Medical therapy versus implantable cardioverter -defibrillator in preventing sudden cardiac death in patients with left ventricular systolic dysfunction and heart failure: A meta-analysis of > 35,000 patients

Background

Patients with left ventricular systolic dysfunction (LVSD) are at high risk of sudden cardiac death (SCD). Implantable cardioverter defibrillators (ICDs) have an important role in preventing SCD in selected patients with LVSD and chronic heart failure (CHF). Drug therapies for LVSD and CHF also appear to also be useful in reducing SCD. However, the magnitude of benefit of these approaches on SCD is uncertain. We therefore conducted a meta-analysis comparing the effect on SCD achieved by ICDs versus medical therapies, additional to standard background medical therapies including ACE inhibitors and/or beta-blockers (BBs).

Methods

Our meta-analysis included trials of > 100 patients with reduced left ventricular ejection fraction (LVEF), i.e., < 40%. Fourteen randomized controlled trials met the criteria for meta-analysis, 10 involving medical therapies (angiotensin receptor blockers [ARBs], mineralocorticoid receptor antagonists [MRAs], ivabradine, n3-polyunsaturated fatty acid [PUFA], ferric carboxymaltose and aliskiren) and four involving ICDs. Results were pooled using the Mantel–Haenszel random effects method.

Results

Drug therapy (n = 36,172) reduced the risk of SCD overall (risk ratio (RR) = 0.89, 95% confidence interval (CI) = 0.82–0.98, p = 0.02) when compared to placebo. MRAs alone were most effective in reducing SCD (n = 11,032, RR = 0.79 [0.68–0.91], p = 0.001). ICD insertion greatly reduced SCD (n = 4,269, RR = 0.39 [0.30–0.51], p < 0.00001) compared with placebo. The difference in treatment effect between the ICD and drug therapy was significant (p < 0.002), and between ICD and MRAs (p < 0.002).

Conclusions

Drug therapies when added to a standard background regimen comprising ACE inhibitor and/or BB reduced SCD overall and MRAs alone were most effective in this regard. ICDs were more effective than drugs in SCD abrogation. However, the added procedural morbidity and the cost of ICD need to be considered in decision-making re-approach to SCD reduction in the individual patient.     

Stroke risk and suboptimal thromboprophylaxis in Chinese patients with atrial fibrillation: Would the novel oral anticoagulants have an impact?

Background

The risk of stroke associated with atrial fibrillation (AF) is higher in Far Eastern population than in Western population, and warfarin use suboptimal. There is uncertainty whether the novel oral anticoagulants (NOACs) would have a major impact on stroke prevention in Far Eastern populations with AF.

Objectives

We investigated current antithrombotic therapy use on stroke and bleeding risk, determinants of warfarin use and performed a modeling analysis of the net clinical benefit of the NOACs (apixaban, dabigatran) in a large cohort of Chinese patients with AF.

Methods

We studied 1034 Chinese patients (27.1% female, median age 75 years, interquartile range [IQR]: 63–83) with AF who were followed-up for an average of 1.9 years (IQR: 1.43–2.64). Stroke/thromboembolism (TE), and major bleeding associated to antithrombotic treatment were investigated. A modeling analysis was performed for the net clinical benefit balancing major bleeding against stroke/TE for dabigatran 110 mg bid, dabigatran 150 mg bid and apixaban, using their respective recent clinical trial outcome data.

Results

Using a Cox proportional hazard model, the Hazard Ratio [HR (95% confidence interval, CI)] for stroke/TE compared to no-antithrombotic therapy (no ATT) was 1.27 (0.65–2.50) on aspirin, 1.40 (0.35–3.57) on clopidogrel, 1.52 (0.72–3.23) on dual antiplatelets and 1.65 (0.76–3.57) on warfarin. The risk for major bleeding was 0.35 (0.14–0.85) on aspirin, 0.74 (0.24–2.29) on clopidogrel, 0.35 (0.11–1.10) on dual antiplatelets, and 0.88 (0.36–2.17) on warfarin. Binary logistic regression analysis showed persistent/permanent AF (Odds Ratio, OR, 2.03 [95%CI 1.05–3.92], p = 0.035) was associated with warfarin use, but age ≥ 75 years (0.26 [0.16–0.42], p < 0.001), aspirin (0.18 [0.12–0.27], p < 0.001) and clopidogrel (0.17 [0.08–0.33], p < 0.001) were independent determinants of non-use of warfarin.On modeling net clinical benefit (per 100 person-years [95% CI]), apixaban use compared to antiplatelet agents or no ATT was 3.29 (2.15–4.30) using Singer's method and 2.08 (1.18–3.21) with Connolly's method amongst high-risk patients. The use of dabigatran 110 mg bid and 150 mg bid compared to antiplatelet agents could reduce an additional 18.1 stroke/TE and 24.3 stroke/TE events, respectively. Compared to warfarin, dabigatran 150 mg bid had the best net clinical benefit.

Conclusions

There was suboptimal stroke prevention with no difference between antiplatelet and OAC treated patients, perhaps reflecting an inappropriate Target INR range. On modeling analyses, the use of the NOACs (apixaban and dabigatran) could provide better stroke prevention compared to antiplatelet (or warfarin) use in this Chinese AF population, with a positive net clinical benefit.     

A comparison of clinical characteristics and long-term prognosis in asymptomatic and symptomatic patients with first-diagnosed atrial fibrillation: The Belgrade Atrial Fibrillation Study

Background

To investigate baseline characteristics and long-term prognosis of carefully characterized asymptomatic and symptomatic patients with atrial fibrillation (AF) in a ‘real-world’ cohort of first-diagnosed non-valvular AF over a 10-year follow-up period.

Methods and results

We conducted an observational, non-interventional, and single-centre registry-based study of consecutive first-diagnosed AF patients. Of 1100 patients (mean age 52.7 ± 12.2 years and mean follow-up 9.9 ± 6.1 years), 146 (13.3%) had asymptomatic AF.Persistent or permanent AF, slower ventricular rate during AF (< 100/min), CHA₂DS₂–VASc score of 0, history of diabetes mellitus and male gender were independent baseline risk factors for asymptomatic AF presentation (all p < 0.01) with a good predictive ability of the multivariable model (c-statistic 0.86, p < 0.001).Kaplan–Meier 10-year estimates of survival free of progression of AF (log-rank test = 33.4, p < 0.001) and ischemic stroke (log-rank test = 6.2, p = 0.013) were significantly worse for patients with asymptomatic AF compared to those with symptomatic arrhythmia. In the multivariable Cox regression analysis, intermittent asymptomatic AF was significantly associated with progression to permanent AF (Hazard Ratio 1.6; 95% CI, 1.1–2.2; p = 0.009).

Conclusions

In a ‘real-world’ setting, patients with asymptomatic presentation of their first-diagnosed AF could have different risk profile and long-term outcomes compared to those with symptomatic AF. Whether more intensive monitoring and comprehensive AF management including AF ablation at early stage following the incident episode of AF and increased quality of oral anticoagulation could alter the long-term prognosis of these patients requires further investigation.     

Prognostic value of plasma von Willebrand factor and its cleaving protease ADAMTS13 in patients with atrial fibrillation

Background

The von Willebrand factor (vWF) is essential for platelet adhesion and arterial thrombosis. It is degraded into less active multimers by ADAMTS13. Patients with atrial fibrillation (AF) exhibit higher plasma vWF and lower ADAMTS13 antigen levels. The vWF/ADAMTS13-ratio might help to estimate the pro-thrombotic risk of patients with AF. We therefore investigated whether a high ratio of vWF/ADAMTS13, independently of clinical risk scores, predicts major adverse cardiovascular events (MACE) in patients with AF.

Methods

This prospective longitudinal single center study included 269 patients with AF. Blood samples were analyzed for vWF and ADAMTS13-antigen concentration by means of enzyme-linked immunoassay kits.

Results

After adjustment for all univariable predictors for MACE (p ≤ 0.1), ADAMTS13 ≤ 49.77% (HR 1.833 (95% CI 1.089–3.086); p = 0.023) and vWF/ADAMTS13-ratio > 27.57 (HR 2.174 (95% CI 1.238–3.817); p = 0.007) remained independently associated with outcome. vWF > 1434.92 mU/ml (HR 1.539 (95% CI 0.883–2.682); p = 0.128) alone failed to independently predict MACE. In patients with low and intermediate risk for MACE according to the CHADS₂-score the addition of high vWF/ADAMTS13-ratio levels (> 27.57) had significant impact on the patients' outcome.

Conclusion

A high ratio of vWF/ADAMTS13 independently predicts MACE in patients with AF. Therefore, vWF and its cleaving protease ADAMTS13 might play an important role in the development and perpetuation of vascular disease in AF patients. This might be a novel target for future treatment strategies or an additional help for risk stratification in AF patients.     

Predictive value of ankle-brachial index and PAI-1 in symptomatic intracranial atherosclerotic disease recurrence

Background and purpose

We prospectively examine the single and combined predictive value of biological and clinical markers in recurrent strokes related to intracranial atherosclerotic disease (ICAD).

Methods

In 73 ICAD first-ever stroke patients, ankle-brachial index (ABI) was assessed three months after TIA or stroke together with CRP, Lp-PLA2, ICAM-1, E-selectin and PAI-1 measurements. Appearance of new TIA/stroke was assessed every 6 months.

Results

After a median follow-up of 22.4 months, 13 patients (17.8%) suffered a new stroke or TIA. Risk of new cerebrovascular events (CVEs) was associated with lowered ABI (p = 0.011), baseline PAI-1 > 22.52 ng/ml (<0.001), E-selectin > 24.75 ng/ml (p = 0.008) and ICAM-1 > 205 ng/ml (p = 0.029). The combination of PAI-1 with ABI or ESRS reclassified 55.4% (p < 0.005) and 48.3% (p < 0.05) of patients between low, high and very high-risk categories.

Conclusions

This tentative study shows that ABI and PAI-1 are associated with the risk of new CVEs in symptomatic ICAD patients, and their combination might improve identification of patients at higher risk.     

Comparison of new point-of-care troponin assay with high sensitivity troponin in diagnosing myocardial infarction

Objectives

The aim of this study is to compare a new improved point of care cardiac troponin assay (new POC-cTnI) with 1. its predecessor (old POC-cTnI) and 2. a high sensitivity assay (hs-cTnI) for the diagnosis of acute myocardial infarction (AMI) and for major adverse cardiac events (MACE) by 30 days.

Methods

This is a single centre observational study, set in Christchurch Hospital, New Zealand. Patients presenting to the emergency department with non-traumatic chest pain underwent blood sampling at 0 h and 2 h post presentation for analysis with the 3 cTnI assays for the outcome of AMI and for analysis using an accelerated diagnostic protocol (ADP-normal 2 h troponins, normal electrocardiograms and Thrombolysis In Myocardial Infarction (TIMI) score of 0 or ≤ 1) for 30 day MACE.

Results

Of 962 patients, 220 (22.9%) had AMI. Old POC-cTnI was least sensitive at 70.0% (65.4–73.9%) by 2 h (p < 0.001). New POC-cTnI, sensitivity 93.6% (89.9–96.2%) had similar sensitivity to hs-cTnI, sensitivity 95.0% (91.5–97.3%) (p = 0.508). There were 231 (24.0%) patients with 30 day MACE. When used as part of the ADP, all assays had 100% (98.0–100%) sensitivity using TIMI = 0. Sensitivities of new POC-cTnI ADP, 98.3% (95.4–99.4%), old POC-cTnI, 96.5% (93.2–98.4%) and hs-cTnI, 98.7% (96.0–99.7%) were similar (p = 0.063–0.375) using TIMI ≤ 1.

Conclusions

A new POC-cTnI has improved sensitivity for AMI and MACE compared with its predecessor and comparable sensitivity to a high sensitivity assay. Now that sensitivities of the POC assay are improved, the new assay may be a useful alternative to central laboratory assays when rapid turn-around times are not possible.     

High post-clopidogrel platelet reactivity assessed by a point-of-care assay predicts long-term clinical outcomes in patients with ST-segment elevation myocardial infarction who underwent primary coronary stenting

Background

Recent studies have shown that post-clopidogrel high platelet reactivity (HPR), assessed by a point-of-care assay, is associated with a higher risk of adverse events after percutaneous coronary intervention (PCI). We assessed the clinical impact of HPR by the VerifyNow P2Y12 point-of-care assay in 181 patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary PCI with drug-eluting stents (DES) at 3 hospitals.

Methods

The primary endpoint of the study was the 12-month major adverse cardiovascular events (MACE), which comprised cardiovascular death, nonfatal MI and ischemic stroke. All patients received a single loading dose of 600 mg clopidogrel and 300 mg aspirin followed by a daily maintenance dose of 75 mg clopidogrel and 100 mg aspirin.

Results

A P2Y12 reaction unit (PRU) ≥ 282 (AUC 0.719, 95% CI 0.588–0.851, p = 0.004, sensitivity 68.8%, specificity 73.8%) was the optimal cut-off value in predicting 12-month MACE by receiver operating characteristic curve analysis. Occurrence of MACE was significantly more frequent in patients with HPR (PRU ≥ 282) compared to patients without HPR (20.4% vs. 3.9%, HR 6.24, 95% CI 2.05–18.99, p = 0.001). By multivariate analysis, HPR (HR 3.84, 95% CI 1.17–12.58, p = 0.026) and elderly patients above 80 years of age (HR: 8.13, 95% CI 1.79–37.03, p = 0.007) were found to be the significant predictors of 12-month MACE. The MACE-free survival rate was significantly lower in patients with HPR compared to patients without HPR (p < 0.001).

Conclusion

HPR assessed by a point-of-care assay was able to predict 12-month MACE in patients with STEMI who underwent primary PCI with DES.     

Long duration of radiofrequency energy delivery is an independent predictor of clinical recurrence after catheter ablation of atrial fibrillation: Over 500 cases experience

Background

Although radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) is an effective rhythm control strategy, there is a substantial amount of recurrence. We explored the predictors of AF recurrence after RFCA with consistent ablation strategy.

Methods and results

This study included 575 patients (77% male, 56 ± 11 years old) with AF (65.7% paroxysmal AF [PAF], 34.3% persistent AF [PeAF]) who underwent RFCA. We evaluated the clinical, serological, and electrophysiological parameters thereof. Results: 1. During 15 ± 7 months of follow-up, patients who experienced AF recurrence (21.8%) were older (58 ± 10 vs. 55 ± 11 years old, p = 0.019) and more likely to have PeAF (50.4% vs. 29.4%, p < 0.001) and greater LA volume (137.3 ± 49.1 vs. 116.6 ± 37.9 mL, p < 0.001). 2. In patients with clinical recurrence after RFCA, both ablation time (110.1 ± 43.8 vs. 92.3 ± 30.1 min, p < 0.001) and procedure time (222.7 ± 79.6 vs. 205.8 ± 58.8 min, p < 0.001) were prolonged, and the early recurrence rate within 3 months of the procedure was higher (63.0% vs. 26.4%, p < 0.001) than those without clinical recurrence. 3. In logistic regression analysis, LA volume (OR 1.008, CI 1.001–1.014), ablation time (per quartile, OR 1.380, CI 1.031–1.847), and early recurrence (OR 3.858, CI 2.420–6.150) were independent risk factors for recurrence of AF after RFCA.

Conclusion

In this single center consistent study of over 500 cases of AF ablation, patients with AF recurrence had a larger atrium, longer ablation time, and a higher chance of early recurrence than those remained in sinus rhythm. Inadvertent, long duration of ablation was an independent predictor of worse clinical outcomes after catheter ablation of AF.     

Revisiting a classical clinical sign: Jugular venous ultrasound

Background

Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult.

Methods

In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest.

Results

211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15–0.20) cm in controls and 0.23 (0.17–0.33) cm in patients with HF (p = 0.012), JVD ratio was 6.3 (4.3–6.8) in controls and 4.4 (2.7–5.8) in patients with HF (p = 0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15–0.23) cm, 0.21 (0.16–0.29) cm, 0.25 (0.18–0.35) cm and 0.34 (0.20–0.53) cm (P = < 0.001), whilst JVD ratio decreased (5.4 (4.2–6.4), 4.4 (3.5–6.3), 3.9 (2.4–5.4) and 2.8 (1.7–4.7); p = < 0.001). JVD ratio correlated with log (NT-proBNP) (r = − 0.39, p = < 0.001), LV filling pressures (E/E′, r = − 0.33, p = < 0.001) and left atrial volume (r = − 0.21, p = 0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R² = 0.27).

Conclusions

Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure     

Prevalence and correlates of fear of falling in Korean community-dwelling elderly subjects

Purpose

This study was conducted to investigate the factors related to fear of falling in elderly subjects, with a view to developing interventions to prevent falls.

Methods

Data from 9033 elderly subjects aged ≥ 65 years were analyzed from the 2008 National Elderly Survey of the Korea Ministry of Health & Welfare.

Results

In total, 76.6% of elderly Korean subjects had fear of falling. Factors associated with an increased risk of fear of falling in elderly subjects were, in order from highest to lowest, previous experience of falling (odds ratio [OR] = 6.41, p < 0.001), experience of body pain (OR = 2.45, p < 0.001), lower perceived health status (OR = 1.89, p < 0.001), presence of depression (OR = 1.82, p < 0.001), receipt of more doses of drugs per day for those receiving 1–2 (OR = 1.72, p < 0.001) or ≥ 3 doses of drugs per day (OR = 1.67, p = 0.001), older age (OR = 1.68, p < 0.001), female gender (OR = 1.64, p < 0.001), dependence for instrumental activities of daily living (OR = 1.55, p < 0.001), dependence for activities of daily living (OR = 1.44, p = 0.017), and lower education level (OR = 1.18, p = 0.016).

Conclusion

The fear of falling can be attenuated by providing interventions to reduce the impact of modifiable risk factors that were identified in this study.     

A novel scale predicting postoperative delirium (POD) in patients undergoing cerebrovascular surgery

Purpose

The purpose of this study was to develop and test a scale for predicting POD in patients undergoing cerebrovascular surgery.

Methods

The predictive scale for POD was composed of 32 items reflecting the strongest risk factors as determined by a literature review. The NEECHAM Confusion Scale determined POD onset and severity.

Results

Delirium developed in 38 (31.1%) of the 122 patients in our sample. Logistic regression revealed the following risk factors: dehydration, age, disturbance of consciousness, underlying illness, and anxiety or depression. The final scale was weighted by referring to odds ratios. The area under the curve was 0.844 (95% CI = 0.766–0.921). The possible total score on this scale was 20 points. A cutoff score of 11 was set for risk of POD (patients scoring over 12 were considered at higher risk). The median score was 8 (range: 4–9) in the non-delirium group and 13 (range: 9–16) in the delirium group (U = 499.0; df = 120; p < 0.001). Scale scores were moderately correlated with delirium duration (ρ = 0.532; p < 0.001).

Conclusion

The present scale is a promising a tool for predicting POD but needs to be studied further.     

Short stature and ischemic stroke in nonvalvular atrial fibrillation: New insight into the old observation

Background

For decades, repeated epidemiologic observations have been made regarding the inverse relationship between stature and cardiovascular disease, including stroke. However, the concept has not been fully evaluated in patients with atrial fibrillation (AF). We investigated whether patient’s height is associated with ischemic stroke in patients with nonvalvular AF and attempted to ascertain a potential mechanism.

Methods

All 558 AF patients were enrolled: 211 patients with ischemic stroke (144 men, 68 ± 10 years) and 347 no-stroke patients (275 men, 56 ± 11 years) as a control group. Clinical characteristics and echocardiographic parameters were compared between the two groups.

Results

(1) Stroke patients were shorter than those in the control group (164 ± 8, vs. 169 ± 8 cm, p < 0.001). However, body mass index failed to predict ischemic stroke; (2) Short stature (OR 0.93, 95% CI 0.91– 0.95, p < 0.001) along with left atrial (LA) anterior-posterior diameter and diastolic mitral inflow velocity (E) to diastolic mitral annuls velocity (E’) (E/E’) were independent predictor of stroke; (3) Height showed inverse correlation with E/E’ independently, even after adjusting for other variables, including age, sex, and body weight, and comorbidities β − 0.20, p = 0.003); (4) LA size showed no correlation with stature (R = − 0.06, p = 0.18), whereas left ventricular size increases according to height of patients.

Conclusions

Short stature is associated with occurrence of ischemic stroke and diastolic dysfunction in patients with AF and preserved systolic function. Height is a non-modifiable risk factor of stroke and might be more important than obesity in Asian AF patients, who are relatively thinner than western populations.     

Endothelial function and cardiovascular events in chronic kidney disease

Background

As patients with chronic kidney disease (CKD) are at high risk of developing coronary artery disease (CAD), it is important to stratify their cardiovascular risk. We investigated whether peripheral endothelial dysfunction is associated with the presence of CAD in patients with CKD and is a predictor of cardiovascular events.

Methods

We enrolled 383 CKD patients with at least one coronary risk factor. Peripheral endothelial function was assessed by reactive hyperemia peripheral arterial tonometry index (RHI). The presence of CAD was determined by coronary angiography. Cardiovascular events were assessed during follow-up.

Results

Ln-RHI was significantly lower in risk factor-matched CKD patients (n = 323) than risk factor-matched non-CKD patients (n = 323) (0.527 ± 0.192 vs. 0.580 ± 0.218, p = 0.001). In CKD patients (n = 383), Ln-RHI was significantly lower in CAD (0.499 ± 0.183, n = 262) than non-CAD (0.582 ± 0.206, n = 121) (p < 0.001) patients. Multivariate logistic regression analysis identified Ln-RHI as an independent factor associated with the presence of CAD (p = 0.001). During a mean follow-up period of 30 months, 90 cardiovascular events were recorded in CKD patients. Multivariate Cox hazard analysis identified low-Ln-RHI as an independent predictor of cardiovascular events (hazard ratio = 2.70, 95% confidence interval = 1.62–4.51, p < 0.001). The predictive value of combined Ln-RHI and Framingham risk score (FRS) was evaluated by net reclassification index (NRI) and C-statistics, which showed significant improvement (NRI = 22%, p < 0.001) (C-statistics: FRS = 0.49, FRS + Ln-RHI = 0.62, p = 0.005).

Conclusions

Endothelial function was significantly impaired in CKD patients and correlated with the presence of CAD. Severe endothelial dysfunction was an independent and incremental predictor of cardiovascular events in CKD.     

The association of asthma and atrial fibrillation — A nationwide population-based nested case–control study

Background

Asthma and atrial fibrillation (AF) have been reported to be related to an increased risk of cardiovascular events. However, the relationship between asthma and AF has not been fully elucidated. The purpose of this study was to examine the association between asthma and AF risk.

Methods

We conducted a population-based nested case–control study including a total of 7439 newly-diagnosed adult patients with AF and 10,075 age-, gender-, comorbidity-, and cohort entry date-matched subjects without AF from the Taiwan National Health Insurance database. Exposure to asthma as well as medications including bronchodilators and corticosteroid before the index date was evaluated to investigate the association between AF and asthma as well as concurrent medications.

Results

AF patients were 1.2 times (adjusted OR 1.2, 95% CI 1.109–1.298) more likely to be associated with a future occurrence of asthma independent of comorbidities and treatment with corticosteroids and bronchodilator. In addition, the risks of new-onset AF were significantly higher among current users of inhaled corticosteroid, oral corticosteroids, and bronchodilators. Newly users (within 6 months) have the highest risk (inhaled corticosteroid: OR, 2.13; 95% CI, 1.226–3.701, P = 0.007; oral corticosteroid: OR, 1.932; 95% CI, 1.66–2.25, P < 0.001; non-steroid bronchodilator: OR, 2.849; 95% CI, 2.48–3.273, P < 0.001). A graded association with AF risk was also observed among subjects treated with corticosteroid (inhaled and systemic administration) and bronchodilators. New users (within 6 months) of these medications had the highest risk of AF (ICS: OR, 2.13; 95% CI, 1.226–3.701, P = 0.007; oral corticosteroid: OR, 1.932; 95% CI, 1.66–2.25, P < 0.001; non-steroid bronchodilator: OR, 2.849; 95% CI, 2.48–3.273, P < 0.001). A graded association with AF risk was also observed among subjects treated with ICS or bronchodilator.

Conclusions

Asthma was associated with an increased risk of developing future AF.     

Validation of contemporary stroke and bleeding risk stratification scores in non-anticoagulated Chinese patients with atrial fibrillation

Background

Risk stratification schemes assessing stroke and thromboembolism (stroke/TE) and bleeding relating to atrial fibrillation (AF) have largely been derived and validated in Western populations. We assessed risk factors that constitute scores for assessing stroke/TE (CHADS₂, CHA₂DS₂-VASc) and bleeding (HAS-BLED), and the predictive value of these scores in a large cohort of Chinese patients with AF.

Methods and results

We studied 1034 AF patients (27.1% female, median age 75; 85.6% non-anticoagulated) with mean follow-up of 1.9 years. On multivariate analysis, vascular disease was independently associated with stroke/TE in non-anticoagulated patients (p = 0.04). In patients with a CHADS₂ or CHA₂DS₂-VASc score = 1, the rate of stroke/TE was 2.9% and 0.9% respectively, but in patients at “high risk” (scores ≥ 2), this rate was 4.6% and 4.5%, respectively. The c-statistics for predicting stroke/TE with CHADS₂ and CHA₂DS₂-VASc were 0.58 (p = 0.109) and 0.72 (p < 0.001), respectively. Compared to CHADS₂, the use of CHA₂DS₂-VASc would result in a Net Reclassification Improvement (NRI) of 16.6% (p = 0.009) and an Integrated Discrimination Improvement (IDI) of 1.1% (p = 0.002). Cumulative survival of the patients with a CHA₂DS₂-VASc score ≥ 2 was decreased compared to those with a CHA₂DS₂-VASc score 0–1 (p < 0.001), but the CHADS₂ was not predictive of mortality. There was an increased risk of major bleeding with increasing HAS-BLED score (c-statistic 0.61, 95% CI: 0.51–0.71, p = 0.042).

Conclusions

Vascular disease was a strong independent predictor of stroke/TE in Chinese patients with AF. The CHA₂DS₂-VASc score performed better than CHADS₂ in predicting stroke/TE in this Chinese AF population. Cumulative survival of the patients at high risk with the CHA₂DS₂-VASc score (but not using CHADS₂) was significantly decreased.     

Importance of pericardial fat in the formation of complex fractionated atrial electrogram region in atrial fibrillation

Background/Objectives

Pericardial fat (PF) and complex fractionated atrial electrogram (CFAE) are both associated with atrial fibrillation (AF). Therefore, we examined the relation between PF and CFAE area in AF.

Methods

The study population included 120 control patients without AF and 120 patients with AF (80 paroxysmal AF and 40 persistent AF) who underwent catheter ablation. Total cardiac PF volume, representing all adipose tissue within the pericardial sac, was measured by contrast-enhanced computed tomography. The location and distribution of CFAE region were identified by left atrial endocardial mapping using a three-dimensional mapping system. We analyzed the significance of total cardiac PF volume and total area of CFAE region on AF, persistence of AF from paroxysmal to persistent form, and the relation between total cardiac PF volume and total CFAE area. We also evaluated the regional distribution of PF volume and CFAE area in five areas of the left atrium (LA).

Results

Total cardiac PF volume correlated with AF (odds ratio [OR]: 1.024, p < 0.001). Total cardiac PF volume and total CFAE area were both independently associated with persistence of AF (OR: 1.018, p = 0.018, OR: 1.144, p = 0.002, respectively). Multivariate linear regression analysis identified total cardiac PF volume as a significant and independent determinant of total CFAE area (r = 0.488, p < 0.001). Furthermore, regional PF volume correlated with local CFAE area in an each LA area.

Conclusions

PF volume correlated significantly with CFAE area in patients with AF. This finding suggests that PF is directly related to the progression of CFAE area and promotes the pathogenic process of AF.     

Use of covered Cheatham-Platinum stents in congenital heart disease

Background

Controversy remains regarding the use of covered stents in congenital heart disease (CHD). We evaluate the possibilities and safety of covered Cheatham-Platinum (CCP) stents in CHD.

Methods

Single-center retrospective CHD-database study of all CCP stents, 2003–2012. Three study groups: aortic coarctation (CoA), right ventricular outflow tract pre-stenting for percutaneous revalvulation (RVOT), and miscellaneous. Continuous data expressed as median (range).

Results

114 CCP stents in 105 patients, age 16.8 years (4.2–71.2).CoA group: 54 CCP stents in 51 patients: 3/54 for aneurysm exclusion, in 51/54 covering used “prophylactically” because of increased risk for vessel tear. Overall, CCP stenting increased the coarctation diameter from 6 mm (0–15) to 15 mm (10–20) (p < 0.001).RVOT group: 39 CCP stents in 37 patients (34 with RVOT graft, 3 with transannular patch): the graft lumen had shrunken from nominal 21 mm (10–26) to 13 mm (5–22); with the CCP stent the RVOT was redilated to 22 mm (16–26, p < 0.001 vs stenosis).Miscellaneous group: 21 CCP stents in 17 patients: closure of Fontan-circuit fenestration (n = 5), restoration of superior caval vein (n = 2) or pulmonary artery (n = 3) patency, relief of supra-pulmonary stenosis (n = 2), exclusion of aberrant pulmonary arteries (n = 1), cavopulmonary conduit expansion (n = 2), Blalock–Taussig shunt flow reduction (n = 1), and defibrillator lead protection from sharp stents (n = 1). Hybrid procedures performed in 3/17 patients. CCP stent was used as rescue treatment in 2/patients to seal iatrogenic bleeding.

Conclusion

CCP stents can safely be applied in CHD patients. The covering allows adequate sealing of existing or expected tears, thereby increasing the safety margin with more complete dilation.     

Early intravenous beta-blockers in patients with acute coronary syndrome—A meta-analysis of randomized trials

Background

Intravenous (IV) beta-blockade is currently a Class IIa recommendation in early management of patients with acute coronary syndromes (ACS) without obvious contraindications.

Methods

We searched the PubMed, EMBASE and the Cochrane Register for Controlled Clinical Trials for randomized clinical trials from 1965 through December, 2011, comparing intravenous beta-blockers administered within 12 hours of presentation of ACS with standard medical therapy and/or placebo. The primary outcome assessed was the risk of short-term (in-hospital mortality-with maximum follow up duration of 90 days) all-cause mortality in the intervention group versus the comparator group. The secondary outcomes assessed were ventricular tachyarrhythmias, myocardial reinfarction, cardiogenic shock, and stroke. Pooled treatment effects were estimated using relative risk with Mantel–Haenszel risk ratio, using a random-effects model.

Results

Sixteen studies enrolling 73,396 participants met the inclusion ⁄ exclusion criteria. In- hospital mortality was reduced 8% with intravenous beta-blockers, RR = 0.92 (95% CI, 0.86–1.00; p = 0.04) when compared with controls. Moreover, intravenous beta-blockade reduced the risk of ventricular tachyarrhythmias (RR = 0.61; 95 % CI 0.47–0.79; p = 0.0003) and myocardial reinfarction (RR = 0.73, 95 % CI 0.59–0.91; p = 0.004) without increase in the risk of cardiogenic shock, (RR = 1.02; 95% CI 0.77–1.35; p = 0.91) or stroke (RR = 0.58; 95 % CI 0.17–1.98; p = 0.38).

Conclusions

Intravenous beta-blockers early in the course of appropriate patients with ACS appears to be associated with significant reduction in the risk of short-term cardiovascular outcomes, including a reduction in the risk of all-cause mortality.     

Fever after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction is associated with adverse outcomes

Background

Fever is a common finding after primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, its prognostic value is not validated yet.

Objectives

This study sought to evaluate the impact of fever after PPCI in STEMI on adverse clinical outcomes.

Methods

Five hundred fourteen consecutive patients who underwent PPCI due to STEMI were enrolled. Body temperature (BT) was checked every 6 h for 5 days after PPCI. Patients were divided into two groups according to the highest quartile of peak BT; peak BT ≤ 37.6 °C (control group) and peak BT > 37.6 °C (fever group). Rates of 1-year major adverse cardiovascular events (MACE; death, myocardial infarction, any revascularization) were compared.

Results

The prevalence of fever group (peak BT > 37.6 °C) was 24.7% (127/514). White blood cell count, highly sensitive C-reactive protein and serum cardiac troponin I level were higher in fever group than control group (12,162 ± 4199/μL vs. 10,614 ± 3773/μL, p < 0.001; 22.9 ± 49.4 mg/L vs. 7.4 ± 2.5 mg/L, p = 0.001, 16.7 ± 36.9 ng/dl vs. 8.70 ± 26.2 ng/dl, p = 0.027, respectively). The frequency of a history of previous myocardial infarction and left ventricular ejection fraction was lower in fever group (0.0% vs. 4.7%, p = 0.010; 47 ± 8 % vs. 49 ± 9 %, p = 0.002, respectively). There was no significant difference in angiographic characteristics between 2 groups. 1-year MACE rates were higher in fever group (11.0% vs. 4.7%, p = 0.010). Multivariate analysis revealed fever (OR 2.358, 95% CI 1.113–4.998, p = 0.025), diabetes mellitus as risk factor (2.227, 1.031–4.812, 0.042), and left anterior descending artery as infarct related artery (2.443, 1.114–5.361, 0.026) as independent predictors for 1-year MACE.

Conclusions

Fever after PPCI in patients with STEMI is frequently developed and it can predict adverse clinical outcome.     

Use of IVUS guided coronary stenting with drug eluting stent : A systematic review and meta-analysis of randomized controlled clinical trials and high quality observational studies

Background/objectives

Long term safety of DES, particularly regarding thrombosis is of concern. The hypothesized underlying mechanisms (stent underexpansion, malapposition) could be prevented by IVUS guidance.Aim of this meta-analysis of randomized controlled clinical trials (RCT) and high quality observational cohort studies (HQ-OBS) is to quantify the potential clinical benefit of intravascular ultrasound (IVUS) guidance in drug-eluting stents (DES) implantation.

Methods

We performed an extensive literature search for full-text articles published in 2003–2013. The primary outcome was the rate of major adverse cardiac events (MACE) in RCT and HQ-OBS; secondary outcomes were death, myocardial infarction (MI), revascularization, thrombosis and post-procedural minimum lumen diameter (MLD). Fixed/random effect relative risks (RRs) or standardized mean difference (SMD) and 95% confidence interval (95% CI) were computed for the meta-analysis.

Results

Thirty-four articles were retrieved from 268 found; of these 3 were RCT and 9 were HQ-OBS; 18,707 patients were enrolled, 1037 in RCT and 17,670 in OBS. Median follow-up was 20 months. IVUS guidance was associated with a significantly lower rate of MACE (RR = 0.80, 95% CI 0.71–0.89, p < 0.001), death (RR = 0.60, 95% CI 0.48–0.74, p < 0.001), MI (RR = 0.59, 95% CI 0.44–0.80, p = 0.001) and thrombosis (RR = 0.50, 95% CI 0.32–0.80, p = 0.007) and larger MLD (SMD = 0.15, 95% CI 0.03 to 0.27, p = 0.014), but not of revascularization (RR = 0.95, 95% CI 0.82–1.09, p = 0.75).

Conclusions

In this meta-analysis, IVUS guidance in DES implantation appears to reduce MACE, mortality and MI, possibly by reducing thrombosis rather than restenosis rate. Patients at high risk for thrombosis might be identified as the best candidate for IVUS guidance.