Substrate and procedural predictors of outcomes after catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy

Background: Hypertrophic cardiomyopathy (HCM) is often accompanied by atrial fibrillation (AF) due to diastolic dysfunction, elevated left atrial pressure, and enlargement. Although catheter ablation for drug‐refractory AF is an effective treatment, the efficacy in HCM remains to be established. Methods: Thirty‐three consecutive patients (25 male, age 51 ± 11 years) with HCM underwent pulmonary vein (PV) isolation (n = 8) or wide area circumferential ablation with additional linear ablation (n = 25) for drug‐refractory AF. Twelve‐lead and 24‐hour ambulating ECGs, echocardiograms, event monitor strips, and SF 36 quality of life (QOL) surveys were obtained before ablation and for routine follow‐up. Results: Twenty‐one (64%) patients had paroxysmal AF and 12 (36%) had persistent/permanent AF for 6.2 ± 5.2 years. The average ejection fraction was 0.63 ± 0.12. The average left atrial volume index was 70 ± 24 mL/m 2 . Over a follow‐up of 1.5 ± 1.2 years, 1‐year survival with AF elimination was 62%(Confidence Interval [CI]: 66‐84) and with AF control was 75%(CI: 66‐84). AF control was less likely in patients with a persistent/chronic AF, larger left atrial volumes, and more advanced diastolic disease. Additional linear ablation may improve outcomes in patient with severe left atrial enlargement and more advanced diastolic dysfunction. Two patients had a periprocedureal TIA, one PV stenosis, and one died after mitral valve replacement from prosthetic valve thrombosis. QOL scores improved from baseline at 3 and 12 months. Conclusion: Outcomes after AF ablation in patients with HCM are favorable. Diastolic dysfunction, left atrial enlargement, and AF subtype influence outcomes. Future studies of rhythm management approaches in HCM patients are required to clarify the optimal clinical approach.     

Complex electrograms within the coronary sinus: time- and frequency-domain characteristics, effects of antral pulmonary vein isolation, and relationship to clinical outcome in patients with paroxysmal and persistent atrial fibrillation

Background: The mechanistic and clinical significance of complex fractionated atrial electrograms (CFAE) in the coronary sinus (CS) has been unclear. Methods and Results: Antral pulmonary vein isolation (APVI) was performed in 77 patients with paroxysmal (32) or persistent AF (45). CS electrograms recorded for 60 seconds before and after APVI were analyzed in the time‐ and frequency‐domains. Dominant frequency (DF), complexity index (CI: change in polarity of depolarization), and fractionation index (FI: change in direction of depolarization slope) were determined. Before APVI, there was no difference in DF, CI, or FI between paroxysmal and persistent AF. APVI resulted in a significant decrease in DF, CI, and FI in all patients. Baseline CI (43 ± 13/s vs 54 ± 14/s, P = 0.03) and FI (64 ± 23/s vs 87 ± 30/s, P = 0.02) were lower in patients with paroxysmal AF who had AF terminated by ablation than who did not. At 10 ± 2 months, 69% of patients with paroxysmal AF and 49% of patients with persistent AF were free from AF after single ablation. Baseline CI was higher among patients with paroxysmal AF who had AF after APVI (56 ± 20/s vs 44 ± 10/s, P = 0.03). In patients with persistent AF, there was a larger decrease in DF after APVI among patients who remained free from AF (13 ± 11% vs 7 ± 9%, P < 0.05). Conclusions: Complexity of CS electrograms may reflect drivers of AF that perpetuate paroxysmal AF after APVI. In persistent AF, the extent to which APVI decreases DF in the CS correlates with efficacy, suggesting that DF identifies patients who may require additional ablation beyond APVI.     

Effect of Imidafenacin before Sleeping on Nocturia

Objectives: Clinical efficacy, influence on quality of life (QOL), and safety of imidafenacin before sleeping were assessed in patients with overactive bladder (OAB) who suffered from nocturia. Methods: A total of 60 OAB patients with a mean age of 74 years (45 men and 15 women) who mainly complained of nocturia were enrolled. Imidafenacin (0.1 mg) was administered once daily before sleeping for four weeks. Then the patients were divided into two groups, “a stable‐dose group” with sufficient efficacy who remained on 0.1 mg of imidafenacin daily, and “a dose‐escalation group” with insufficient efficacy in whom the daily dose of imidafenacin was increased to 0.2 mg before sleeping. Lower urinary tract symptoms and postvoid residual volume (PVR) were examined before treatment and after 4 and 8 weeks of imidafenacin therapy. Results: In the stable‐dose group, nighttime frequency decreased significantly from 3.4 ± 1.1 to 2.3 ± 1.1 and 2.6 ± 2.0 times after four and eight weeks, respectively. In the dose‐escalation group, nighttime frequency did not change significantly (from 3.8 ± 1.5 to 3.6 ± 1.8 times) at four weeks, but decreased significantly to 2.8 ± 1.4 times at eight weeks. Daytime frequency, OAB symptom score, and IPSS‐QOL index score were significantly improved in both groups at four and/or eight weeks. There was no increase of PVR and no serious adverse events. Conclusion: Administration of imidafenacin at 0.1–0.2 mg once daily before sleeping was safe and effective for the treatment of OAB with the main symptom of nocturia.     

First evidence: rivaroxaban and apixaban reduce thrombin-dependent platelet aggregation

Rivaroxaban and apixaban are direct oral anticoagulants whose target specificity is to activate factor X (FXa). It is still not fully understood how xabans impact platelet function. This single-center observational study aimed to assess in vitro platelet function in patients with atrial fibrillation receiving rivaroxaban or apixaban. It examined quantification of platelet aggregation assessed by light transmission aggregometry in thirty-four patients treated with apixaban or rivaroxaban. The thrombin-induced platelet aggregation was significantly lower 2 h after taking selected xabans compared to baseline value (69.55?±?32.15% vs. 44.79?±?34.97.9%; p?<?0.0001). This effect was only observed in patients who received rivaroxaban or apixaban for more than 1 week. The thrombin-induced platelet aggregation is reduced in cardiovascular patients receiving rivaroxaban or apixaban. This reduction is likely to depend on the duration of the treatment. Duration of treatment should be considered in future studies focusing on DOACs and platelet aggregation.     

Comparison of twice-daily injections of biphasic insulin lispro and basal-bolus therapy: glycaemic control and quality-of-life of insulin-naïve type 2 diabetic patients

Objective: The aim of this study was to evaluate twice‐daily injections of biphasic insulin lispro vs. basal–bolus (BB) therapy with regard to quality‐of‐life (QOL) and glycaemic control in insulin‐naïve type 2 diabetic patients. Methods: Twenty‐eight patients with type 2 diabetes were randomized to receive either twice‐daily 50/50 premixed insulin lispro (Mix50 group) or BB (NPH insulin at bedtime and preprandial insulin lispro) therapy (BB group) for 12 weeks. Glycated haemoglobin (HbA1C), 1,5‐anhydroglucitol (1,5‐AG), blood plasma glucose level, body mass index (BMI), daily total insulin dosage and insulin therapy–related QOL (ITR‐QOL) were studied. Results: ITR‐QOL was significantly better in the Mix50 than in the BB group (103.1 ± 9.8 vs. 90.6 ± 19.4; p < 0.05). HbA_1c improved in both groups (from 11.1 ± 2.1 to 6.9 ± 1.0% with Mix50 vs. from 11.0 ± 2.3 to 6.6 ± 0.8% with BB therapy). Conclusion: These results might suggest that twice‐daily injections of premixed rapid‐acting insulin analogue therapy could achieve good glycaemic control and better QOL compared with BB therapy in insulin‐naïve type 2 diabetes.     

Quality of life in older patients with atrial fibrillation

This review summarizes what is known about quality of life (QOL) in older patients with atrial fibrillation (AF). The studies reviewed in this paper represent an increasingly broad repertoire of therapies for the treatment of AF and suggest that QOL in older patients does improve with treatment. The most dramatic improvements in QOL are noted in patients who are highly symptomatic and have poorer QOL at baseline. The data from studies where ablation and pacing therapy is used for treatment in patients with refractory AF vividly demonstrate this statement. There is also evidence of improvement in QOL in those with less severe symptoms, though it is extremely challenging to measure improvements in older patients who are asymptomatic (e.g., silent AF) or mildly symptomatic. Recommendations about new knowledge needed to optimize outcomes, particularly QOL, in patients with AF are based on these findings and the gaps in existing knowledge.     

The Value of P Dispersion on Predicting Atrial Fibrillation After Coronary Artery Bypass Surgery: Effect of Magnesium on P Dispersion

Background: AF is a frequent arrhythmia complicating CABG, and it is well known that dispersion and prolongation of P wave increases the risk of AF. The aim of this study was to investigate the effect of magnesium (Mg) treatment on P‐wave duration and dispersion in patients undergoing CABG. Method: The study included 148 consecutive patients (33 women, 115 men; mean age 62.1 ± 7.0 years) undergoing CABG who were randomly allocated to two groups. Group A consisted of 93 patients to whom 1.5 g daily MgSO₄ infusion was applied the day before surgery, just after operation, and 4 days following surgery, and group B consisted of 55 control patients. From the preoperative and postoperative fourth day, 12‐lead ECG recordings, duration of the P waves, and P‐wave dispersions were calculated. Results: There were no differences between the two groups with regard to age, sex, and blood Mg level. Comparison of the baseline and day 4 ECG measurements showed no difference as far as heart rates, duration of PQ, and QRS intervals were concerned. AF developed in 2 (2%) cases in group A and in 20 (36%) cases in group B (P < 0.001). There was no difference between the two groups when average basal P max, P min, P dispersion, and day 4 P min values were compared. In group A, fourth day P max (94.3 ± 11.8 vs 101.0 ± 13.2 ms; P = 0.0025) and P dispersion (38.2 ± 9.2 vs 44.9 ± 10.9 ms; P = 0.0002) were significantly lower as compared to group B. Comparing the patients who developed AF, and who did not, no difference was detected with regard to baseline P max, P min, P dispersion, and day 4 P min. Day 4 P max (95.1 ± 11.8 vs 106.4 ± 14.0 ms, P = 0.0015) and P dispersion (38.9 ± 8.8 vs 50.7 ± 13.0 ms, P = 0.001) of patients who developed AF were significantly higher. Baseline Mg levels were similar in patients who developed AF, and who did not, but the day 4 Mg level was significantly lower in AF group (2.0 ± 0.23 vs 2.15 ± 0.26 mg/dL, P < 0.001). Conclusion: Perioperative Mg treatment reduces P dispersion and the risk of developing AF in patients undergoing CABG. A.N.E. 2002;7(3):211–218     

Comparison of 50-mg and 100-mg sustained-release isosorbide mononitrate in the treatment of stable angina pectoris: effects on quality-of-life indices. Dutch Mononitrate Quality of Life (DUMQOL) Study Group

High-dosage nitrates are more effective for the management of anginal symptoms but produce more adverse effects, including development of tolerance and the zero-hour effect (rebound angina at the end of the dosing interval). Such effects may reduce the beneficial effect of treatment on quality of life. In a self-controlled, 6-month study, the effects on symptoms and quality of life of 50 mg and 100 mg sustained-release isosorbide mononitrate (SR ISMN), administered once daily, on anginal symptoms and quality of life (QOL) were assessed in 453 patients with stable angina pectoris. QOL was assessed by means of a test battery based on the Medical Outcomes Short-Form 36 Health Survey and the Angina Pectoris Quality of Life Questionnaire. The internal consistency and reliability of the multiitem scales were estimated by use of Cronbach's alpha coefficient. Based on their improvements in New York Heart Association (NYHA) angina classification, patients who received 100 mg daily showed greater improvement than those who received 50 mgdaily; the mean difference between treatments was consistent with a significantly greater improvement of mobility and angina indices. Adverse effects, as estimated by side-effect index, including rebound angina at times of rest, and by patient compliance rating, differed slightly between the two treatment regimens and were even less problematic with the higher dosage than with the lower dosage. Psychological distress index and life satisfaction scores also were significantly higher with 100 mg than with 50 mg daily. The results of this study suggest that SR ISMN 100 mg once daily provided a better NYHA angina classification than SR ISMN 50 mg did and did not produce further adverse effects. In addition SR ISMN 100 mg improved various QOL indices more than SR ISMN 50 mg did, particularly the mobility index and certain life satisfaction scores, which are the most important indicators of QOL in this category of patients.     

Outcome of Direct Oral Anticoagulant Treatment for Acute Lower Limb Deep Venous Thrombosis After Total Knee Arthroplasty Or Total Hip Arthroplasty

Abstract

Objective: The aim of this study was to examine the treatment outcomes of edoxaban and apixaban on deep venous thrombosis (DVT) in Japanese patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA).

Methods: We examined 100 patients receiving edoxaban or apixaban to treat lower limb DVT. The primary efficacy outcome was defined as the disappearance of DVT at three months post-treatment. The primary safety outcome was the change in hemoglobin (Hb) value after two and seven days of treatment compared with baseline, which was the start of treatment with edoxaban or apixaban.

Results: The primary efficacy outcome occurred in 61 of the 70 patients (87.1%) in the edoxaban group and in 28 of the 30 patients (93.3%) in the apixaban group. There was no significant difference between the edoxaban and apixaban groups in the disappearance of DVT at three months (p?=?.497). The change in Hb value from baseline to two days post-treatment was ?0.53?±?0.98 in the edoxaban group and ?0.06?±?0.75 in the apixaban group (p?=?.010). At seven days post-treatment, the changes in Hb were ?0.03?±?1.60 and 0.30?±?0.68 (p?=?.007) in the edoxaban and apixaban groups, respectively.

Conclusion: Edoxaban and apixaban were equivalent in efficacy. However, apixaban was superior to edoxaban in terms of the change in Hb value. In cases of major bleeding, both edoxaban and apixaban need to be used carefully when treating DVT.     

环肺静脉消融与抗心律失常药物治疗心房颤动对患者生活质量影响的对比研究

目的:比较环肺静脉消融与抗心律失常药物治疗心房颤动(房颤)对患者生活质量的影响.方法:入选2009-01至2010-05就诊于我院住院部房颤患者123例,其中66例行环肺静脉消融治疗的患者(消融组)和57例同期入院未行手术治疗的患者(药物组),对所有入选的患者采用健康调查简表SF-36(SF-36量表)调查方式分别于入院时及治疗后6个月进行生活质量评价.结果:消融组与药物组比较治疗后6个月SF-36量表中除肌体疼痛差异无统计学意义外,躯体功能、躯体角色、总体健康状况、活力、社会功能、情感角色和心理健康,以及躯体健康评分、精神健康评分均升高,差异均有统计学意义(P均＜0.05).将消融组患者按疗效分为成功者(41例)和未成功者(25例)分别进行比较,成功者SF-36量表中8个维度评分术后6个月与治疗前比较均有提高(P＜0.05),躯体健康评分从(227.4±57.0)分提高到(293.4±54.3)分(P＜0.001),精神健康评分从(243.8±51.7)分提高到(309.0±58.0)分(P＜0.001),差异均有统计学意义.结论:环肺静脉消融较抗心律失常药物治疗能明显改善患者房颤的症状,提高患者的生活质量.尤其消融成功患者中,环肺静脉消融治疗房颤可使患者生活质量明显改善.     

Off-label reduced-dose apixaban does not reduce hemorrhagic risk in Taiwanese patients with nonvalvular atrial fibrillation: A retrospective,observational study

East Asians are reportedly at high risk of anticoagulant-related bleeding; therefore, some physicians prefer to prescribe low-dose direct oral anticoagulants (DOACs). Little is known about the therapeutic effectiveness and safety of off-label reduced-dose apixaban in East Asians with nonvalvular atrial fibrillation (AF). We aimed to investigate the effectiveness and safety of off-label reduced-dose apixaban in Taiwanese patients with nonvalvular AF.This retrospective cohort study enrolled 1073 patients with nonvalvular AF who took apixaban between July 2014 and October 2018 from 4 medical centers in southern Taiwan. The primary outcomes included thromboembolic events (stroke/transient ischemic attack or systemic embolism), major bleeding, and all-cause mortality.Among all patients, 826 (77%) patients were classified as the “per-label adequate-dose” treatment group (i.e., consistent with the Food and Drug Administration label recommendations) while 247 (23%) patients were the “off-label reduced-dose” treatment group. The mean follow-up period was 17.5 ± 13 months. The “off-label reduced-dose” group did not have a lower major bleeding rate than the “per-label adequate-dose” group (4.8% vs 3.8%, adjusted hazard ratio [HR] 1.20, 95% confidence interval [CI] 0.69–2.09), but had a nonsignificantly higher incidence of thromboembolic events (4.23% vs 3.05%, adjusted HR: 1.29, 95% CI: 0.71–2.34).An off-label reduced-dose apixaban treatment strategy may not provide incremental benefits or safety for Taiwanese patients with nonvalvular AF.     

Effect of Apixaban on All-Cause Death in Patients with Atrial Fibrillation: a Meta-Analysis Based on Imputed Placebo Effect

Purpose

Vitamin K antagonists (VKAs) are the standard of care for stroke prevention in patients with atrial fibrillation (AF); therefore, there is not equipoise when comparing newer oral anticoagulants with placebo in this setting.

Methods

To explore the effect of apixaban on mortality in patients with AF, we performed a meta-analysis of apixaban versus placebo using a putative placebo analysis based on randomized controlled clinical trials that compared warfarin, aspirin, and no antithrombotic control. We used data from two prospective randomized controlled trials for our comparison of apixaban versus warfarin (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) and apixaban versus aspirin (Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment). Using meta-analysis approaches, we indirectly compared apixaban with an imputed placebo with respect to the risk of death in patients with AF. We used results from meta-analyses of randomized trials as our reference for the comparison between warfarin and placebo/no treatment, and aspirin and placebo/no treatment.

Results

In these meta-analyses, a lower rate of death was seen both with warfarin (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.57–0.97) and aspirin (OR 0.86, 95% CI 0.69–1.07) versus placebo/no treatment. Using data from ARISTOTLE and AVERROES, apixaban reduced the risk of death by 34% (95% CI 12–50%; p = 0.004) and 33% (95% CI 6–52%; p = 0.02), respectively, when compared with an imputed placebo. The pooled reduction in all-cause death with apixaban compared with an imputed placebo was 34% (95% CI 18–47%; p = 0.0002).

Conclusions

In patients with AF, indirect comparisons suggest that apixaban reduces all-cause death by approximately one third compared with an imputed placebo.

     

Long-Term Clinical Outcomes of Underdosed Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Atrial Flutter

BackgroundAlthough direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF.MethodsWe conducted a study of subjects with AF who had a clinical indication for stroke prophylaxis (with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 47 years, sex category [CHA₂DS₂-VASc] of 2 or greater) and were prescribed 1 of the 4 clinically approved DOACs (apixaban, rivaroxaban, dabigatran, or edoxaban). We compared all-cause mortality, composite of stroke and systemic embolism, composite of myocardial infarction (MI), acute coronary syndromes (ACS), and coronary revascularization, and major bleeding between patients appropriately dosed and inappropriately underdosed.ResultsA total of 8125 patients met inclusion criteria, with a mean follow up of 2.2 ± 2 years. Of those, 1724 patients (21.2%) were inappropriately dosed. After adjusting for baseline variables, there was no difference in all-cause mortality, risk of stroke or systemic embolism, International Society on Thrombosis and Haemostasis (ISTH) major bleeding, or composite of myocardial infarction, acute coronary syndromes, or coronary revascularization between patients appropriately dosed and inappropriately underdosed. In subgroup analysis, only apixaban demonstrated an increased incidence all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.03-1.49) with inappropriate underdosing. There was no difference in the remaining clinical outcomes noted on subgroup analysis.ConclusionUnderdosing of DOACs did not minimize risk of bleeding, systemic embolization or all-cause mortality in patients with AF. Inappropriate underdosing with apixaban in particular was associated with increased all-cause mortality.     

抗心房颤动起搏器的应用初探

为评价心房程序起搏治疗阵发性心房颤动 (简称房颤 )的有效性 ,1 1例阵发性房颤患者中 1 0例置入Selec tion90 0E(AF2 .0 )型起搏器、1例置入IntegrityTMAFXDR5346型起搏器。对患者进行术前 1个月和术后 1 ,2个月阵发性房颤事件和SF 36生活质量调查。结果 :患者术后 1 ,2个月较术前 1个月在有症状阵发性房颤事件数和生活质量评分有明显降低 (1 3 .0 1± 8.51 ,9.81± 5 .91vs 2 7.0 0± 1 3 .2 1 ;62 .82± 2 1 .57,55 .73± 1 8.48vs 1 1 0 .0 0± 1 6 .57,P值均<0 .0 5) ,术后 2个月较术后 1个月有症状阵发性房颤事件数 (9.81± 5 .91vs 1 3 .0 1± 8.51 )、阵发性房颤总数 (2 1 0 .0 0± 2 69.59vs 30 9.82± 41 8.1 4 )、房颤总持续时间 (6 .0 0± 4 .1 4dvs 7.87± 4 .2 6d)、房颤负荷 (2 0 .0 1 %± 1 3 .80 %vs 2 6 .2 4 %± 1 4 .2 0 % )及生活质量评分 (55 .73± 1 8.48vs 62 .82± 2 1 .57)均降低 (P值均 <0 .0 5)。结论 :心房程序起搏能够减少阵发性房颤事件的发生 ,降低房颤负荷 ,有望成为阵发性房颤药物治疗的重要辅助手段     

Efficacy of landiolol hydrochloride for atrial fibrillation after open heart surgery

It is important to establish effective treatment for postoperative atrial fibrillation (AF), the most common complication after cardiac surgery. We evaluated the efficacy and safety of landiolol hydrochloride for rhythm conversion in patients with postoperative AF. Among 134 patients who developed new-onset AF after open heart surgery between 2007 and 2009, 69 patients who received landiolol hydrochloride for treatment of postoperative AF were enrolled. The AF conversion rate, the percentage of patients with 20 % reduction of the ventricular rate, and the factors related to successful treatment were evaluated. Then, the landiolol group was compared with 65 patients who had postoperative AF and did not receive landiolol hydrochloride. Landiolol hydrochloride was the first-line treatment in 46 patients and the only therapy in 26 patients. Reversion to sinus rhythm was achieved in 51 patients, while the conversion rate in patients without landiolol hydrochloride was only 56.8 % (p < 0.05). A 20 % reduction of the ventricular rate was achieved more frequently in the landiolol group. Although landiolol hydrochloride was highly effective in patients who had undergone off-pump coronary artery bypass grafting, patients with cardiopulmonary bypass did not respond as well. The heart rate was reduced from 130 ± 26 to 81 ± 12 (p < 0.05) after landiolol administration, while blood pressure did not decrease significantly. Landiolol hydrochloride was effective for conversion of postoperative AF. This ultra-short-acting β-blocker is a safe first-line treatment for postoperative AF after open heart surgery, and is most effective in patients who have undergone off-pump coronary artery bypass grafting.     

Relative effects of different non-vitamin K antagonist oral anticoagulants on global thrombotic status in atrial fibrillation

Non-vitamin K antagonist oral anticoagulants (NOACs) reduce the risk of thromboembolism in patients with atrial fibrillation (AF). There has been no head-to-head comparison of the effect of these agents on ex vivo thrombotic and thrombolytic status. Enhanced platelet reactivity and impaired endogenous thrombolysis are risk factors for recurrent thrombotic events. We aimed to assess the comparative effect of NOACs and warfarin using an ex vivo test of thrombosis and thrombolysis. Eighty patients with newly diagnosed non-valvular AF were tested before, and after being established on apixaban (n = 20), dabigatran (n = 20), rivaroxaban (n = 20), or warfarin (n = 20). Thrombotic status was assessed with the automated, point-of-care Global Thrombosis Test (GTT) that assesses both platelet reactivity and endogenous thrombolysis from native blood. The time taken to form an occlusive thrombus (occlusion time, OT) and the time required to restore flow through endogenous thrombolysis (lysis time, LT) were measured. All anticoagulants caused OT prolongation compared to baseline (apixaban 403 ± 102s vs. 496 ± 125s, p = 0.006; dabigatran 471 ± 106s vs. 656 ± 165s, p < 0.00001; rivaroxaban 381 ± 119s vs. 579 ± 158, p < 0.00001; warfarin 420 ± 145s vs. 604 ± 124s, p < 0.00001). Apixaban reduced LT from baseline (1895[1702–2167]s vs. 1435[347–1990]s; p = 0.006). A trend for LT reduction was seen with other NOACs (dabigatran 1594[1226–2069]s vs. 1539[561–2316]s, p = 0.499; rivaroxaban 2085[1366–2428]s vs. 1885[724–2420]s, p = 0.295) but not with warfarin (1490[1206–1960]s vs. 1776[1545–2334], p = 0.601). Our results suggest that NOACs and warfarin have a similar favorable effect on reducing platelet reactivity. All NOACs exhibited a trend toward enhancing endogenous thrombolytic status, although this was significant only for apixaban. This raises the possibility of using NOACs to enhance impaired endogenous fibrinolysis in patients at high-thrombotic risk.     

Willingness score obtained after a short CPAP trial predicts CPAP use at 1 year

Purpose

To predict continuous positive airway pressure (CPAP) adherence at 1 year.

Methods

We followed consecutive OSA patients scheduled for CPAP initiation for 1 year. Patients completed a self-efficacy questionnaire (5 = low, 25 = high score) before CPAP initiation. After CPAP initiation, we enquired about patients’ satisfaction in CPAP trial and their eagerness and willingness to continue CPAP therapy (0 = unsatisfied, uneager, or refused CPAP; 100 = satisfied, eager, or willing to continue CPAP treatment).

Results

Of the 580 patients we followed, 377 continued CPAP therapy beyond 1 year. A low willingness score (<50) was expressed by 77 patients but only 7 of them used CPAP >4 h daily at 1 year, yielding a specificity of 97 % in predicting CPAP failure. At 1 year, patients with a self-efficacy score >20, expressed prior to CPAP initiation, used CPAP more often than the patients with a score <20 (average use 4.4?±?2.2 h vs. 3.7?±?2.3 h, p?<?0.001).

Conclusions

A low score of willingness to continue CPAP therapy after a short trial predicts CPAP failure and poor CPAP adherence at 1 year.     

Apixaban in patients with atrial fibrillation and prior coronary artery disease: Insights from the ARISTOTLE trial

Background

A substantial portion of patients with atrial fibrillation (AF) also have coronary artery disease (CAD) and are at risk for coronary events. Warfarin is known to reduce these events, but increase the risk of bleeding. We assessed the effects of apixaban compared with warfarin in AF patients with and without prior CAD.

Methods and results

In ARISTOTLE, 18,201 patients with AF were randomized to apixaban or warfarin. History of CAD was defined as documented CAD, prior myocardial infarction, and/or history of coronary revascularization. We analyzed baseline characteristics and clinical outcomes of patients with and without prior CAD and compared outcomes by randomized treatment using Cox models. A total of 6639 (36.5%) patients had prior CAD. These patients were more often male, more likely to have prior stroke, diabetes, and hypertension, and more often received aspirin at baseline (42.2% vs. 24.5%). The effects of apixaban were similar among patients with and without prior CAD on reducing stroke or systemic embolism and death from any cause (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.71–1.27, P for interaction = 0.12; HR 0.96, 95% CI 0.81–1.13, P for interaction = 0.28). Rates of myocardial infarction were numerically lower with apixaban than warfarin among patients with and without prior CAD. The effect of apixaban on reducing major bleeding and intracranial hemorrhage was consistent in patients with and without CAD.

Conclusions

In patients with AF, apixaban more often prevented stroke or systemic embolism and death and caused less bleeding than warfarin, regardless of the presence of prior CAD. Given the common occurrence of AF and CAD and the higher rates of cardiovascular events and death, our results indicate that apixaban may be a better treatment option than warfarin for these high-risk patients.     

Quality of life in adult patients with Familial Mediterranean fever living in Germany or Turkey compared to healthy subjects: a study evaluating the effect of disease severity and country of residence

We assessed quality of life (QOL) and disease activity in patients with Familial Mediterranean fever (FMF) of Turkish ancestry living in Germany or Turkey and conducted a correlation with FMF disease activity. 40 FMF patients in Turkey (TR), 40 FMF patients in Germany (G) and 40 healthy controls in Germany (C) were included. QOL was evaluated with the short form of the World Health Organisation Quality of Life scale (WHOQOL-BREF). FMF disease activity was examined with the Pras score. Mean age was TR 30.5 ± 10.6, G 35.2 ± 10.2, C 34.6 ± 10.7. Of the 120 participants, 77 were female. FMF patients in TR and G had a significantly decreased QOL physical health domain compared to controls (TR 59.7 ± 18.8, G 60.4 ± 19.4, C 76.5 ± 14.6). Turkish FMF patients had a lower QOL environment domain compared to controls (TR 62.3 ± 17.5, G 69.7 ± 16.5, C 72.3 ± 13.5). In the other QOL domains, no significant differences were found. The differences in QOL were robust to a regression analysis. No significant correlation between QOL and FMF disease activity was found. German FMF patients had longer duration of disease, younger age at onset and longer delay from disease onset to colchicine treatment. A total of 5 of 40 German FMF patients were not taking colchicine (TR:0). Erythrocyte sedimentation rate was lowest in TR with significant difference between TR and G as well as G and C (TR 13.2 ± 10.3, G 27.8 ± 19.4, C 16.3 ± 12.8 mm/h). C-reactive protein did not differ between TR and G. FMF has an important impact on QOL physical health domain. No correlation between FMF disease activity and the WHOQOL-BREF could be found.