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1.
Vartan Mardigyan Atul Verma David Birnie Peter Guerra Damian Redfearn Giuliano Becker Jean Champagne John Sapp Lorne Gula Ratika Parkash Laurent Macle Eugene Crystal Gilles O'Hara Yaariv Khaykin Marcio Sturmer George D. Veenhuyzen Isabelle Greiss Jean-Francois Sarrazin Iqwal Mangat Paul Novak Allan Skanes Jean-Francois Roux Vijay Chauhan Tom Hadjis Carlos A. Morillo Vidal Essebag 《The Canadian journal of cardiology》2013
Background
Anticoagulation in patients undergoing atrial fibrillation (AF) ablation is crucial to minimize the risk of thromboembolic complications. There are broad ranges of approaches to anticoagulation management pre and post AF ablation procedures. The purpose of this study was to determine the anticoagulation strategies currently in use in patients peri- and post AF ablation in Canada.Methods
A Web-based national survey of electrophysiologists performing AF ablation in Canada collected data regarding anticoagulation practice prior to ablation, periprocedural bridging, and duration of postablation anticoagulation.Results
The survey was completed by 36 (97%) of the 37 electrophysiologists performing AF ablation across Canada. Prior to AF ablation, 58% of electrophysiologists started anticoagulation for patients with paroxysmal AF CHADS2 scores of 0 to 1, 92% for paroxysmal AF CHADS2 scores ≥ 2, 83% for persistent AF CHADS2 scores of 0 to 1, and 97% for persistent AF CHADS2 scores ≥ 2. For patients with CHADS2 0 to 1, warfarin was continued for at least 3 months by most physicians (89% for paroxysmal and 94% for persistent AF). For patients with CHADS2 ≥ 2 and with no recurrence of AF at 1 year post ablation, 89% of physicians continued warfarin.Conclusions
Although guidelines recommend long-term anticoagulation in patients with CHADS2 ≥ 2, 11% of physicians would discontinue warfarin in patients with no evidence of recurrent AF 1 year post successful ablation. Significant heterogeneity exists regarding periprocedural anticoagulation management in clinical practice. Clinical trial evidence is required to guide optimal periprocedural anticoagulation and therapeutic decisions regarding long-term anticoagulation after an apparently successful catheter ablation for AF. 相似文献2.
Sameer Arora Sreekanth Vemulapalli Amanda Stebbins Cassandra J. Ramm Andrzej S. Kosinski Paul Sorajja Jonathan P. Piccini Matthew A. Cavender John P. Vavalle 《JACC: Cardiovascular Interventions》2019,12(6):569-578
Objectives
The aim of this study was to compare 1-year outcomes following transcatheter mitral valve (MV) repair in patients with and without atrial fibrillation (AF).Background
The development of AF in degenerative mitral regurgitation (MR) is considered a sign of MR progression and is associated with adverse clinical events. However, the impact of AF in patients undergoing transcatheter MV repair remains uncertain.Methods
The TVT (Transcatheter Valve Therapy) Registry was used to identify patients undergoing transcatheter MV repair with the MitraClip between November 2013 and June 2016. Using Centers for Medicare and Medicaid Services–linked data, the 1-year rate of death, heart failure hospitalization, stroke, and bleeding following transcatheter MV repair was compared in patients with and without AF. Outcomes were analyzed using multivariate Cox regression modeling.Results
A total of 5,613 patients underwent commercial transcatheter MV repair in the United States during the study period, including 3,555 (63%) with pre-existing AF. Compared with patients without AF, patients with AF were older, were more likely to be male and Caucasian, had more comorbidities, and had higher Society of Thoracic Surgeons Predicted Risk of Mortality scores (median 7% vs. 5%; p < 0.0001). Acute procedural success (post-procedural ≥2+ MR, 37.4% vs. 35.0%; p = 0.20) and in-hospital mortality were similar, but length of hospital stay was longer for patients with AF (mean 4.91 days vs. 4.37 days; p = 0.0004). A total of 3,261 patients were linked to Centers for Medicare and Medicaid Services claims data. After adjustment, patients with AF had a higher 1-year rate of death or HF (hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 1.11 to 1.44; p < 0.001). Patients with AF had higher rates of mortality (HR: 1.44; 95% CI: 1.22 to 1.70; p < 0.001), HF hospitalization (HR: 1.17; 95% CI: 1.00 to 1.36; p = 0.05), stroke (HR: 1.63; 95% CI: 1.01 to 2.64; p = 0.047), and bleeding (HR: 1.34; 95% CI: 1.10 to 1.64; p = 0.004) at 1 year as well. Among those with AF, the risk for stroke was lower (HR: 0.55; 95% CI: 0.32 to 0.93; p = 0.026) among those on anticoagulation.Conclusions
In patients undergoing transcatheter MV repair, AF is common and is associated with worse clinical outcomes at 1 year despite similar acute procedural success. Further study is needed to investigate if early treatment of MR reduces the future risk for developing AF and to identify therapies that improve outcomes in these patients. 相似文献3.
Amit N. Vora Dadi Dai Roland Matsuoka J. Kevin Harrison G. Chad Hughes Matthew W. Sherwood Jonathan P. Piccini Bhaskar Bhardwaj Renato D. Lopes David Cohen David R. Holmes Vinod H. Thourani Eric Peterson Ajay Kirtane Samir Kapadia Sreekanth Vemulapalli 《JACC: Cardiovascular Interventions》2018,11(17):1746-1756
Objectives
The aim of this study was to evaluate incidence, care patterns, and clinical outcomes in patients developing new-onset atrial fibrillation (AF) following transcatheter aortic valve replacement (TAVR).Background
Pre-procedural AF has been associated with adverse outcomes in patients undergoing TAVR, but the incidence of new-onset AF, associated anticoagulant management, and subsequent clinical outcomes are unclear.Methods
Using the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry linked with Medicare claims, patients undergoing TAVR from 2011 to 2015 who developed post-procedural AF were evaluated. Patients with known AF prior to TAVR were excluded. Outcomes of interest included in-hospital mortality and stroke and all-cause mortality, stroke, and bleeding at 12 months. Multivariate adjustment was then performed to determine differences in 1-year outcomes among those with and without new post-procedural AF, stratified by anticoagulation status.Results
We identified 1,138 of 13,556 patients (8.4%) who developed new onset AF (4.4% of transfemoral [TF]–access patients, 16.5% of non-TF-access patients). Patients developing AF were older, more likely female, had higher Society of Thoracic Surgeons risk scores, and were often treated using non-TF access. Despite having a median CHA2DS2-VASc score of 5 (25th and 75th percentile: 5 to 6), only 28.9% of patients with new AF were discharged on oral anticoagulation. In-hospital mortality (7.8% vs. 3.4%; p < 0.01) and stroke (4.7% vs. 2.0%; p < 0.01) were higher among patients who developed post-procedural AF compared with those who did not. At 1 year, rates of death (adjusted hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.19 to 1.59), stroke (adjusted HR: 1.50; 95% CI: 1.14 to 1.98), and bleeding (adjusted HR: 1.24; 95% CI: 1.10 to 1.40) were higher among patients with new-onset AF. One-year mortality rates were highest among patients who developed new-onset AF but were not discharged on anticoagulation.Conclusions
Post-TAVR AF occurred in 8.4% of patients (4.4% with TF access, 16.5% with non-TF access), with fewer than one-third of patients receiving anticoagulation at discharge, and was associated with increased risk for in-hospital and 1-year mortality and stroke. Given the clinical significance of post-TAVR AF, additional studies are necessary to delineate the optimal management strategy in this high-risk population. 相似文献4.
Arash Salemi Art Sedrakyan Jialin Mao Adham Elmously Harindra Wijeysundera Derrick Y. Tam Antonino Di Franco Simon Redwood Leonard N. Girardi Stephen E. Fremes Mario Gaudino 《JACC: Cardiovascular Interventions》2019,12(1):90-97
Objectives
The aim of this study was to assess the impact of individual operator experience on transfemoral transcatheter aortic valve replacement (TAVR) outcomes.Background
TAVR volume-outcome relationships have not been evaluated at the individual operator level.Methods
New York Statewide Planning and Research Cooperative System data from 8,771 transfemoral TAVR procedures performed by 207 operators between 2012 and 2016 were analyzed. Operator volume was defined as the number of TAVR procedures performed during 1 year prior to the index procedure. Hierarchical and restrictive cubic spline regression models were used to evaluate the impact of individual operator experience on risk-adjusted in-hospital outcomes. The primary outcome was a composite of in-hospital mortality, stroke, and/or acute myocardial infarction. Secondary outcomes were the individual components of the primary outcome.Results
After adjusting for hospital and physician characteristics, patients undergoing TAVR performed by high-volume physicians (≥80/year) had a significantly lower risk for death, stroke, or acute myocardial infarction (odds ratio: 0.59; 95% confidence interval: 0.37 to 0.93) compared with those treated by low-volume physicians (<24/year). Being treated by operators who performed 200 procedures during the prior year was associated with significantly lower risks for post-procedural stroke (odds ratio: 0.41; 95% confidence interval: 0.17 to 0.97) and composite events (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78). This relationship was nonlinear, and a sensitivity analysis excluding the first 10, 20, and 30 procedures for each operator mitigated the effect of the initial learning curve.Conclusions
Increased TAVR experience of operators is associated with improved risk-adjusted in-hospital outcomes. These results have potentially important implications for individual training and hospital programs in TAVR. 相似文献5.
Ju Youn Kim Sung-Hwan Kim Jun-Pyo Myong Yoo Ri Kim Tae-Seok Kim Ji-Hoon Kim Sung-Won Jang Yong-Seog Oh Man Young Lee Tai-Ho Rho 《Journal of the American College of Cardiology》2019,73(10):1123-1131
Background
Patients with mitral stenosis and atrial fibrillation (AF) require anticoagulation for stroke prevention. Thus far, all studies on direct oral anticoagulants (DOACs) have excluded patients with moderate to severe mitral stenosis.Objectives
The aim of this study was to validate the efficacy of DOACs in patients with mitral stenosis.Methods
The study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea, and it included patients who were diagnosed with mitral stenosis and AF and either were prescribed DOACs for off-label use or received conventional treatment with warfarin. The primary efficacy endpoint was ischemic strokes or systemic embolisms, and the safety outcome was intracranial hemorrhage.Results
A total of 2,230 patients (mean age 69.7 ± 10.5 years; 682 [30.6%] males) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group (adjusted hazard ratio for DOAC: 0.28; 95% confidence interval: 0.18 to 0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC group and 0.93% of the warfarin group (adjusted hazard ratio for DOAC: 0.53; 95% confidence interval: 0.22 to 1.26).Conclusions
In patients with AF accompanied with mitral stenosis, DOAC use is promising and hypothesis generating in preventing thromboembolism. Our results need to be replicated in a randomized trial. 相似文献6.
Ronpichai Chokesuwattanaskul Charat Thongprayoon Tarun Bathini Aldo Torres-Ortiz Oisin A. O’Corragain Kanramon Watthanasuntorn Ploypin Lertjitbanjong Konika Sharma Somchai Preechawat Patompong Ungprasert Paul T. Kröner Karn Wijarnpreecha Wisit Cheungpasitporn 《Digestive and liver disease》2019,51(4):489-495
Objective
The atrial fibrillation-related stroke is clearly prevented by anticoagulation treatment, however, management of anticoagulation for AF in patients with cirrhosis represents a challenge due to bleeding concerns. To address this issue, a systematic review and meta-analysis of the literature was performed.Methods
A literature search for studies reporting the incidence of AF in patients with cirrhosis was conducted using MEDLINE, EMBASE and Cochrane Database, from inception through July 2018.Results
7 cohort studies including 19,798 patients with AF and cirrhosis were identified. The use of anticoagulation (%) among included studies ranged from 8.3% to 53.9%. Anticoagulation use for AF in patients with cirrhosis was significantly associated with a reduced risk of stroke, with a pooled HR of 0.58 (95%CI: 0.35–0.96). When compared with no anticoagulation, the use of anticoagulation was not significantly associated with a higher risk of bleeding, with a pooled HR of 1.45 (95%CI: 0.96–2.17). Compared to warfarin, the use of direct oral anticoagulants (DOACs) was associated with a lower risk of bleeding among AF patients with cirrhosis.Conclusion
Our study demonstrates that anticoagulation use for AF in patients with cirrhosis is associated with a reduced risk of stroke, without increasing significantly the risk of bleeding, when compared to those without anticoagulation. 相似文献7.
Lorne J. Gula Damian P. Redfearn Krista B. Jenkyn Britney Allen Allan C. Skanes Peter Leong-Sit Salimah Z. Shariff 《The Canadian journal of cardiology》2018,34(6):774-783
Background
The risk of stroke from atrial flutter and its relationship with progression to atrial fibrillation (AF) is unclear. This study describes the incidence of AF and stroke in patients with atrial flutter, and whether atrial flutter ablation attenuates the incidence of AF and stroke.Methods
We performed a population-based retrospective cohort study of adults with typical atrial flutter with no AF history. Using linked health administrative databases we defined 3 cohorts: (1) adult patients diagnosed with new isolated atrial flutter; (2) a contemporary, 1-to-1 matched cohort from the Ontario population; and (3) patients with isolated atrial flutter who underwent atrial flutter ablation.Results
A total of 9339 new typical atrial flutter patients were identified and 7248 were matched to general population subjects. Over the 3-year follow-up, AF occurred in 40.4% of patients with atrial flutter, and 3.3% of the matched general population (rate ratio, 12.2; P < 0.001). Stroke occurred in 4.1% of patients with atrial flutter and 1.2% of the general population cohort (rate ratio, 3.4; P < 0.001). Among 218 patients who had an atrial flutter ablation, AF occurred in 47 (21.6%) over the following 3 years, and incidence of stroke was between 0 and 2.3%.Conclusions
Patients with isolated atrial flutter develop AF and stroke at a higher rate than the general population. Catheter ablation reduces but does not eliminate future AF incidence and stroke risk and continued anticoagulation after successful atrial flutter ablation might therefore be warranted. 相似文献8.
João Pedro Ferreira Nicolas Girerd John Gregson Ichraq Latar Abhinav Sharma Marc A. Pfeffer John J.V. McMurray Azmil H. Abdul-Rahim Bertram Pitt Kenneth Dickstein Patrick Rossignol Faiez Zannad 《Journal of the American College of Cardiology》2018,71(7):727-735
Background
Stroke can occur after myocardial infarction (MI) in the absence of atrial fibrillation (AF).Objectives
This study sought to identify risk factors (excluding AF) for the occurrence of stroke and to develop a calibrated and validated stroke risk score in patients with MI and heart failure (HF) and/or systolic dysfunction.Methods
The datasets included in this pooling initiative were derived from 4 trials: CAPRICORN (Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction), OPTIMAAL (Optimal Trial in Myocardial Infarction With Angiotensin II Antagonist Losartan), VALIANT (Valsartan in Acute Myocardial Infarction Trial), and EPHESUS (Eplerenone Post–Acute Myocardial Infarction Heart Failure Efficacy and Survival Study); EPHESUS was used for external validation. A total of 22,904 patients without AF or oral anticoagulation were included in this analysis. The primary outcome was stroke, and death was treated as a “competing risk.”Results
During a median follow-up of 1.9 years (interquartile range: 1.3 to 2.7 years), 660 (2.9%) patients had a stroke. These patients were older, more often female, smokers, and hypertensive; they had a higher Killip class; a lower estimated glomerular filtration rate; and a higher proportion of MI, HF, diabetes, and stroke histories. The final stroke risk model retained older age, Killip class 3 or 4, estimated glomerular filtration rate ≤45 ml/min/1.73 m2, hypertension history, and previous stroke. The models were well calibrated and showed moderate to good discrimination (C-index = 0.67). The observed 3-year event rates increased steeply for each sextile of the stroke risk score (1.8%, 2.9%, 4.1%, 5.6%, 8.3%, and 10.9%, respectively) and were in agreement with the expected event rates.Conclusions
Readily accessible risk factors associated with the occurrence of stroke were identified and incorporated in an easy-to-use risk score. This score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF. 相似文献9.
David Conen Nicolas Rodondi Andreas Müller Juerg H. Beer Peter Ammann Giorgio Moschovitis Angelo Auricchio Daniel Hayoz Richard Kobza Dipen Shah Jan Novak Jürg Schläpfer Marcello Di Valentino Stefanie Aeschbacher Steffen Blum Pascal Meyre Christian Sticherling Leo H. Bonati Ramun Schmid 《Journal of the American College of Cardiology》2019,73(9):989-999
Background
Patients with atrial fibrillation (AF) have an increased risk of cognitive decline, potentially resulting from clinically unrecognized vascular brain lesions.Objectives
This study sought to assess the relationships between cognitive function and vascular brain lesions in patients with AF.Methods
Patients with known AF were enrolled in a multicenter study in Switzerland. Brain magnetic resonance imaging (MRI) and cognitive testing using the Montreal Cognitive Assessment (MoCA) were performed in all participants. Large noncortical or cortical infarcts (LNCCIs), small noncortical infarcts (SNCIs), microbleeds, and white matter lesions were quantified by a central core laboratory. Clinically silent infarcts were defined as infarcts on brain MRI in patients without a clinical history of stroke or transient ischemic attack.Results
The study included 1,737 patients with a mean age of 73 ± 8 years (28% women, 90% taking oral anticoagulant agents). On MRI, LNCCIs were found in 387 patients (22%), SNCIs in 368 (21%), microbleeds in 372 (22%), and white matter lesions in 1715 (99%). Clinically silent infarcts among the 1,390 patients without a history of stroke or transient ischemic attack were found in 201 patients with LNCCIs (15%) and 245 patients with SNCIs (18%). The MoCA score was 24.7 ± 3.3 in patients with and 25.8 ± 2.9 in those without LNCCIs on brain MRI (p < 0.001). The difference in MoCA score remained similar when only clinically silent LNCCIs were considered (24.9 ± 3.1 vs. 25.8 ± 2.9; p < 0.001). In a multivariable regression model including all vascular brain lesion parameters, LNCCI volume was the strongest predictor of a reduced MoCA (β = ?0.26; 95% confidence interval: ?0.40 to ?0.13; p < 0.001).Conclusions
Patients with AF have a high burden of LNCCIs and other brain lesions on systematic brain MRI screening, and most of these lesions are clinically silent. LNCCIs were associated with worse cognitive function, even among patients with clinically silent infarcts. Our findings raise the question of MRI screening in patients with AF. 相似文献10.
Błażej Głowicki Paweł T. Matusik Krzysztof Plens Anetta Undas 《The Canadian journal of cardiology》2019,35(5):634-643
Background
It is unclear whether a prothrombotic state occurs in atrial fibrillation (AF) with low stroke risk.Methods
We studied 118 patients with AF with the Congestive Heart Failure, Hypertension, Age (≥ 75 years), Diabetes, Stroke/Transient Ischemic Attack/Systemic Embolism, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score of 1 in men or 2 in women vs 52 patients with AF with the CHA2DS2-VASc score of 0 in men or 1 in women. Plasma clot permeability (Ks), a measure of fibrin clot density, and clot lysis time (CLT), endogenous thrombin potential (ETP), von Willebrand factor antigen, and plasminogen activator inhibitor-1 were evaluated in nonanticoagulated subjects.Results
Patients with the CHA2DS2-VASc score of 1 (beyond sex), compared with those with 0, had lower Ks, prolonged CLT, increased ETP, von Willebrand factor antigen, and plasminogen activator inhibitor-1 (all P < 0.001), without any sex-dependent differences. Heart failure (odds ratio [OR]: 10.28; 95% confidence interval [CI]: 2.32-45.41), age 65-74 years (OR: 4.37; 95% CI: 1.76-10.83), and hypertension (OR: 5.03; 95% CI: 1.81-13.94) were independently associated with low Ks (the lowest quartile, ≤ 6.4 × 10?9 cm2), whereas only age 65-74 years (OR: 3.33; 95% CI: 1.59-6.96) significantly predicted prolonged CLT (the top quartile, ≥ 108 minutes). Age 65-74 years (OR: 5.21; 95% CI: 2.12-12.80), heart failure (OR: 6.58; 95% CI: 1.49-29.06), and hypertension (OR: 4.33; 95% CI: 1.54-12.15) were independently associated with high ETP (the top quartile, ≥ 1681.3 nM × minutes).Conclusions
A prothrombotic state (increased thrombin generation, denser fibrin clots, impaired fibrinolysis, and endothelial injury) characterizes patients with AF with 1 additional clinical stroke risk factor (beyond sex), with age 65-74 years being particularly associated with prothrombotic indices. 相似文献11.
Patrick J. Donio Cassandra Freitas Peter C. Austin Heather J. Ross Husam M. Abdel-Qadir Harindra C. Wijeysundera Karen Tu Peter Cram Peter Liu Howard Abrams Jacob A. Udell Susanna Mak Michael E. Farkouh Jack V. Tu Xuesong Wang Sheldon W. Tobe Douglas S. Lee 《The Canadian journal of cardiology》2019,35(3):341-351
Background
Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South.Methods
We examined 30-day and 1-year mortality and readmissions for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF), or stroke in Northern compared with Southern Ontario, using the Canadian Institute for Health Information Discharge Abstract Database (2005-2016). Northern patients were defined as those residing and hospitalized in the Northwest or Northeast Local Health Integration Network regions. We used multiple Cox proportional hazards regression analysis for time-to-first event and Prentice-Williams-Peterson method to evaluate repeat and multiply admitted patients.Results
A total of 47,745 Northern and 465,353 Southern patients hospitalized with AMI (n = 182,158), HF (n = 130,770), AF (n = 72,326), or stroke (n = 127,844) were studied. Rates of first readmission were higher among Northern patients for AMI (adjusted hazard ratio [HR], 1.32), HF (HR, 1.16), AF (HR, 1.21), and stroke (HR, 1.27) compared with Southern patients (all P < 0.001). Repeat readmission rates among Northern patients for AMI (HR, 1.23), HF (HR, 1.13), AF (HR, 1.18), and stroke (HR, 1.22) were also increased (all P < 0.001 vs Southern). Thirty-day mortality did not differ significantly between Northern and Southern patients.Conclusions
Readmissions were increased in those residing and hospitalized in the North. To reduce readmissions in the North, the quality of postacute transitional care should be examined further. 相似文献12.
Francesco Grigioni Giovanni Benfari Jean-Louis Vanoverschelde Christophe Tribouilloy Jean-Francois Avierinos Francesca Bursi Rakesh M. Suri Federico Guerra Agnés Pasquet Dan Rusinaru Emanuela Marcelli Alexis Théron Andrea Barbieri Hector Michelena Siham Lazam Catherine Szymanski Vuyisile T. Nkomo Alessandro Capucci L. Bacchi-Reggiani 《Journal of the American College of Cardiology》2019,73(3):264-274
Background
Scientific guidelines consider atrial fibrillation (AF) complicating degenerative mitral regurgitation (DMR) a debated indication for surgery.Objectives
This study analyzed the prognostic/therapeutic implications of AF at DMR diagnosis and long-term.Methods
Patients were enrolled in the MIDA (Mitral Regurgitation International Database) registry, which reported the consecutive, multicenter, international experience with DMR due to flail leaflets echocardiographically diagnosed.Results
Among 2,425 patients (age 67 ± 13 years; 71% male, 67% asymptomatic, ejection fraction 64 ± 10%), 1,646 presented at diagnosis with sinus rhythm (SR), 317 with paroxysmal AD, and 462 with persistent AF. Underlying clinical/instrumental characteristics progressively worsened from SR to paroxysmal to persistent AF. During follow-up, paroxysmal and persistent AF were associated with excess mortality (10-year survival in SR and in paroxysmal and persistent AF was 74 ± 1%, 59 ± 3%, and 46 ± 2%, respectively; p < 0.0001), that persisted 20 years post-diagnosis and independently of all baseline characteristics (p values <0.0001). Surgery (n = 1,889, repair 88%) was associated with better survival versus medical management, regardless of all baseline characteristics and rhythm (adjusted hazard ratio: 0.26; 95% confidence interval: 0.23 to 0.30; p < 0.0001) but post-surgical outcome remained affected by AF (10-year post-surgical survival in SR and in paroxysmal and persistent AF was 82 ± 1%, 70 ± 4%, and 57 ± 3%, respectively; p < 0.0001).Conclusions
AF is a frequent occurrence at DMR diagnosis. Although AF is associated with older age and more severe presentation of DMR, it is independently associated with excess mortality long-term after diagnosis. Surgery is followed by improved survival in each cardiac rhythm subset, but persistence of excess risk is observed for each type of AF. Our study indicates that detection of AF, even paroxysmal, should trigger prompt consideration for surgery. 相似文献13.
Luisa Ciuffo Susumu Tao Esra Gucuk Ipek Tarek Zghaib Muhammad Balouch Joao A.C. Lima Saman Nazarian David D. Spragg Joseph E. Marine Ronald D. Berger Hugh Calkins Hiroshi Ashikaga 《JACC: Cardiovascular Imaging》2019,12(2):310-319
Objectives
The purpose of this study was to evaluate the usefulness of intra-atrial dyssynchrony as a marker of underlying left atrial (LA) remodeling to predict recurrence after the first atrial fibrillation (AF) ablation.Background
Catheter ablation for AF remains far from curative with relatively high recurrence rates. One of the causes of recurrence is poor patient selection out of a diverse patient population with different degrees of LA remodeling.Methods
We included 208 patients with a history of AF (59.4 ± 10.0 years of age; 26.0% nonparoxysmal AF) referred for catheter ablation of AF who underwent pre-ablation cardiac magnetic resonance in sinus rhythm. Clinical follow-up was 20 ± 6 months. Using tissue tracking cardiac magnetic resonance, we measured the LA longitudinal strain in each of 12 equal-length segments in 2- and 4-chamber views. We defined intra-atrial dyssynchrony as the standard deviation of the time to the peak longitudinal strain corrected by the cycle length (SD-time to peak strain [TPS], %).Results
Patients with AF recurrence after ablation (n = 101) had significantly higher SD-TPS than those without (n = 107; 3.9% vs. 2.2%; p < 0.001). Multivariable cox analysis showed that SD-TPS was associated with recurrence after adjusting for clinical risk factors, AF type, LA structure and function, and fibrosis (p < 0.001). Furthermore, receiver-operating characteristics analysis showed SD-TPS improved prediction of recurrence better than clinical risk factors, LA structure and function, and fibrosis.Conclusions
Intra-atrial dyssynchrony during sinus rhythm is an independent predictor of recurrence after the first catheter ablation of paroxysmal or persistent AF. Assessment of intra-atrial dyssynchrony may improve ablation outcomes by refining patient selection. 相似文献14.
Padma Kaul Karen P. Alexander E. Magnus Ohman Anamaria Savu Matthew T. Roe Shaun G. Goodman Keith A. Fox Harvey D. White Dorairaj Prabhakaran Judith S. Hochman Peter Clemmensen Paul W. Armstrong 《The Canadian journal of cardiology》2019,35(4):430-437
Background
The effect of sex on self-reported frailty in acute coronary syndromes (ACS) is unclear. We examined the prevalence of self-reported frailty and its association with all-cause death among men and women.Methods
Elderly (≥ 65 years) male (n = 2691) and female (n = 2305) patients with ACS enrolled in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial were screened using the Fried Frailty Index. Sex differences in prevalence of frailty symptoms and categories (not frail; prefrail [1 to 2 symptoms]; and frail [≥ 3 symptoms]) and their prognostic importance were examined.Results
Women were older and had higher rates of comorbidities than men. A total of 739 (27.5%) men and 645 (28%) women reported ≥ 1 frailty symptom. Prevalence of frailty increased with age among men but not women. During a median follow-up of 17.3 months, 353 (13.1%) men and 266 (11.5%) women died. After adjusting for age, prefrail men had a 35% increased risk (hazard ratio [HR] 1.35; 95% confidence interval [CI], 1.07-1.71), and frail men had an 80% increased risk (HR 1.80; 95% CI, 1.22-2.67) of death relative to not-frail men. The age-adjusted HR for death in prefrail women was 1.40 (95% CI, 1.07-1.84), and 1.55 (95% CI, 0.96-2.49) in frail women relative to not-frail women. Self-reported slow walk time and decreased physical activity appeared to provide the most prognostic information.Conclusion
Self-reported frailty was similar among men and women with ACS. Frailty increased with age only among men, in whom it added more prognostic information. Patient-reported frailty may identify elderly patients with ACS, particularly men, at high-risk of mortality. 相似文献15.
Ralf Langhoff Joachim Schofer Dierk Scheinert Andrej Schmidt Gerald Sedgewick Elizabeth Saylors Ravish Sachar Horst Sievert Thomas Zeller 《JACC: Cardiovascular Interventions》2019,12(4):395-403
Objectives
This study evaluated the safety and performance of the Paladin System, a novel angioplasty balloon with an integrated embolic protection filter designed to increase embolic protection during post-dilation.Background
The risk of major adverse events during carotid artery stenting (CAS) is equivalent to carotid endarterectomy. However, the risk of minor stroke remains higher with CAS. Much of this risk occurs during post-stent dilation.Methods
A total of 106 patients were enrolled in 5 centers in Germany. The study’s primary endpoint was all-cause death, myocardial infarction, and stroke at 30 days post-procedure. Pre- and post-procedural diffusion-weighted magnetic resonance imaging evaluated new ischemic lesions in 30 subjects. Filter histomorphometric analysis was performed in 23 patients. Retrospective analyses compared outcome rates to historical controls.Results
Device and procedural success rates were 100%. The combined major adverse event rate (death, myocardial infarction, and stroke) at discharge and at 30 days was 0% and 1.0%, respectively. The single adverse event was a stroke, which occurred at day 12 and was believed unrelated to the device or procedure. New ischemic lesions were found in 11 (36.7%) patients in the diffusion-weighted magnetic resonance imaging subset. New ipsilateral lesions were seen in 9 (30.0%) patients. Mean lesion volume per patient was 0.010 cm3. Debris was present in all filters, and approximately 90% of captured particles were <100 μm.Conclusions
Use of the Paladin System for post–stent dilation during CAS appears safe, and it may effectively decrease the number of embolic particles reaching the brain, which may help reduce the risk of procedure-related stroke. (A Multi-Center Study to Evaluate Acute Safety and Clinical Performance of Paladin® Carotid Post-Dilation Balloon System With Integrated Embolic Protection; NCT02501148) 相似文献16.
So-Ryoung Lee Eue-Keun Choi Chan Soon Park Kyung-Do Han Jin-Hyung Jung Seil Oh Gregory Y.H. Lip 《Journal of the American College of Cardiology》2019,73(8):919-931
Background
It is unclear whether the overall effectiveness and safety of direct oral anticoagulants (DOACs) are consistent in patients with nonvalvular atrial fibrillation (AF) and extremely low body weight (<50 kg).Objectives
This study compared DOACs with warfarin in AF patients with low body weight.Methods
Using data from the Korean National Health Insurance Service database from January 2014 to December 2016, AF patients with body weight ≤60 kg and who were treated with oral anticoagulants (n = 14,013 taking DOACs and n = 7,576 taking warfarin) were included and examined for ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, major bleeding, all-cause death, and composite outcome. The propensity score weighting was used to balance the 2 groups.Results
Baseline characteristics were well balanced between the 2 groups (mean age 73 years, mean CHA2DS2-VASc score 4, and 28% of patients weighed <50 kg). DOACs were associated with lower risks of ischemic stroke (hazard ratio [HR]: 0.591; 95% confidence interval [CI]: 0.510 to 0.686) and major bleeding (HR: 0.705; 95%: CI 0.601 to 0.825), which were caused by a reduction in ICH (HR: 0.554; 95% CI: 0.429 to 0.713) compared with warfarin. DOAC improved the net clinical benefit compared with warfarin (HR for composite outcome: 0.660; 95% CI: 0.606 to 0.717), and this was consistent in patients who weighed <50 kg (HR for composite outcome: 0.665; 95% CI: 0.581 to 0.762).Conclusions
In this real-world Asian AF population with low body weight, DOACs showed better effectiveness and safety than warfarin. These results were consistent in patients with extremely low body weight. Regular dosages of DOACs showed comparable results as reduced dosages of DOACs in both effectiveness and safety. 相似文献17.
Yang Zhan Jacqueline Joza Mohamed Al Rawahi Rodrigo S. Barbosa Michelle Samuel Martin Bernier Thao Huynh George Thanassoulis Vidal Essebag 《The Canadian journal of cardiology》2018,34(3):252-261
Background
Intracardiac thrombi arising in the left atrial appendage (LAA) are the principal cause of stroke in nonvalvular atrial fibrillation (AF). Predicting the presence of LAA thrombi is of vital importance in stratifying patients that would need further LAA imaging prior to cardioversion or AF ablation.Methods
We comprehensively searched PubMed from its inception to November 2017 for randomized controlled trials, cohort and case control studies, as well as for case series on LAA thrombi risk factors, imaging, prevention, and anticoagulation management in atrial fibrillation.Results
A systematic review of the literature identified 106 articles that investigated the presence of LAA thrombi in AF patients. We classified the articles according to topic and reported on: (1) risk factors; (2) diagnostic imaging modalities; (3) prevention strategies before cardioversion; (4) prevention strategies before AF ablation; and (5) management of detected LAA thrombi.Conclusions
Integration of clinical, biomarker, and imaging risk factors can improve overall prediction for the presence of LAA thrombi, translating into improved patient selection for imaging. The gold standard for the diagnosis of LAA thrombi remains transesophageal echocardiography, although intracardiac ultrasound, cardiac computed tomography, and cardiovascular magnetic imaging are promising alternative modalities. When LAA thrombi are discovered, the treatment regimen remains variable, although direct oral anticoagulants might have efficacy similar to vitamin K antagonists. Future trials will help further elucidate direct oral anticoagulant use for the treatment of LAA thrombi. 相似文献18.
Mousa Alharbi Nicholas Giacomantonio Lindsey Carter John Sapp Martin Gardner Chris J. Gray Amir M. AbdelWahab Ratika Parkash 《The Canadian journal of cardiology》2019,35(4):382-388
Background
Cardiac rehabilitation (CR) intervention programs are currently not part of management in patients with atrial fibrillation (AF). We sought to determine the effect of CR compared with a specialized AF clinic (AFC) and usual care on outcomes in patients with AF.Methods
This was a single-centre retrospective cohort study that was carried out using 3 databases: the Hearts in Motion database (2010-2014), prospectively collected data in an AFC (2011-2014), and a retrospective chart review for patients in usual care (2009-2012). Three care pathways were compared: (1) CR; (2) AFC; and (3) usual specialist-based care. The main outcome was AF-related emergency department visits and cardiovascular hospitalizations.Results
Of 566 patients with newly diagnosed AF, 133 (23.5%) patients underwent CR, 197 patients (34.8%) attended the AFC, whereas the remaining 236 (41.7%) were followed in a usual specialist-based care clinic. At 1 year, AF-related emergency department visits and cardiovascular hospitalization rates occurred in 7.5% in the CR group, 16.8% in the AFC group, and 29.2% in usual care. After a propensity matched analysis, usual care was associated with the highest rate of the main outcome (odds ratio, 4.91; 95% confidence interval, 2.09-11.53) compared with CR, as did the AFC compared with CR (odds ratio, 2.75; 95% confidence interval, 1.14-6.6).Conclusions
Among patients with AF, CR was associated with a lower risk of AF-related outcomes. These findings support further study of the use of CR in the management of these patients to determine the optimal model of care for AF patients. 相似文献19.
Yvonne Schwammenthal Nathan M. Bornstein Uri GoldbourtSilvia Koton Roseline SchwartzNina Koren-Morag Ehud Grossman David Tanne 《International journal of cardiology》2011,152(3):356-361
Background
Atrial fibrillation (AF) is a major risk factor of ischemic stroke. We tested whether the adoption of the CHADS2 score in clinical guidelines has impacted treatment strategies for stroke prevention, and examined how AF affects stroke outcome.Methods
In the setting of two national surveys [National Acute Stroke Israeli Surveys; all patients hospitalized for stroke in Israel during February-March 2004, and March-April 2007] data of patients with and without AF were analyzed with respect to patient characteristics, use of anticoagulation, stroke severity, clinical course, and long-term outcome.Results
Of 3040 patients with acute ischemic stroke, 586 patients (19%) had a history of AF. Severe strokes on admission were significantly more frequent in patients with AF, as was the proportion of total anterior circulation strokes. Ischemic stroke associated with AF predicted poor outcome at discharge (adjusted OR 1.56; 95%CI 1.24-1.96) and higher mortality rates throughout follow-up. Among patients with a CHADS2 score ≥ 2 prior to the index stroke and without known contraindications, 41% received anticoagulation. This proportion increased to only 62% after the index stroke, even after excluding patients with severe disability and no significant increase between 2004 and 2007 was detectable. Increasing age, in-hospital infectious complications, and unfavorable functional status at discharge were independently associated with decreased likelihood of receiving anticoagulation.Conclusions
In deviation from current recommendations and in spite of the introduction of CHADS2 criteria, anticoagulation for stroke prevention remains underutilized, despite the particularly poor outcome of strokes associated with AF. 相似文献20.
Combination of Circulating Type I Collagen-Related Biomarkers Is Associated With Atrial Fibrillation
Susana Ravassa Gabriel Ballesteros Begoña López Pablo Ramos Jean Bragard Arantxa González María U. Moreno Ramón Querejeta Enrique Vives Ignacio García-Bolao Javier Díez 《Journal of the American College of Cardiology》2019,73(12):1398-1410
