Device-related infection and mortality in patients with chronic kidney disease receiving cardiac implantable electronic devices: a propensity score-matched cohort study.

BACKGROUND: Chronic kidney disease (CKD) was reported to be a risk factor of cardiac implantable electronic device (CIED) infection. The application of bundled skin antiseptic preparation before CIED implantation decreased the risk of CIED infection, even in patients undergoing complex procedures. However, the effect of bundled skin antiseptic preparation to prevent CIED infection in patients with CKD was not tested. METHODS: Between July 2012 and December 2019, 1668 patients receiving CIEDs comprised this retrospective cohort study and were categorized into two groups by the diagnosis of CKD: group with CKD (n = 750, 45%) and group without CKD (n = 918, 55%). The primary outcome was clinical CIED infection, including major and minor infection, and the secondary outcomes were cardiovascular mortality and all-cause mortality. Propensity score matching (PSM) was applied to reduce selection bias between the study groups. RESULTS: During a 4-year follow-up period, 30 patients (1.8%) had a CIED infection. After PSM, the incidence of CIED infection was similar between the patients with CKD and without CKD (1.0% vs. 1.8%). The incidences of cardiovascular mortality and all-cause mortality were higher in patients with CKD compared to patients without CKD (6.5% vs. 3.0%, P = 0.009; 22.8% vs. 11.8%, P < 0.001, respectively). CONCLUSION: The incidence of clinical CIED infection in patients with CKD was as lower as in patients without CKD after applying the bundled skin antiseptic preparation strategy. The cumulative incidences of cardiovascular mortality and all-cause mortality were significantly higher in the matched CIED recipients with CKD compared to the matched cohort without CKD.

Impact of Coexisting Risk Factors on Outcomes in Patients with Acute Coronary Syndrome: A Real-World Analysis Using the Taiwan Chang Gung Research Database.

BACKGROUND Diabetes mellitus (DM), chronic kidney disease (CKD), and advanced age are associated with poor outcomes in patients with acute coronary syndrome (ACS). This real-world study utilized data from the Taiwan Chang Gung Research Database (CGRD) to compare outcomes in ACS patients with DM, CKD, and the elderly. MATERIAL AND METHODS The study enrolled 28,613 ACS patients diagnosed based on CGRD medical records between January 2005 and December 2019. Baseline characteristics and clinical outcomes were compared among groups based on patient characteristics. RESULTS Within the ACS cohort, 42.1% had DM, 48.2% had CKD, and 33.6% were elderly. Among them, 10.7% (3,070) were elderly patients with both DM and CKD. Elderly patients with DM and CKD had significantly higher risks of gastrointestinal bleeding (hazard ratio=11.32), cardiovascular events (HR=7.29), and all-cause mortality (HR=8.59). Patients with three or at least two of these risk factors had a 2.20-2.99-fold increased risk of recurrent ACS during the three-year follow-up period. CONCLUSIONS Patients with the combination of DM, CKD, and advanced age (elderly) experienced an 11.32-fold increased risk of gastrointestinal bleeding, 7.29-fold increased risk of cardiovascular events, and 8.59-fold increased risk of all-cause mortality compared to those without these risk factors. Furthermore, patients with two or more of these risk factors had a 2- to 3-fold increased risk of recurrent ACS. These findings emphasize the importance of managing multiple risk factors in ACS patients to improve outcomes.

The Impact of FEV1/FVC Ratio on the Clinical Outcomes in Acute Coronary Syndrome Patients Treated with Dual Anti-Platelet Agents.

Background: Few studies have investigated the clinical efficacy and pulmonary side effects of different P2Y12 inhibitors in acute coronary syndrome (ACS) patients. The aim of this study was to explore the impact of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) ratio on the clinical outcomes in ACS patients treated with dual antiplatelet therapy after percutaneous coronary intervention (PCI). Methods: ACS patients who underwent PCI, had documented pre-existing spirometry tests, and received aspirin with either ticagrelor or clopidogrel were enrolled for retrospective analysis. Results: Of the enrolled ACS patients, 275 and 247 received ticagrelor and clopidogrel, respectively. The incidence of wheeze was significantly higher in the ticagrelor group compared to the clopidogrel group within 360 days (14.91% vs. 8.09%, p = 0.016). Multivariable analysis revealed that ticagrelor treatment, as compared to clopidogrel treatment, independently predicted 1-year hospitalization for acute exacerbation (AE) of obstructive airway disease (hazard ratio: 3.44; 95% confidence interval: 1.92 to 6.15; p < 0.01). The receiver operating characteristic curve indicated that an FEV1/FVC ratio of 63.85% had the highest sensitivity and specificity for predicting the incidence of AE of obstructive airway disease within 1 year (p < 0.001). The 1-year hospitalization rate for AE of obstructive airway disease was significantly higher in the ticagrelor group when the FEV1/FVC ratio was < 63%. Conclusions: This study demonstrated higher incidence of wheeze and hospitalization for AE of obstructive airway disease in ACS patients treated with ticagrelor compared to clopidogrel. Furthermore, the FEV1/FVC ratio ≤ 63% in the ACS patients predicted hospitalization for AE of obstructive airway disease in 1 year.

Impact of baseline renal function on the efficacy and safety of different Anticoagulants in Atrial Fibrillation Patients - A cohort study.

BACKGROUND: Vitamin K antagonists and different direct oral anticoagulants (DOACs) have different renal clearance rates. However, the impact of different stages of chronic renal impairment on the efficacy and safety of warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban in atrial fibrillation (AF) patients remains unclear. METHODS: This study enrolled AF patients from the Chang Gung Research Database. The study endpoints included thromboembolic events, major/fatal bleeding, gastrointestinal (GI) bleeding and intracranial hemorrhage (ICH). The risks of time to study endpoints between groups were compared using a Cox proportional hazards regression model with adjustment. RESULTS: This study enrolled 3525 patients with moderate renal impairment (30 ≤ creatinine clearance (CrCl) < 60 mL/min), 2846 patients with mild renal impairment (60 ≤ CrCl < 90 mL/min) and 1153 patients with CrCl ≥ 90 mL/min. Over the 3.3 ± 0.9 years follow-up period, the cumulative thromboembolic events rates and the cumulative event rates of major/fatal bleeding and ICH did not differ among the warfarin and different DOAC groups at different stages of chronic renal impairment. The annual incidences of thromboembolic events, major/fatal bleeding, GI bleeding, and ICH were similar among the warfarin and different DOAC groups at different stages of renal impairment. CONCLUSION: There did not appear to be major differences in bleeding or thromboembolic risk compared to warfarin in AF patients across a range of degree of renal failure when appropriate dose reductions of the DOACs are made.

The Relationship of Conduction Disorder and Prognosis in Patients with Acute Coronary Syndrome.

Objective: Conduction disorders with a widened QRS are associated with poor prognosis in patients with acute coronary syndrome (ACS). Conduction disorders include left bundle branch block (LBBB), right bundle branch block (RBBB), and nonspecific intraventricular conduction delay (NICD). Previous studies did not have conflicting results regarding the type of bundle branch block (BBB) with the worst prognosis, and few studies have focused on the prognosis of patients with NICD. Methods: Patients with ACS were enrolled between January 2005 and December 2019, and their medical history (International Classification of Diseases codes) was obtained from the Chang Gung Research Database. Age, sex, comorbidities, left ventricular ejection fraction (LVEF), and drug use were compared between the patients with and without conduction disorders. The following clinical outcomes were compared between patients with and without conduction disorders: heart failure (HF) hospitalization, cardiovascular (CV) mortality, and all-cause mortality. After propensity score matching, the Kaplan-Meier curve analysis for HF hospitalization, CV mortality, and all-cause mortality were compared among patients with LBBB, RBBB, and NICD. Results: This study enrolled a total of 33970 participants and involved 3392 and 30578 patients with and without conduction disorders, respectively. Older age and a higher prevalence of comorbidities were noted in patients with conduction disorders. Lower mean LVEF was exhibited in the patients with conduction disorders (with vs. without; 44.64 ± 20.73% vs. 49.85 ± 20.63%; p < 0.001). During the 3-year follow-up period, higher incidences of HF hospitalization (21.55% vs. 17.51%; p < 0.001), CV mortality (17.98% vs. 12.14%; p < 0.001), and all-cause mortality (38.86% vs. 31.15%; p < 0.001) were noted in the patients with conduction disorder. After ACS events, 10.0% of patients presented with conduction disorders, with LBBB in 3.3%, RBBB in 6.0%, and NICD in 0.7%. The lowest mean of LVEF was presented in the patients with NICD (LBBB vs. RBBB vs. NICD; 41.00 ± 19.47% vs. 47.73 ± 20.82% vs. 34.57 ± 20.02%; p < 0.001). Among the three groups, the highest incidence of HF hospitalization was noted in patients with LBBB after propensity score matching. The lowest incidence of CV and all-cause mortality was observed in patients with RBBB. After adjustment of age, gender, comorbidities, medication, and mean LVEF, those with LBBB had the highest hazard ratio for major adverse cardiovascular events (MACEs) of 1.113 (p=0.029; 95% CI = 1.013-1.266). Conclusions: In the ACS population, patients with conduction delay had a poor prognosis due to a higher prevalence of comorbidities and lower mean LVEF. Among the patients with LBBB, RBBB, and NICD, those with LBBB and NICD had a higher incidence of HF hospitalization, CV mortality, and all-cause mortality. Patients with NICD had the lowest mean LVEF compared to those with LBBB and RBBB. Patients with LBBB had a significantly highest HR of MACE.

The Performance of Risk Scores for Bleeding and Ischemia as Outcome Predictors in Acute Myocardial Infarction Patients with End-Stage Renal Disease.

Background: In patients with end-stage renal disease (ESRD), acute myocardial infarction (AMI) increases the risks of cardiovascular events, death, and bleeding. Several scores have been developed for predicting ischemic and bleeding outcomes in AMI patients, but none have been validated specifically for ESRD patients. Objectives: To compare and validate different risk scores as predictors of ischemic and bleeding outcomes in AMI patients with ESRD. Methods: This retrospective study enrolled 340 patients who had received percutaneous coronary intervention for AMI while undergoing maintenance hemodialysis for ESRD. Ischemic risk scores (TIMI-STEMI, TIMI-NSTEMI, GRACE, DAPT) and bleeding risk scores (PRECISE-DAPT, CRUSADE, ACUITY, ACTION, SWEDEHEART) were calculated. The ischemic outcome mainly focused on major adverse cardiovascular events (MACEs) within 14 days after hospitalization, and the bleeding outcome was 14-day major bleeding according to the CRUSADE criteria. Results: The GRACE score was superior in discriminating ischemic outcomes, especially in 14-day MACEs [area under curve (AUC) 0.791, p < 0.001]. None of the scores could ideally discriminate 14-day CRUSADE major bleeding, while the PRECISE- DAPT score had the best discriminative power (AUC 0.636, p < 0.001). Either GRACE score > 222 or PRECISE-DAPT score > 48 was associated with higher net adverse cardiovascular events (a composite of 14-day MACEs and 14-day CRUSADE major bleeding). Conclusions: In AMI patients with ESRD, the GRACE score can effectively discriminate the risk of short-term ischemic events. None of the scores could ideally discriminate the bleeding risk, but a high PRECISE-DAPT score still represented a higher rate of bleeding events.

The impact on renal function after long-term use of anticoagulants in atrial fibrillation patients.

OBJECTIVE: Long-term oral anticoagulant should be considered or recommended in patients with atrial fibrillation (AF) and CHA2DS2VASc score ≥ 1 for stroke prevention. Warfarin and different direct oral anticoagulants (DOACs) are metabolized differently by the kidney. The impact on renal function after long-term use of anticoagulants in the patients with AF remains unclear. This study aimed to compare DOACs and warfarin's impact on the decline in renal function from a large cohort with AF. METHODS: This study included patients with nonvalvular AF from 2000 to 2018, mainly through the medical history (ICD code) of the Chang Gung Research Database. Baseline estimated glomerular filtration rate (eGFR), follow-up eGFR and the change in eGFR between 2-year eGFR and baseline eGFR were compared between different DOACs and warfarin after propensity score matching. The primary study endpoint was acute kidney injury (AKI). RESULTS: 3657 patients were enrolled in this study and the mean observation time was 3.3 ± 0.9 years. During the observation period, there was a significantly higher incidence of AKI during follow-up in the warfarin group than in the different DOAC groups before and after propensity score matching (before: warfarin vs. DOAC: 9.2% vs. 5.2%, p <  0.001; after: warfarin vs. DOAC: 8.9% vs. 4.4%, p <  0.001). There was no difference in the incidence of AKI between dabigatran group and anti-factor Xa inhibitor group after propensity score matching. The incidence of AKI was similar among rivaroxaban, apixaban and edoxaban groups after propensity score matching. The change in eGFR between 2-year eGFR and baseline eGFR did not differ between the warfarin and DOAC groups after propensity score matching (warfarin vs. DOAC: - 1.27 ± 20.32 vs. -1.94 ± 17.24 mL/min/1.73 m2, p = 0.461). CONCLUSIONS: During the mean observation time of 3.3 ± 0.9 years, warfarin was associated with a higher incidence of AKI compared with DOACs. The decline in renal function did not differ among warfarin and different DOAC groups.

Feature and impact of guideline-directed medication prescriptions for heart failure with reduced ejection fraction accompanied by chronic kidney disease.

Background: With respect to total mortality and cardiovascular mortality, the feature and impact of guideline-directed medication (GDM) prescriptions for heart failure with reduced ejection fraction (HFrEF) with chronic kidney disease (CKD) are unknown. Therefore, we aimed to determine these aspects. Methods: GDM prescriptions and their impact on discharged patients with and without CKD were analyzed. To analyze differences in one-year clinical outcomes, propensity score matching was conducted on a cohort of patients with concomitant HFrEF and CKD who received more and fewer GDM prescriptions. Results: A total of 1509 patients were enrolled in Taiwan's HFrEF registry from May 2013 to October 2014, and 1275 discharged patients with complete one-year follow-up were further analyzed. Of these patients, 468 (36.7%) had moderate CKD, whereas 249 (19.5%) had advanced CKD. Patients with advanced CKD received fewer prescribed GDMs than other patients. Multivariate analysis revealed that peripheral arterial occlusive disease, thyroid disorder, advanced HF at discharge, diastolic blood pressure, digoxin use, and fewer prescribed GDMs were independent predictors of one-year total mortality. After propensity score matching, patients with fewer prescribed GDMs had higher one-year total mortality rate than those with more prescribed GDMs (P=0.036). Conclusions: CKD at discharge from HF hospitalization was associated with fewer GDM prescriptions, particularly in patients with more advanced CKD. The propensity-matched analysis indicated that more GDM prescriptions led to better clinical outcomes in HFrEF patients with CKD. Careful interpretation of changes in renal function during HF hospitalization may improve GDM prescriptions.

Impact of chronic kidney disease on atrial fibrillation recurrence following radiofrequency and cryoballoon ablation: A meta-analysis.

OBJECTIVES: In observational studies, patients with chronic kidney disease (CKD) exhibited a controversial risk of atrial fibrillation (AF) recurrence following radiofrequency (RF) or cryoballoon ablation compared with non-CKD patients. This meta-analysis analysed the impact of CKD on AF recurrence following ablation. METHODS: We searched the PubMed, Embase, ProQuest, ScienceDirect, Cochrane Library, ClinicalKey, Web of Science, and ClinicalTrials.gov databases for articles published between January 1, 2010, and May 31, 2020. In total, seven observational studies with 23 468 patients were analysed. Data included demographics, AF classification, left atrial size, incidence of AF recurrence, and ablation method. RESULTS: The prevalence of CKD was 8.0% (7.6%-24.4%) in the AF ablation population. The CKD population was older and had a higher prevalence of diabetes mellitus, hypertension, and heart failure, a higher CHA2DS2-VASc score, larger left atrial dimension, and lower left ventricular ejection fraction compared with the non-CKD population. The CKD patients had a higher AF recurrence rate following ablation than non-CKD patients (odds ratio [OR], 3.71; 95% confidence interval (CI), 1.35-10.19). CKD was associated with higher AF recurrent risk after ablation in patients with only paroxysmal AF (OR = 4.81, 95% CI 2.48-9.35). CKD was associated with higher AF recurrent risk in patients receiving radiofrequency ablation (OR = 3.28, 95% CI 2.17-4.94) or cryoballoon ablation (OR = 6.50, 95% CI 2.24-18.89) and in Asian region (OR = 4.86, 95% CI, 2.69-8.78). CONCLUSIONS: CKD population had worse outcomes in terms of AF recurrence following RF or cryoballoon ablation.

Impact of multi-disciplinary treatment strategy on systolic heart failure outcome.

BACKGROUND: Patients with reduced ejection fraction have high rates of mortality and readmission after hospitalization for heart failure. In Taiwan, heart failure disease management programs (HFDMPs) have proven effective for reducing readmissions for decompensated heart failure or other cardiovascular causes by up to 30%. However, the benefits of HFDMP in different populations of heart failure patients is unknown. METHOD: This observational cohort study compared mortality and readmission in heart failure patients who participated in an HFDMP (HFDMP group) and heart failure patients who received standard care (non-HFDMP group) over a 1-year follow-up period after discharge (December 2014 retrospectively registered). The components of the intervention program included a patient education program delivered by the lead nurse of the HFDMP; a cardiac rehabilitation program provided by a physical therapist; consultation with a dietician, and consultation and assessment by a psychologist. The patients were followed up for at least 1 year after discharge or until death. Patient characteristics and clinical demographic data were compared between the two groups. Cox proportional hazards regression analysis was performed to calculate hazard ratios (HRs) for death or recurrent events of hospitalization in the HFDMP group in comparison with the non-HFDMP group while controlling for covariates. RESULTS: The two groups did not significantly differ in demographic characteristics. The risk of readmission was lower in the HFDMP group, but the difference was not statistically significant (HR = 0.36, p = 0.09). In patients with ischemic cardiomyopathy, the risk of readmission was significantly lower in the HFDMP group compared to the non-HFDMP group (HR = 0.13, p = 0.026). The total mortality rate did not have significant difference between this two groups. CONCLUSION: The HFDMP may be beneficial for reducing recurrent events of heart failure hospitalization, especially in patients with ischemic cardiomyopathy. TRIAL REGISTRATION: Longitudinal case-control study ISRCTN98483065 , 24/09/2019, retrospectively registered.

Late fractionated potentials in catheter ablation for right ventricular outflow tract ventricular arrhythmias.

BACKGROUND: Endocardial late fractionated potentials during sinus rhythm mapping may reflect abnormal "subendocardial" substrates associated with right ventricular outflow tract (RVOT) ventricular arrhythmias (VAs). The aim of this study was to explore the clinical outcomes of catheter ablation guided by these late fractionated potentials for RVOT VAs in patients without structural heart disease. METHODS: From January 2016 to March 2018, 28 patients underwent catheter ablation for RVOT premature ventricular contractions (PVCs) or ventricular tachycardia (VT), guided by the EnSite NavX or Velocity V5.0 three-dimensional mapping system (Abbott, St. Paul, MN, USA). Among them, 10 patients (35.7%) were found to have endocardial late fractionated potentials during sinus rhythm mapping (Group 1). Group 2 was composed of 18 patients in whom no endocardial late fractionated potentials were seen. The burden of VAs, acute procedural success, and 3-month clinical outcomes were analyzed. RESULTS: The average duration of late fractionated potentials after the end of QRS during sinus rhythm mapping in group 1 was 45.00 ± 17.15 ms. Baseline demographics and morphology and burden of PVCs were similarly distributed between both groups. Group 1 had higher acute procedural success compared to group 2 (100% vs 66.7%; P = .039). Moreover, at 3-month follow-up, group 1 had lower total PVCs (49 (1-5986) versus 4316 (1-23231); P = .048), PVC burden (0% (0-5.9) vs 4.3% (0-18.9); P = .055), and higher clinical success (100% vs 55.6%; P = .025) compared to group 2. CONCLUSION: The identification and elimination of endocardial late fractionated potentials during sinus rhythm mapping could improve the acute success and short-term outcomes of ablation for RVOT VAs.

Evaluation of Bleeding Risk in Patients with Acute Myocardial Infarction Undergoing Transradial Percutaneous Coronary Intervention.

We investigated the accuracy of various bleeding risk scores to estimate the bleeding risk in patients with acute myocardial infarction (AMI) managed with percutaneous coronary intervention (PCI) access via the radial artery.We retrospectively enrolled 1,651 patients who were definitively diagnosed with ST-elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI). We assessed the predictive validities of 30-day bleeding events in various scoring systems using receiver operating characteristic curves.Overall, ACUITY-HORIZONS exhibited the highest area under the curve to predict 30-day bleeding, followed by ACTION and CRUSADE; HAS-BLED displayed the lowest score. With a cut-off of 17, ACUITY-HORIZONS demonstrated the best discrimination for the Thrombolysis in Myocardial Infarction (TIMI) 30-day serious bleeding rate. We observed significant differences among all-cause death, cardiovascular death, and major adverse cardiac events between the ACUITY-HORIZONS groups with a score of ≤ 17 and > 17. ACUITY-HORIZONS score > 17, initial systolic blood pressure (SBP) < 90 mmHg, and Killip III and IV upon admission positively predicted the 30-day bleeding risk, whereas myocardial infarction (MI) and TIMI major bleeding within 30 days, heart failure at admission, and initial SBP < 90 mmHg positively predicted the 30-day mortality.Comparatively, ACUITY-HORIZON is the most reliable system in predicting 30-day bleeding for patients with AMI via transradial PCI. In the transradial scenario, bleeding and MI within 30 days are substantially related to 30-day mortality.

Impact of Pharmacist Interventions on the Long-Term Clinical Outcomes in Patients with Myocardial Infarction.

BACKGROUND: Controlling modifiable risk factors (MRFs) in patients with cardiovascular diseases has been shown to be effective in reducing re-hospitalization rates. The aim of this study was to investigate the rates of controlled MRFs and clinical outcomes after pharmacist interventions in patients with myocardial infarction (MI) after hospital discharge. METHODS: This prospective randomized clinical study was conducted at one medical center in Taiwan, and enrolled patients with MI from January 1, 2012 to December 31, 2014. Patients received medication reconciliation and education from a pharmacist before hospital discharge. The intervention group (IG) received continuous consultations from the pharmacist after discharge, whereas the control group (CG) did not. Primary outcomes included achieving blood pressure < 140/70 mmHg, low-density lipoprotein-cholesterol (LDL-C) < 70 mg/dL, and hemoglobin A1c (HbA1c) < 7% targets. The secondary outcome was major adverse cardiac events (MACEs), defined as re-hospitalization due to MI, unstable angina and stroke. RESULTS: Two hundred and eight patients completed the study protocol (106 in the IG and 102 in the CG). The rate of achieving blood pressure goal was similar between the two groups. More patients in the IG achieved LDL-C and HbA1c goals than those in the CG at 1 year and 2 years post discharge. However, there was no significant difference in the cumulative incidence of MACEs between the two groups (5.7% vs. 9.8%) (p = 0.262). Diabetes was the only independent predictor of re-hospitalization due to a MACE. CONCLUSIONS: Pharmacist interventions led to a higher rate of optimal controlled MRFs but did not significantly reduce the MACE rate in the patients with MI.

Benefit of cardiac rehabilitation in acute heart failure patients with cognitive impairment.

Aims: This study aimed to evaluate the prevalence of cognitive impairment among patients with acute heart failure (AHF), its prognosis, and the effects of cardiac rehabilitation (CR) on these patients' outcomes. Methods: Overall, 247 consecutive AHF patients (median age, 60 years; males, 78.5 %) were evaluated from March 2015 to May 2021. Patients received an AHF disease management program coordinated by an HF specialist nurse and underwent a Luria-Nebraska Neuropsychological battery-screening test (LNNB-S) assessment during admission. Cognitive impairment was defined as an LNNB-S score ≥10. Patients who underwent at least one session of phase II CR and continued with the home-based exercise program were considered to have received CR. The primary endpoint was composite all-cause mortality or readmission after a 3.30-year follow-up (interquartile range, 1.69-5.09 years). Results: Cognitive impairment occurred in 53.0 % and was associated with significantly higher composite endpoint, all-cause mortality, and readmission rates (p=<0.001, 0.001, and 0.015, respectively). In the total cohort, 40.9 % of patients experienced the composite endpoint. Multivariate analysis showed that the peak VO2 was a significant predictor of the composite endpoint. After adjustment, CR significantly decreased the event rate of the composite endpoint and the all-cause mortality in patients with cognitive impairment (log-rank p = 0.024 and 0.009, respectively). However, CR did not have a significant benefit on the composite endpoint and the all-cause mortality in patients without cognitive impairment (log-rank p = 0.682 and 0.701, respectively). Conclusion: Cognitive impairment is common in AHF patients and can lead to poor outcomes. CR is a standard treatment to improve prognosis.

Outcomes of catheter ablation vs. medical treatment for atrial fibrillation and heart failure: a meta-analysis.

Background: The benefit of catheter ablation vs. medical treatment has been reported to be inconsistent in randomized controlled trials (RCTs) for patients with atrial fibrillation (AF) and heart failure (HF) due to different enrollment criteria. This meta-analysis aimed to decipher the differential outcomes stratified by different left ventricular ejection fractions (LVEFs) and AF types. Methods: We searched PubMed, Embase, ProQuest, ScienceDirect, Cochrane Library, ClinicalKey, Web of Science, and ClinicalTrials.gov databases for RCTs comparing medical treatment and catheter ablation in patients with AF and HF published before March 31, 2023. Nine studies were included. Results: When patients were stratified by LVEF, improved LVEF and 6-min walk distance, less AF recurrence, and lower all-cause mortality in favor of catheter ablation were observed in patients with LVEF ≤50% but not in patients with LVEF ≤35%, and short HF hospitalization was observed in patients with LVEF ≤50% and LVEF ≤35%. When patients were stratified by AF types, improved LVEF and 6-min walk distance, better HF questionnaire score, and short HF hospitalization in favor of catheter ablation were observed both in patients with nonparoxysmal AF and mixed AF (paroxysmal and persistent) and less AF recurrence and lower all-cause mortality in favor of catheter ablation were observed in only patients with mixed AF. Conclusions: This meta-analysis showed improved LVEF and 6-min walk distance, less AF recurrence, and lower all-cause mortality in favor of catheter ablation vs. medical treatment in AF patients with HF and LVEF of 36%-50%. Compared with medical treatment, catheter ablation improved LVEF and had better HF status in patients with nonparoxysmal AF and mixed AF; however, AF recurrence and all-cause mortality in favor of catheter ablation were observed in only HF patients with mixed AF.

Comparing Vitamin K Antagonists and Direct Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement: A Meta-Analysis.

Aortic stenosis (AS) is the most prevalent valvular disease in the elderly population and the prevalence of atrial fibrillation (AF) increases in the elderly population. Transcatheter aortic valve replacement (TAVR) becomes an important treatment for patients with AS at high surgical risk. This metanalysis aimed to compare the efficacy and safety of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) in patients with AF undergoing TAVR. We searched the different databases for articles published before January 31, 2022. In total, 7 studies including 25,255 patients were analyzed. Data on demographics, comorbidities, CHA2DS2-VASc score, Society of Thoracic Surgeons (STS) score, and incidences of all-cause mortality, major bleeding, intracranial hemorrhage (ICH), stroke, and thromboembolic events were obtained and analyzed. The VKA group had a lower CHA2DS2-VASc score (3.2 ± 1.2 vs 3.3 ± 1.2; P < .001) and a higher STS score (6.6 ± 3.2 vs 6.1 ± 2.9; P < .001) than the DOAC group. The risks of all-cause mortality (odds ratio [OR]: 0.88; 95% confidence interval [CI], 0.67-1.16), ischemic stroke (OR: 1.06; 95% CI, 0.90-1.24), and thromboembolism (OR: 1.24; 95% CI, 0.63-2.47) in the DOAC group were comparable to the VKA group. The risks of major bleeding (OR: 0.77; 95% CI, 0.71-0.84) and ICH (OR: 0.62; 95% CI, 0.42-0.90) were lower in the DOAC group compared to the VKA group. DOACs were associated with lower risks of major bleeding and ICH, and comparable risks of all-cause mortality, ischemic stroke, and thromboembolism in patients with AF undergoing TAVR compared to VKAs.

Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in East-Asian Patients with Acute Coronary Syndrome: Large Cohort Study.

AIM: A high risk of bleeding is observed in East Asian patients with acute coronary syndrome (ACS). Therefore, the choice between two antiplatelet therapy drugs, ticagrelor and clopidogrel, remains controversial in this population with ACS. This study aimed to use a large cohort database to assess the clinical outcomes of ticagrelor and clopidogrel therapy, including major bleeding, recurrent ACS, and mortality, in this population. METHODS: Between January 2009 and December 2019, 43,696 patients were diagnosed with ACS based on the medical history (International Classification of Diseases [ICD] code) of the Chang Gung Research Database. After excluding patients without percutaneous coronary intervention, with concurrent medical problems, and on non-standard dual antiplatelet therapy (DAPT) or a single antiplatelet agent, 18,046 patients were recruited for analysis. Ticagrelor- and clopidogrel-based DAPT were administered to 3666 patients and 14,380 patients, respectively. Baseline characteristics and clinical outcomes were compared between the two groups. A total of 4225 patients were defined as a high-bleeding-risk subgroup according to Academic Research Consortium for High Bleeding Risk (ARC-HBR) score (met one major or two minor criteria), of which 466 and 3759 patients received ticagrelor- and clopidogrel-based DAPT, respectively. RESULTS: Before propensity score matching (PSM), younger age, higher prevalence of male sex, and higher body mass index were noted in the ticagrelor-based DAPT group in the whole cohort and high-bleeding-risk subgroup. After PSM, no difference in baseline characteristics and comorbidities between ticagrelor-based and clopidogrel-based DAPT groups in the whole cohort and high-bleeding-risk subgroup was noted. The Kaplan-Meier curves of recurrent ACS and major bleeding were significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of cardiovascular (CV) and all-cause mortality showed no significant differences. After PSM, in the high-bleeding-risk subgroup, the Kaplan-Meier curve of recurrent ACS was significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of major bleeding, CV, and all-cause mortality showed no significant differences. CONCLUSION: In this large cohort study, patients receiving ticagrelor-based DAPT were at lower risk of recurrent ACS compared to those receiving clopidogrel-based DAPT, especially in the patients with myocardial infarction. Ticagrelor-based DAPT did not result in a higher risk of major bleeding in the whole ACS population and high-bleeding-risk subgroup. The rate of CV and all-cause mortality were similar between both the groups.

Optimizing exercise testing-based risk stratification to predict poor prognosis after acute heart failure.

AIMS: The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO2 ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO2 and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era. METHODS AND RESULTS: We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO2 and HFSS in predicting primary outcomes. The median follow-up period was 3.3 years. The primary outcome occurred in 57 participants. Peak VO2 outperformed HFSS when predicting 1 year (0.81 vs. 0.61; P = 0.017) and 2 year (0.78 vs. 0.58; P < 0.001) major outcomes. The cutoff peak VO2 for predicting a 20% risk of a major outcome within 2 years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO2 , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes. CONCLUSIONS: Optimizing the cutoff value of peak VO2 is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.

Mobility Status Plays an Important Role in the Risk of Cardiovascular Rehospitalizations in Patients with Heart Failure Undergoing Cardiac Rehabilitation: A Retrospective Cohort Study.

The aim of this study was to investigate the association between mobility status and cardiovascular rehospitalizations in patients with heart failure undergoing cardiac rehabilitation. This retrospective cohort study included patients with heart failure undergoing cardiac rehabilitation. Mobility status was evaluated using functional ambulation categories (FAC), and each cardiovascular hospitalization was recorded by the case manager. A Poisson regression model was used to analyze the association between mobility status and cardiovascular rehospitalizations. This study included 154 patients with heart failure undergoing cardiac rehabilitation. For cardiovascular rehospitalizations within 6 months, the Poisson regression model reported that the impaired mobility group had a higher risk than the fair mobility group (incidence rate ratio (IRR) = 2.38, 95% CI 1.27-4.46, p = 0.007). For cardiovascular rehospitalizations within 12 months, the Poisson regression model also reported that the impaired mobility group had a higher risk than the fair mobility group (IRR = 1.91, 95% CI 1.16-3.13, p = 0.010). Other covariates, such as LVEF, peak oxygen consumption, and PAOD, could have impacted the risk of cardiovascular rehospitalizations. Among patients with heart failure undergoing cardiac rehabilitation, the impaired mobility group had a twofold risk of cardiovascular rehospitalizations, compared with the fair mobility group within both 6 and 12 months.