR therapeutic range of 2–3.ConclusionAtrial fibrillation patients are commonly elderly, polymorbid and high-risk patients on a pharmacological medication two to three times a day. INR monitoring was close to the level described in large international studies, almost 2/3 of patients were within the therapeutic range.     

Coronary bare metal stent implantation in homozygous LDL receptor deficient swine induces a neointimal formation pattern similar to humans

ObjectiveMethylarginines have been shown to interfere with nitric oxide (NO) formation by inhibiting NO synthase (asymmetric dimethylarginine, ADMA, and monomethylarginine, NMMA) and the cellular l-arginine uptake system (ADMA, NMMA and symmetric dimethylarginine, SDMA), thereby causing endothelial dysfunction. ADMA is a predictor of cardiovascular events and mortality in diverse populations.MethodsWe investigated whether methylarginines are predictors of mortality in 394 patients after acute ischemic stroke during 7.4 years of follow-up.ResultsPatients who died (N = 231) were older and more frequently had one of the traditional risk factors for stroke (previous stroke/TIA, atrial fibrillation, prevalent ischemic heart disease, peripheral vascular disease, each p < 0.05). ADMA (0.52 μmol/l vs. 0.50 μmol/l, p = 0.015) and SDMA (0.56 μmol/l vs. 0.43 μmol/l, p < 0.001) were higher in patients who died. In multivariable-adjusted hazard models, SDMA but not ADMA or NMMA was an independent predictor of all-cause mortality after stroke (SDMA, hazard ratio 2.41 (1.55–3.72), p < 0.001; ADMA, hazard ratio 1.43 (0.99–2.07), p = 0.06). SDMA was significantly associated with atrial fibrillation (0.55 μmol/l vs. 0.50 μmol/l, p = 0.03) but there was no significant interaction between SDMA and AF in relation to mortality (p = 0.81). SDMA remained significantly associated with mortality after adjusting for eGFR and also additionally adjusting for C-reactive protein, albumin, β-thromboglobulin, and von Willebrand factor.ConclusionOur study demonstrates that SDMA is an independent predictor of total mortality after acute stroke irrespective of renal function. SDMA is associated with atrial fibrillation, endothelial and platelet activation, and may therefore play a previously unknown role in the pathophysiology of stroke.     

Warfarin use and long-term outcomes in patients with acute myocardial infarction and atrial fibrillation

Warfarin use in patients with acute myocardial infarction (AMI) and atrial fibrillation (AF) remains challenging. We describe use of warfarin up to 1 year after hospitalization among patients with AMI and AF according to stroke and bleeding risk, and identify factors associated with long-term mortality in this population. Patients with AMI and AF who underwent cardiac catheterization during their AMI hospitalization in 1995–2007 were identified from the Duke Databank for Cardiovascular Disease. Warfarin use at discharge, 6 months, and 1 year as well as long-term vital status were assessed by surveys. Rates of warfarin use were presented according to CHADS₂ and CHA₂DS₂VASc stroke and ATRIA bleeding risk scores. Cox proportional hazards modeling was used to determine whether warfarin use at discharge was independently associated with 1-year mortality. A total of 879 patients hospitalized with AMI with AF were identified. Median age was 72 (25th, 75th percentiles: 64, 79), and median follow-up was 4.1 years (1.3, 7.4). The rate of warfarin use at discharge was 24 % and did not differ by CHADS₂, CHA₂DS₂VASc, or ATRIA risk scores. Warfarin use remained similar at 6 months (26 %) and 1 year (27 %). Long-term mortality was high and did not differ by whether warfarin was or was not prescribed at discharge (72 and 71 %, respectively). Factors associated with 1-year mortality were history of heart failure (HR 1.58, 95 % CI 1.32–1.90), higher Charlson comorbidity index (HR 1.19, 95 % CI 1.11–1.28), and older age (HR 1.03 per 1-year increase, 95 % CI 1.02–1.05). Warfarin use at discharge among patients hospitalized for AMI who had comorbid AF was low and remained low at 1 year. Warfarin use at hospital discharge was not associated with either 1-year mortality or long-term mortality.     

Hospitalized patients with atrial fibrillation compared to those included in recent trials on novel oral anticoagulants: A population-based study

BackgroundNonvalvular atrial fibrillation is associated with a substantial risk of stroke. Novel oral anticoagulants (NOACs) with predictable anticoagulant effect and no need for routine coagulation monitoring have recently shown good results when compared with warfarin in phase III clinical trials.ObjectiveTo describe clinical features and pharmacological treatments of a population-based cohort of patients with nonvalvular atrial fibrillation and ascertain whether they are comparable with those included in the three main phase III clinical trials on NOACs.ResultsOf the 2,862,264 subjects considered for this study 13,360 patients (0.47%) were recently discharged from the hospital with a diagnosis of nonvalvular atrial fibrillation. Mean age was 76.3 (SD 10.7), 49.8% were men and 64.6% were ≥ 75 years of age. 50% of patients were treated with warfarin and 44.1% with antiplatelet agents. The proportion of patients on antiplatelet therapy increased with age up to a rate of 54.3% in subjects ≥ 85 years. 92.9% of the studied cohort was on polypharmacy (mean 8 drugs/patient). Around 20% of the entire cohort was treated with amiodarone, a drug potentially interfering with NOACs, and 3.6% from a subgroup analysis had renal failure, which is an exclusion criterion in trials on NOACs.ConclusionIn patients recently discharged from the hospital with the diagnosis of nonvalvular AF, warfarin use decreases and aspirin treatment increases with patients' age. These patients are older, more frequently female, and on multiple medications. The benefit of NOACs in these subjects needs to be confirmed in phase IV clinical studies.     

The Effect and Safety of the Antithrombotic Therapies in Patients with Atrial Fibrillation and CHADS2 Score 1

Anticoagulation in CHADS₂ Score 1 . Background: The revised ACC/AHA/ESC 2006 guideline recommends either aspirin or warfarin for the prevention of ischemic stroke in patients with atrial fibrillation (AF) in CHADS₂ score 1. We hypothesized that warfarin is superior to aspirin therapy for the prevention of stroke without increasing bleeding complication in AF patients with CHADS₂ score 1. Methods and Results: Among 1,502 patients (mean 62.4 ± 13.8 years old, male 65.4%) who were treated for nonvalvular AF without previous stroke, the number of patients with CHADS₂ score 1 was 422 (62.9 ± 10.7 years old, male 290 [68.7%]) and their antithrombotic therapies were as follows: warfarin (n = 143), aspirin (n = 124), other antiplatelet (n = 45), and no antithrombosis (none: n = 110). We reviewed the incidences of ischemic stroke, mortality, and bleeding complications during the follow‐up period. Results were: (1) during 22.3 ± 17.8 months of follow‐up, the incidence of ischemic stroke was significantly lower in warfarin (6 patients, 4.2%, mean international normalized ratio [INR] 2.0 ± 0.5 IU) than in aspirin (16 patients, 12.9%, P = 0.008) than none (23 patients, 20.9%, P < 0.001) without differences in all‐cause mortality. (2) The incidence of major bleeding (decrease in hemoglobin ≥2 g/dL, requiring hospitalization or red blood cell transfusion ≥2 pints) was not different between warfarin (2.1%) and aspirin (0.8%, P = NS), but minor bleeding was more common in warfarin (10.5%) than in aspirin (2.4%, P = 0.007). Conclusion: In AF patients with CHADS₂ score 1, warfarin was better to prevent ischemic stroke than aspirin without increasing the incidence of major bleeding complications. However, the incidence of minor bleeding was higher in the warfarin group than the aspirin group. (J Cardiovasc Electrophysiol, Vol. 21, pp. 501‐507, May 2010)     

Effectiveness and Safety of Anticoagulants in Adults with Non-valvular Atrial Fibrillation and Concomitant Coronary/Peripheral Artery Disease

Background

Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among patients with nonvalvular atrial fibrillation. Limited evidence is available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral artery disease.

Cierre de la orejuela izquierda por ictus pese a la anticoagulación oral (ictus resistente): resultados del registro Amplatzer Cardiac Plug

Introduction and objectivesDespite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment.MethodsWe analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications.ResultsA total of 115 patients (11%) with RS were identified. The CHA₂DS₂-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5 ± 1.5 vs 4.3 ± 1.6; P < .001; 3.9 ± 1.3 vs 3.1 ± 1.2; P < .001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P = .1). With a mean clinical follow-up of 16.2 ± 12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction).ConclusionsPatients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.     

Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty: a meta-analysis of 8 randomized trials

BackgroundAdjunctive abciximab administration has been demonstrated to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over IV route. Therefore, the aim of the current study was to perform a meta-analysis of randomized trials (RCTs) to assess the clinical efficacy and safety of IC vs IV abciximab administration in STEMI patients undergoing primary angioplasty.MethodsWe obtained results from all RCTs enrolling STEMI patients undergoing primary percutaneous coronary intervention (PCI). The primary endpoint was mortality, while recurrent myocardial infarction, postprocedural epicardial (TIMI 3) and myocardial (MBG 2–3) perfusion were identified as secondary endpoints. The safety endpoint was the risk of major bleeding complications.ResultsA total of 8 randomized trials were finally included in the meta-analysis, enrolling a total of 3259 patients. As compared to IV route, IC abciximab was associated with a significant improvement in myocardial perfusion (OR [95% CI] = 1.76 [1.28–2.42], p < 0.001), without significant benefits in terms of mortality (OR [95% CI] = 0.85 [0.59–1.23], p = 0.39), reinfarction (OR [95% CI] = 0.79 [0.46–1.33], p = 0.37), or major bleeding complications (OR [95% CI] = 1.19 [0.76–1.87], p = 0.44). However, we observed a significant relationship between patient's risk profile and mortality benefits from IC abciximab administration (p = 0.011).ConclusionsThe present updated meta-analysis showed that IC administration of abciximab is associated with significant benefits in myocardial perfusion, but not in clinical outcome at short-term follow-up as compared to IV abciximab administration, without any excess of major bleedings in STEMI patients undergoing primary PCI. However, a significant relationship was observed between patient's risk profile and mortality benefits from IC abciximab administration. Therefore, waiting for long-term follow-up results and additional randomized trials, IC abciximab administration cannot be routinely recommended, but may be considered in high-risk patients.     

Gender differences in epicardial and tissue-level reperfusion in patients undergoing primary angioplasty for acute myocardial infarction

ObjectivePregnancy associated plasma protein-A (PAPP-A) is a potential new marker for vulnerable plaques in the coronary arteries only examined in stable coronary disease (CAD) in patients undergoing coronary angiography. Here we address the prognostic value of serum PAPP-A in unselected stable CAD patients.MethodBlood samples were drawn at study entry. Serum PAPP-A values ≥4 mIU/L were considered elevated. Mortality and non-fatal myocardial infarction was prospectively registered. The primary outcome was the composite outcome of myocardial infarction and all-cause mortality, secondary outcomes were all-cause mortality and myocardial infarction.ResultsPatients (n = 4243) were followed for a median of 2.8 years. In a Cox analysis, elevated PAPP-A was significantly related to the composite outcome of myocardial infarction and death (HR 1.99, 95% CI 1.62–2.45, p < 0.0005), all-cause mortality (HR 2.42, 1.92–3.06, p < 0.0005), and myocardial infarction (HR 1.40, 1.01–1.94, p = 0.046). After Holm's correction, the latter significance disappeared. After adjustment for risk factors and medication at entry, elevated PAPP-A remained significantly related to the composite outcome (HR 1.51, 1.22–1.86, p < 0.0005) and all-cause mortality (HR 1.68, 1.32–2.13, p < 0.0005).ConclusionIn patients with stable CAD elevated serum PAPP-A seems promising as aid in identifying patients at high risk for death.     

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.