Aspirin attenuates the incidence of silent brain lesions in patients with nonvalvular atrial fibrillation.

BACKGROUND: Abnormal findings, including silent cerebral infarction, are frequently observed by magnetic resonance imaging (MRI) in patients with nonvalvular atrial fibrillation (NVAF); however, the prevalence and prevention strategy for these lesions have not been extensively studied. In the present study the preventive effects of aspirin on silent ischemic lesions was investigated. METHODS AND RESULTS: Silent lesions were counted using cranial MRI performed in 78 neurologically normal adults with sinus rhythm and in 212 patients with NVAF without a history of stroke. MRIs were repeated twice in the NVAF patients at 12-month intervals. During the first year, patients received neither antiplatelet agent nor anticoagulant; in the second year, aspirin (330 mg daily) was administered. The prevalence of lesions in the initial MRI was higher in NVAF patients (86.4%) than in sinus rhythm subjects (53.8%; p<0.001). After 12 months without aspirin, new lesions were seen in 20.6% of NVAF patients. The yearly occurrence of new lesions was decreased to 9.6% during the year of treatment with aspirin (p=0.014). CONCLUSIONS: In patients with NVAF, abnormal lesions are frequently observed by MRI and aspirin treatment may be effective in preventing further small silent lesions.     

Echocardiographic findings and the increased risk of stroke in nonvalvular atrial fibrillation.

We studied whether cardiac abnormalities contribute to the increased risk of stroke in patients with nonvalvular atrial fibrillation (NVAF). M-mode and 2D echocardiography were performed in four age- and gender-matched groups: 20 stroke patients with NVAF, 20 patients with NVAF who had not suffered a previous stroke, 20 stroke patients with sinus rhythm, and 40 healthy controls. Their mean age was 77 years. The two groups with atrial fibrillation differed from healthy controls in that they had more 2D-echocardiographic findings of severe left-ventricular-wall-motion abnormalities (p < 0.05) and tended more often to have enlarged left ventricles, and hypertrophic and congestive cardiomyopathy. Left atrial diameter was 47 mm compared to 41 and 39 mm in the two groups with sinus rhythm (p < 0.001). Intracardiac thrombi were only found in the two atrial-fibrillation groups (with stroke: 15% without stroke: 5%). Aortic sclerosis was common in all groups (30-60%), as was mitral annulus calcification (10-20%). The only significant difference between the two atrial-fibrillation groups was a higher frequency of earlier ischemic heart disease in the stroke group. Both atrial-fibrillation groups had cardiac abnormalities predisposing for embolic as well as thrombotic stroke.     

Trajectories of cognitive decline and functional status in the frail older adults

This study investigates the implications of different levels of cognitive decline on functional status in frail older adults. Four cognitive trajectories, including two with catastrophic cognitive decline, were defined in a 3-year study. Participants with complete cognitive and functional status data at baseline, 12 and 36 months of follow-up were included in the study (n=456). Data were analysed with repeated measures statistics. Substantial functional deterioration over time was observed for the participants with catastrophic cognitive decline. Catastrophic cognitive decline influenced performance in instrumental activities of daily living (IADL) and activities of daily living (ADL) at 12 months, whereas basic physical and mental actions were affected at 36 months. IADL were found to deteriorate more than ADL. The results have implications on planning appropriate geriatric rehabilitation and long-term care program.     

Effects of anticoagulation intensity on hemostatic markers in patients with non-valvular atrial fibrillation.

BACKGROUND: Elevation of hemostatic markers may account for the increased risk of ischemic stroke in patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to determine the effects of anticoagulation intensity on hemostatic markers in patients with NVAF. METHODS AND RESULTS: In 509 patients with NVAF, comprising 263 patients treated with warfarin and 246 patients without warfarin, the hemostatic markers of prothrombin fragment F1.2 (F1.2), fibrin D-dimer, platelet factor 4 (PF4), and beta-thromboglobulin were determined and compared with those in 111 patients with sinus rhythm. F1.2 was inversely related with anticoagulation intensity and D-dimer increased with age. All hemostatic markers, except F1.2, were greater in patients with NVAF than in patients with sinus rhythm. F1.2 and D-dimer were significantly lower in patients with international normalized ratio (INR) > or =1.5 than in NVAF patients without warfarin and were not different between NVAF patients with INR of 1.5-1.9 and with INR > or =2.0. CONCLUSIONS: Low intensity of anticoagulation (INR 1.5-1.9) suppresses the elevated concentration of F1.2 and D-dimer in patients with NVAF, and might be favorable in Japanese patients with NVAF in view of the balance between prevention of thromboembolism and the adverse effect by warfarin (ie, bleeding).     

Nonvalvular atrial fibrillation associated with cardioembolic stroke: the role of hypertensive heart disease

Abstract Epidemiologists have not identified high risk groups nor the entire spectrum of heart disease, especially the subclinical forms underlying nonvalvular atrial fibrillation (NVAF) predisposing to cardioembolic (CE) stroke. We analysed 36 cases of ‘isolated’ NVAF among 106 consecutive cases of CE stroke after excluding cases of AF associated with valvular disease, myocardial infarcts, ischaemic and other cardio-myopathies (34 cases). This revealed echocardiographic left ventricular hypertrophy (LV mass index 136 ± 25 g, vs normal 68 ± 12 g p < 0.001), enlarged left atria (left atrial area 27.4 ± 3.6 cm² vs normal 14.3 ± 1.6 cm²p < 0.001), normal systolic function and formed the largest group associated with CE stroke (34%), mean age 72.6 years – Study Group D. Eighty nine per cent had known or undetected hypertension compared to 60% in matched controls (x²= 8.3 df= 1 p < 0.01), and hypertension remained the predominant risk factor for left ventricular hypertrophy (LVH). Although all had echocardiographic LVH, 60% had neither electrocardiographs LVH nor cardiomegaly on chest X-ray. Hence usual epidemiologic methods may fail to detect these cases. Hypertensive heart disease is known to predispose to left atrial enlargement and AF. Progressive atrial enlargement is associated with increasing risk of embolie stroke. We conclude that NVAF associated with hypertensive heart disease forms a major component of the spectrum of heart disease associated with NVAF predisposing to CE stroke. Detection and treatment of hypertension to prevent or reverse LVH and atrial enlargement should be an important preventive measure.     

Impact of rate versus rhythm control on quality of life in patients with persistent atrial fibrillation. Results from a prospective randomized study.

AIMS: Despite the high prevalence of atrial fibrillation (AF), there are only limited data on quality of life (QoL) stemming from prospective trials comparing rate versus rhythm control. This prospective study evaluated QoL in patients with symptomatic persistent AF randomized to therapy aiming at rate versus rhythm control. METHODS AND RESULTS: Patients with symptomatic persistent AF (7 to 360 days duration) were prospectively randomized to ventricular rate control (n=125) or to cardioversion and maintenance of sinus rhythm (n=127). QoL was assessed by the Medical Outcomes Study Short Form health survey (SF-36) at baseline and during 1 year of follow-up. Changes in QoL were compared on an intent-to-treat basis, and subsequently between patients in sinus rhythm versus AF. At baseline, all SF-36 scales were reduced compared to healthy controls. At 1 year, six of eight items had improved significantly in patients assigned to rate control, and five of eight items on rhythm control (p=ns). The physical component summary showed a comparable increase with both treatment strategies (rate control: p=0.004; rhythm control: p<0.001) whereas no significant changes were found for the mental component summary. At 1 year, 55% of patients reported a positive health transition with no inter-group differences. There were no significant differences in QoL in patients in sinus rhythm or AF at the end of the observation period. CONCLUSION: In patients with symptomatic persistent AF, the two treatment strategies of rate versus rhythm control are associated with similar improvements in QoL.     

Relationship between the long-term preventive effect of combined treatment with antiarrhythmic drugs plus angiotensin-converting enzyme inhibitors and circadian variation in the onset of paroxysmal atrial fibrillation

We examined the relationship between the efficacy of combined treatment with antiarrhythmic drugs (AAD) plus enalapril for maintaining sinus rhythm and circadian variation in the onset of paroxysmal AF.Three hundred and forty-four patients with paroxysmal AF (239 men, mean age, 69 ± 11 years) who could be followed up ≥ 12 months were divided into 3 groups on the basis of circadian variation in the onset of AF: a diurnal group (7:00 AM-5:00 PM, n = 57), a nocturnal group (5:00 PM-7:00 AM, n = 108), and a mixed group (onset during both periods, n = 169). The maintenance rate of sinus rhythm during the follow-up period was compared between combined therapy (AAD plus enalapril) and AAD alone.In the diurnal group, the maintenance rates of sinus rhythm at 12, 36, 60, and 90 months were 100%, 100%, 100%, and 100%, respectively, for patients treated with AAD plus enalapril (n = 22) versus 97%, 91%, 89%, and 80% for patients treated with AAD alone (n = 35, P < 0.05). In the nocturnal group, the maintenance rates of sinus rhythm at 12, 36, 60, and 90 months were 96%, 96%, 96%, and 92%, respectively, in patients treated with AAD plus enalapril (n = 24) versus 100%, 100%, 100%, and 100% in patients treated with AAD alone (n = 84, P = NS). In the mixed group, maintenance rates of sinus rhythm at 12, 36, 60, and 90 months were 90%, 71%, 61%, and 57%, respectively, in patients treated with AAD plus enalapril (n = 49) versus 88%, 78%, 68%, and 61% in patients treated with AAD alone (n = 120, P = NS). Our findings suggest that the preventive efficacy of combined therapy with AAD plus enalapril is dependent on the timing of onset of paroxysmal AF, and this regimen seems to be most beneficial for the diurnal type of paroxysmal AF.     

Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease

BACKGROUND: High blood pressure and stroke are associated with increased risks of dementia and cognitive impairment. This study aimed to determine whether blood pressure lowering would reduce the risks of dementia and cognitive decline among individuals with cerebrovascular disease. METHODS: The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was a randomized, double-blind, placebo-controlled trial conducted among 6105 people with prior stroke or transient ischemic attack. Participants were assigned to either active treatment (perindopril for all participants and indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo(s). The primary outcomes for these analyses were dementia (using DSM-IV criteria) and cognitive decline (a decline of 3 or more points in the Mini-Mental State Examination score). RESULTS: During a mean follow-up of 3.9 years, dementia was documented in 193 (6.3%) of the 3051 randomized participants in the actively treated group and 217 (7.1%) of the 3054 randomized participants in the placebo group (relative risk reduction, 12% [95% confidence interval, -8% to 28%]; P =.2). Cognitive decline occurred in 9.1% of the actively treated group and 11.0% of the placebo group (risk reduction, 19% [95% confidence interval, 4% to 32%]; P =.01). The risks of the composite outcomes of dementia with recurrent stroke and of cognitive decline with recurrent stroke were reduced by 34% (95% confidence interval, 3% to 55%) (P =.03) and 45% (95% confidence interval, 21% to 61%) (P<.001), respectively, with no clear effect on either dementia or cognitive decline in the absence of recurrent stroke. CONCLUSIONS: Active treatment was associated with reduced risks of dementia and cognitive decline associated with recurrent stroke. These findings further support the recommendation that blood pressure lowering with perindopril and indapamide therapy be considered for all patients with cerebrovascular disease.     

The efficacy of azimilide in the treatment of atrial fibrillation in the presence of left ventricular systolic dysfunction: results from the Azimilide Postinfarct Survival Evaluation (ALIVE) trial

OBJECTIVES: The purpose of this study was to assess the effect of oral azimilide dihydrochloride (AZ) 100 mg versus placebo on the onset, termination, and prevalence of atrial fibrillation (AF) in a subpopulation of patients in the Azimilide Postinfarct Survival Evaluation (ALIVE) trial. BACKGROUND: Previous clinical trials have demonstrated the antiarrhythmic effects of AZ in patients with AF. Azimilide was investigated for its effects on mortality in patients with depressed left ventricular (LV) function after recent myocardial infarction (MI) and in a subpopulation of patients with AF. METHODS: A total of 3,381 post-MI patients with depressed LV function were enrolled in this randomized, placebo-controlled, double-blind study of AZ 100 mg on all-cause mortality. A total of 93 patients had AF on the baseline 12-lead electrocardiogram (ECG). An additional 27 patients developed AF after initially being in sinus rhythm at randomization. These patients were identified through 12-lead ECGs obtained during routine visits at week 2, months 1, 4, 8, and 12. RESULTS: Patients with AF at baseline had a higher mortality than those without AF (p = 0.0006). Among AF patients, there was no difference in mortality between AZ patients and placebo patients (p = 0.82). Fewer AZ patients developed AF than placebo patients (p = 0.04). More AZ patients than placebo patients converted to sinus rhythm, but this difference did not achieve statistical significance (p = 0.076). Over one-year follow-up, more AZ patients were in sinus rhythm than placebo patients (p = 0.04). CONCLUSIONS: Azimilide was safe and effective AF therapy in patients with depressed LV function after an MI.     

Arterial stiffness as an independent predictor of longitudinal changes in cognitive function in the older individual

BACKGROUND: Cognitive decline significantly contributes to disability in older individuals. We previously demonstrated cross-sectionally that arterial stiffness [pulse wave velocity (PWV)] was associated with memory loss independently of traditional cardiovascular risk factors and of neuroimaging findings in older individuals without prior stroke. The present study aimed to evaluate PWV as a predictor of longitudinal changes in cognitive function in older individuals reporting memory problems. PARTICIPANTS AND METHODS: We studied 102 older individuals (mean age 79 +/- 6 years; 31 men, 71 women) reporting memory problems. PWV was measured noninvasively by Complior. Traditional cardiovascular risk factor levels were measured. Global cognitive function was measured by the Mini-Mental State Examination (MMSE) (maximum score = 30) at baseline and at follow-up visit. Cerebral computed tomography evaluated the presence of microvascular damage or cortical atrophy. Individuals with prior stroke or atrial fibrillation were excluded. RESULTS: The baseline MMSE was 22.9 +/- 5.5; 61% were hypertensive, 26.8% diabetic, 9.4% smokers, 10.5% taking statins, and 21.1% taking nitrates. The average PWV was 13.5 +/- 2.2 m/s. After a median follow-up of 12 months, the average per-year decline in MMSE was 2.9 points or 12.1%. Multiple regression models showed that PWV independently predicted cognitive decline (model R2 = 0.50). PWV was the single strongest predictor of cognitive decline, explaining 15.2% of the total variance (each 1 m/s increase in PWV was associated with an average 0.74 per-year decrease in MMSE score, P < 0.001). CONCLUSION: In older individuals, arterial stiffness (PWV) is a strong predictor of loss in cognitive function, independent of age, sex, education, and traditional cardiovascular risk factors.     

Cognitive Decline Before and After Incident Coronary Events

BackgroundPrevious studies have suggested that coronary heart disease (CHD) may be associated with accelerated cognitive decline. However, the temporal pattern of cognitive decline before and after incident CHD remains largely unknown.ObjectivesThe purpose of this study was to determine the cognitive trajectory before and after incident CHD diagnosis in a national representative cohort age ≥50 years.MethodsThis study included 7,888 participants (mean age 62.1 ± 10.2 years) with no history of stroke or incident stroke during follow-up from the English Longitudinal Study of Ageing. Participants underwent a cognitive assessment at baseline (wave 1, 2002 to 2003), and at least 1 other time point (from wave 2 [2004 to 2005] to wave 8 [2016 to 2017]). Incident CHD was identified as a diagnosis of myocardial infarction and/or angina during follow-up.ResultsIncident CHD was associated with accelerated cognitive decline during a median follow-up of 12 years. The annual rate of cognitive decline before CHD diagnosis among individuals who experienced incident CHD was similar to that of participants who remained CHD-free throughout follow-up. No short-term cognitive decline was observed in participants with CHD diagnosis after the event. In the years following CHD diagnosis, global cognition, verbal memory, and temporal orientation scores declined significantly faster than they did before the event, after multivariable adjustment. Sensitivity analyses yielded similar results.ConclusionsIncident CHD is associated with accelerated cognitive decline after, but not before, the event. Attention should be drawn to the long-term cognitive deterioration related to CHD. Careful monitoring of cognitive function is warranted in CHD patients in the years following the event.     

Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study

OBJECTIVES: We studied the influence of rate control or rhythm control in patients with persistent atrial fibrillation (AF) on quality of life (QoL). BACKGROUND: Atrial fibrillation may cause symptoms like fatigue and dyspnea. This can impair QoL. Treatment of AF with either rate or rhythm control may influence QoL. METHOD: Quality of life was assessed in patients included in the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) study (rate vs. rhythm control in persistent AF). Rate control patients (n = 175) were given negative chronotropic drugs and oral anticoagulation. Rhythm control patients (n = 177) received serial electrocardioversion, antiarrhythmic drugs, and oral anticoagulation, as needed. Quality of life was studied using the Short Form (SF)-36 health survey questionnaire at baseline, one year, and the end of the study (after 2 to 3 years of follow-up). At baseline, QoL was compared with that of healthy control subjects. Patient characteristics related to QoL changes were determined. RESULTS: Mean follow-up was 2.3 years. At baseline, QoL was lower in patients than in age-matched healthy controls. At study end, under rate control, three subscales of the SF-36 improved. Under rhythm control, no significant changes occurred compared with baseline. At study end, QoL was comparable between both groups. The presence of complaints of AF at baseline, a short duration of AF, and the presence of sinus rhythm (SR) at the end of follow-up, rather than the assigned strategy, were associated with QoL improvement. CONCLUSIONS: Quality of life is impaired in patients with AF compared with healthy controls. Treatment strategy does not affect QoL. Patients with complaints related to AF, however, may benefit from rhythm control if SR can be maintained.     

Serum high sensitivity C-reactive protein and cognitive function in elderly women

BACKGROUND: Inflammation has been linked to cognitive impairment. However, limited data are available on the association between inflammatory markers and cognitive function. OBJECTIVES: We tested the hypothesis that elevated serum concentration of high sensitivity C-reactive protein (hs-CRP), an established marker of low-grade inflammation, predicts cognitive impairment in elderly women. DESIGN: A 12-year population-based follow-up study. PARTICIPANTS: A total of 97 women between 60 and 70 years of age at baseline. METHODS: Serum hs-CRP concentration was measured by a high sensitivity assay. Global cognitive function was measured with the Mini-Mental State Examination (MMSE), and memory and cognitive speed were measured with a detailed cognitive test battery. RESULTS: Higher baseline hs-CRP was associated with poorer memory at 12-year follow-up without adjustment and after adjustment for age, education and depression (standardised regression coefficient beta -0.842, 95% confidence interval -1.602 to -0.083, P = 0.030), and further adjustment for the use of hormone replacement therapy, smoking, serum LDL cholesterol and body mass index (standardised regression coefficient beta -0.817, 95% confidence interval -1.630 to -0.004, P = 0.049). Memory at 12-year follow-up worsened linearly with increasing hs-CRP at baseline (P = 0.048 for linear trend). There was no association between hs-CRP at baseline and cognitive speed or MMSE score at 12-year follow-up. CONCLUSIONS: High serum hs-CRP concentration predicts poorer memory 12 years later in elderly women. Hs-CRP may be a useful biomarker to identify individuals at an increased risk for cognitive decline.     

Hypercoagulopathy in stroke patients with nonvalvular atrial fibrillation: hematologic and cardiologic investigations.

The coagulation system is activated and coagulation activation markers are elevated in acute ischemic stroke with nonvalvular atrial fibrillation (NVAF). The etiology, severity, and prognosis of the ischemic stroke might be estimated with the level of the activation of the coagulation system. In this study, prothrombin F1+2 (F1+2), D-dimer, and fibrinogen levels were measured in patients with acute ischemic stroke with and without NVAF, and stroke severity was compared with these hemostatic parameters. Of 55 patients, 29 had sinus rhythm (group I), 26 had NVAF (group II); 20 healthy subjects (group III) were included in the study. Subtypes of cerebral infarction were classified. The patients underwent stroke severity, electrocardiography, echocardiography, cranial computed tomography, cervical duplex ultrasonography, and hemostatic parameter studies. In group II, F1+2 level (2.83+/-0.89) was significantly higher than in group I (2.33+/-0.80) and III (1.94+/-0.64) (p values: group I-II, 0.036; groups II-III, 0.001; groups I-III, 0.104). In group III, fibrinogen level (251.64+/-60.96) was significantly lower than that in groups I (347.97+/-111.49) and II (364.04+/-86.20) (p=0.001). D-dimer was not significantly different between groups. In group I, lacunar syndrome (LACS), and in group II, partial and total anterior circulation syndrome (PACS+TACS) were more common (p=0.013, p=0.001, respectively). In group II, Scandinavian Stroke Scale scores were lower than those in group I (group I=45.2+/-14, group II=35.4+/-18.9, p=0.02). In conclusion, activation of coagulation, demonstrated by increment F1+2, is more abundant in the stroke patients with NVAF than in the stroke patients with sinus rhythm. Our results also showed that activation of the hemostatic system might be related to stroke subtype and stroke severity. It is suggested that the oral anticoagulation treatment as prophylaxis is important in the prevention of stroke in patients with NVAF.     

Occurrence and characteristics of stroke events in the Atrial Fibrillation Follow-up Investigation of Sinus Rhythm Management (AFFIRM) study

BACKGROUND: Atrial fibrillation (AF) is a risk factor for stroke, especially when accompanied by other high-risk cardiovascular predictors. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study was a multicenter comparison of high-risk patients with AF who were randomized to either a sinus rhythm control or a rate control strategy. METHODS: Physicians were encouraged to continue anticoagulation therapy for their patients. Patients in the sinus rhythm control group could stop warfarin sodium therapy after 4 (preferably a minimum of 12) weeks if they maintained sinus rhythm while receiving an antiarrhythmic drug. RESULTS: The AFFIRM Study enrolled 4060 patients. Mortality was the same in both groups. Two hundred eleven patients (8.2%) had a stroke event. Ischemic stroke occurred in 157 patients (6.3%), primary intraparenchymal hemorrhage in 34 (1.2%), and subdural or subarachnoid hemorrhage in 24 (0.8%). The most frequently determined ischemic stroke mechanism was cardioembolic (35/71 [49%]). Treatment assignment had no significant effect on the occurrence of ischemic stroke. Patients in AF at the time of the stroke event had a 60% greater chance of having an ischemic stroke, and those taking warfarin at the time of follow-up had a 69% decrease in the risk of having an ischemic stroke. CONCLUSIONS: In the AFFIRM Study, stroke rates were not significantly different in the rate control and sinus rhythm control arms. However, several clinical and therapeutic variables were associated with stroke risk. In patients with a history of AF at high risk for stroke or death, the presence of AF increases the risk of having a stroke, and warfarin therapy reduces the risk of having a stroke. The beneficial effect of warfarin therapy is seen not only in patients in AF but also in patients with a history of AF but who presumably remain in sinus rhythm.     

31例难治性慢性心力衰竭心脏再同步化治疗的疗效观察

目的 总结31例难治性慢性心力衰竭(心衰)患者接受心脏再同步化治疗(CRT)的疗效及临床经验.方法 31例难治性慢性心衰患者,通过药物治疗(28例)或结合床旁连续性肾脏替代治疗(3例)改善心功能后接受CRT治疗.左心室电极置入过程中采用了中空造影导管直接显影(11例)、带球囊的造影导管进行充气造影(20例)来显示冠状静脉窦及其分支.合并心房颤动患者(3例)仅置入左、右心室电极.伴有血液动力学障碍的室性心动过速/心室颤动患者(4例),置入双心室再同步自动复律除颤器(CRT-D).全部患者术前1周接受心电图、24 h动态心电图、超声心动图、临床心功能评价,并在术后6、12、18、24个月时随访上述检查.结果 31例患者均顺利完成起搏器置入术,1例置入CRT-D的患者术后3 d因出现多脏器功能衰竭死亡,1例置入CRT的患者在术后5个月时发生猝死,2例患者分别于3、6个月时失访;余27例患者随访结果显示,术后QRS平均时限较术前缩短,临床评价及超声测定的心功能情况明显改善,3例置入CRT-D的患者再发恶性室性心律失常时全部经电除颤成功转复为窦性心律.结论 CRT能改善难治性慢性心衰患者的心功能,提高患者的生活质量.CRT-D可以有效治疗恶性室性心律失常,预防猝死发生.     

The effects of the ACTIVE cognitive training trial on clinically relevant declines in health-related quality of life

OBJECTIVES: The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study used three cognitive interventions (memory, reasoning, or speed of processing) in order to improve cognitive abilities. In this article, we evaluate ACTIVE's ability to avoid extensive decline in health-related quality of life (HRQoL). METHODS: ACTIVE enrolled 2,802 adults aged 65 or older and randomized them into one of three cognitive interventions or a no-contact control group. Researchers obtained data on 2,147 participants at the 24-month follow-up. We measured HRQoL by using the eight Short Form-36 scales, and we defined clinically relevant decline on each as a drop of 0.5 standard deviations from baseline. We defined extensive HRQoL decline as clinically relevant drops on four or more Short Form-36 scales, and we assessed this by using multiple logistic regression methods that adjusted for sociodemographic, cognitive, and health status covariates, and incorporated propensity score derived weights in order to adjust for potential attrition bias. RESULTS: We found that 25.0% of ACTIVE participants had extensive HRQoL decline. Participants in the speed-of-processing intervention arm were less likely to have extensive HRQoL decline (adjusted odds ratio = 0.643; p =.004) compared with controls, and participants in the memory and reasoning arms were equivalent to controls (adjusted odds ratios = 1.149 and 1.014, respectively; ps =.322 and.919, respectively). DISCUSSION: Although all three intervention arms improved cognitive ability, only the speed-of-processing arm protected against extensive clinically relevant decline in HRQoL.     

Pathogenetic mechanism of stroke in non-valvular atrial fibrillation: follow-up of stroke patients with and without atrial fibrillation

Abstract. Stroke patients with brain infarction and non-valvular atrial fibrillation (NVAF, n = 88) or sinus rhythm (SR, n = 188), treated at a population-based stroke unit, were studied for 5 years. Within 1 month, 13% of NVAF and 2% of SR patients (P < 0.01) had either a stroke recurrence or systemic embolism. After 5 years, the corresponding figures were 26 and 25%, respectively. The 1-month and 5-year mortality values were 35 and 78% in the NVAF group vs. 7 and 52% in the SR group (P < 0.01). Age, ischaemic heart disease and function group on arrival at the hospital were independent risk factors for death. The main cause of death was ischaemic heart disease in the NVAF group, and complications to the initial stroke or a stroke recurrence in the SR group. Thus a higher risk of death, stroke recurrence and peripheral embolism was evident only during the first month after stroke.     

Predictors of combined cognitive and physical decline

OBJECTIVES: To determine the incidence and correlates of combined declines in cognitive and physical performance. DESIGN: Cohort study of community-dwelling older women with moderate to severe disability. SETTING: The community surrounding Baltimore, Maryland. PARTICIPANTS: Participants in the Women's Health and Aging Study I with Mini-Mental State Examination (MMSE) score or 24 or greater and walking speed greater than 0.4 m/s at baseline. MEASUREMENTS: Cognitive decline was defined as an MMSE score less than 24 and physical decline as a walking speed of 0.4 m/s or less in at least one of the three annual follow-up visits. Participants were stratified into groups based on cognitive or physical decline or both. Group characteristics were compared, and results were adjusted for age, race, education, and significant covariates. RESULTS: Of 558 women that met the baseline MMSE and walking speed inclusion criteria, 21% developed physical decline, 12% developed cognitive decline, and 11% experienced combined cognitive and physical decline. After adjustment, physical decline was associated with age, nonwhite race, former smoking, baseline walking speed, and instrumental activities of daily living (IADL) impairment. Cognitive decline was associated with age and baseline MMSE score. Combined decline was associated with age, baseline walking speed, MMSE score, IADL impairment, as well as current smoking (odds ratio (OR)=5.66, 95% confidence interval (CI)=1.49-21.54) and hemoglobin level (OR=0.68, 95% CI=0.47-0.98). CONCLUSION: Potential predictors of cognitive and physical performance decline were identified. The association between smoking and lower hemoglobin levels and combined cognitive and physical decline may represent potentially modifiable risk factors and should be confirmed in future studies.     

Early versus Late Atrial Fibrillation after Atrial Flutter Ablation

Introduction: Radiofrequency catheter ablation of atrial flutter (AFl) has high initial success with a 10–15% recurrence. Atrial fibrillation (AFib) after radiofrequency catheter ablation of AFl can occur but may be transient (lasting no more than four weeks). Methods: Of one hundred seventeen consecutive patients studied, one hundred and four consecutive patients with sustained, symptomatic AFl, as the predominant rhythm disturbance (some of whom had transient pre-ablation AFib), referred for radiofrequency catheter ablation, had clinical follow-up. All had evidence for successful AFl ablation. Patients were followed prospectively. Results: Over a mean follow-up of 28 months, 28 patients developed AFib after ablation of AFl [12 early AFib (<2 months) and 16 late AFib (>2 months)]. Seven of 12 (58%) patients in the early onset group reverted to normal sinus rhythm; none required long-term antiarrhythmic therapy. Only one (8%) developed permanent AFib. No patient in the late onset group remained in sinus rhythm without an antiarrhythmic drug. Three (19%) developed permanent AFib despite therapy among those with late onset AFib. Two (17%) patients with early onset AFib reverted to normal sinus rhythm with treatment versus 5 (31%) in the late onset group. Finally, only 2 patients (17%) with paroxysmal/persistent episodes of Afib from the early onset group stayed in normal sinus rhythm despite therapy, while 8 patients ( ± %) with paroxysmal/persistent AFib episodes from the late onset group required therapy to maintain normal sinus rhythm. Conclusion: Early onset AFib after ablation of AFl is likely to be transient and self-limited. Late onset AFib after ablation of AFl can persist and require chronic therapy.