Upstream Statin Therapy and Long-Term Recurrence of Atrial Fibrillation after Cardioversion: A Propensity-Matched Analysis.

The relationship of statin therapy with recurrence of atrial fibrillation (AF) after cardioversion (CV) has been evaluated by several investigations, which provided conflicting results and particularly long-term data is scarce. We sought to examine whether upstream statin therapy is associated with long-term recurrence of AF after CV. This was a single-center registry study including consecutive AF patients (n = 454) undergoing CV. Cox regression models were performed to estimate AF recurrence comparing patients with and without statins. In addition, we performed a propensity score matched analysis with a 1:1 ratio. Statins were prescribed to 183 (40.3%) patients. After a median follow-up period of 373 (207-805) days, recurrence of AF was present in 150 (33.0%) patients. Patients receiving statins had a significantly lower rate of AF recurrence (log-rank p < 0.001). In univariate analysis, statin therapy was associated with a significantly reduced rate of AF recurrence (HR 0.333 (95% CI 0.225-0.493), p = 0.001), which remained significant after adjustment (HR 0.238 (95% CI 0.151-0.375), p < 0.001). After propensity score matching treatment with statins resulted in an absolute risk reduction of 27.5% for recurrent AF (21 (18.1%) vs. 53 (45.7%); p < 0.001). Statin therapy was associated with a reduced risk of long-term AF recurrence after successful cardioversion.

U-shaped relationship of left ventricular ejection time index and all-cause mortality.

BACKGROUND: Previous studies have suggested that systolic and diastolic heart failure is associated with alterations of left ventricular ejection time index (LVETI). We sought to examine the relation of LVETI to mortality in an elderly population. METHODS: We prospectively enrolled 852 patients undergoing cardiac catheterization for suspected coronary artery disease (CAD) in 2001 and 2002. LVETI was measured noninvasively using radial applantation tonometry and pulse waveform analysis. Mortality data were assessed by telephone interviews with general practitioners, hospital records, and the national mortality register. RESULTS: The mean age was 64.8 years, 60.7% of subjects were men, 70.1% of subjects had significant CAD, and 28.6% of subjects had impaired systolic function. After a mean follow-up of 8.2 ± 2.3 years, 183 deaths occurred. At baseline, LVETI was significantly associated with age, systolic and diastolic blood pressure, pulse pressure, and N-terminal probrain natriuretic peptide. A shorter LVETI was significantly and independently associated with impaired systolic function. Kaplan-Meier analysis revealed that both prolonged and shortened ejection time index (1st and 3rd tertile LVETI) were associated with a decreased survival probability (P <0.05, log-rank-test) compared with normal LVETI (2nd tertile). In multivariable Cox regression analysis, the hazard ratios for all-cause mortality were 1.66 for 1st tertile LVETI (P = 0.01) and 1.75 for 3rd tertile LVETI (P = 0.006). The effect of a shortened LVETI on mortality was partly due to the effect of impaired systolic function on ejection duration. CONCLUSIONS: We observed a U-shaped relation between ejection duration and all-cause mortality.

Pulsatile hemodynamics in patients with exertional dyspnea: potentially of value in the diagnostic evaluation of suspected heart failure with preserved ejection fraction.

OBJECTIVES: This study sought to test whether measures of pulsatile arterial function are useful for diagnosing heart failure with preserved ejection fraction (HFPEF), in comparison with and in addition to tissue Doppler echocardiography (TDE). BACKGROUND: Increased arterial stiffness and wave reflections are present in most patients with HFPEF. METHODS: Patients with dyspnea as a major symptom were categorized as having HFPEF or no HFPEF, based on invasively derived filling pressures and natriuretic peptide levels. Pulse wave velocity (PWV) was measured invasively (aortic PWV). Aortic pulse pressure (aoPP) and its components (incident pressure wave height, forward wave amplitude; augmented pressure; backward wave amplitude [Pb]) were quantified noninvasively. RESULTS: Seventy-one patients were classified as HFPEF and 65 as no HFPEF (223 patients had intermediate results). Patients with HFPEF were older, more often had hypertension and diabetes, and had larger left atria and higher left ventricular mass. Brachial pulse pressure (bPP), aoPP, and all measures of arterial stiffness and wave reflections were higher in HFPEF patients. Receiver-operating curve analysis-derived area under the curve (AUC) values for separating HFPEF from no HFPEF were 0.823 for E/E' at the medial annulus, the best TDE parameter; 0.816 for bPP; and 0.867, 0.851, and 0.825 for aortic PWV, aoPP, and Pb, respectively. Adding measures of pulsatile function to TDE resulted in an increase in AUC to 0.875 (bPP; p = 0.03) and 0.901 (aoPP; p = 0.005). In comparison with a TDE-based algorithm, net reclassification improvement was 32.9% (p < 0.0001). CONCLUSIONS: Measures of pulsatile arterial hemodynamics may complement TDE for the diagnosis of HFPEF. (Pulsatile and Steady State Hemodynamics in Diastolic Heart Failure; NCT00720525).

Wave reflections, assessed with a novel method for pulse wave separation, are associated with end-organ damage and clinical outcomes.

We recently developed a novel method for assessment of arterial wave reflections (ARCSolver method): based on adopted Windkessel methods, flow curves are estimated from pressure waveforms, and wave separation analysis is performed, yielding the amplitudes of the forward and backward waves. The aim of this study was to investigate their clinical correlates and prognostic impact. In 725 patients (417 men; mean age, 64 years) undergoing coronary angiography, we determined wave reflections from radial tonometry and transfer function-derived aortic waveforms using pulse wave analysis, as well as wave separation analysis. Measures of pulsatile arterial function were statistically significant, although moderately associated with markers of cardiac load and subclinic cardiac, renal, and aortic end-organ damage. After a median follow-up duration of 1399 days, 139 patients reached the combined cardiovascular end point (death, myocardial infarction, stroke, coronary, cerebrovascular, and peripheral revascularization). In univariate analysis, the relative risk of the combined end point increased with increasing levels of incident pressure wave height, augmented pressure, and forward and backward wave amplitude (hazard ratio for 1 SD was 1.302, 1.236, 1.226, and 1.276; P<0.01 for all, respectively). In multivariate analysis, backward wave amplitude was the most consistent predictor of the combined end point. Of note, its predictive value was independent of brachial systolic, diastolic, and mean blood pressures and was superior to brachial pulse pressure. In conclusion, the amplitude of the reflected wave, as assessed with a novel method for wave separation, is associated with hypertensive end organ damage and is an independent predictor of cardiovascular events in high-risk patients.