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BACKGROUND: There has been an increasing uptake of transcatheter left atrial appendage occlusion (LAAO) for stroke reduction in atrial fibrillation. OBJECTIVES: To investigate the perceptions and approaches among a nationally representative sample of physicians. METHODS: Using the American Medical Association Physician Masterfile, we selected a random sample of 500 physicians from each of the specialties: general cardiologists, interventional cardiologists, electrophysiologists, and vascular neurologists. The participants received the survey by mail up to three times from November 9, 2021 to January 14, 2022. In addition to the questions about experiences, perceptions, and approaches, physicians were randomly assigned to 1 of the 4 versions of a patient vignette: white man, white woman, black man, and black woman, to investigate potential bias in decision-making. RESULTS: The top three reasons for considering LAAO were: a history of intracranial bleeding (94.3%), a history of major extracranial bleeding (91.8%), and gastrointestinal lesions (59.0%), whereas the top three reasons for withholding LAAO were: other indications for long-term oral anticoagulation (87.7%), a low bleeding risk (77.0%), and a low stroke risk (65.6%). For the reasons limiting recommendations for LAAO, 59.8% mentioned procedural risks, 42.6% mentioned "limiting efficacy data comparing LAAO to NOAC" and 32.8% mentioned "limited safety data comparing LAAO to NOAC." There was no difference in physicians' decision-making by patients' race, gender, or the concordance between patients' and physicians' race or gender. CONCLUSIONS: In the first U.S. national physician survey of LAAO, individual physicians' perspectives varied greatly, which provided information that will help customize future educational activities for different audiences. CONDENSED ABSTRACT: Although diverse practice patterns of LAAO have been documented, little is known about the reasoning or perceptions that drive these variations. Unlike prior surveys that were directed to Centers that performed LAAO, the current survey obtained insights from individual physicians, not only those who perform the procedures (interventional cardiologists and electrophysiologists) but also those who are closely involved in the decision-making and referral process (general cardiologists and vascular neurologists). The findings identify key evidence gaps and help prioritize future studies to establish a consistent and evidence-based best practice for AF stroke prevention.
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Apêndice Atrial , Fibrilação Atrial , Médicos , Acidente Vascular Cerebral , Feminino , Humanos , Masculino , Anticoagulantes , Apêndice Atrial/cirurgia , Fibrilação Atrial/complicações , Fibrilação Atrial/cirurgia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do TratamentoRESUMO
We describe a case of a mass-like echocardiographic density on a mechanical prosthetic aortic valve. We initially suspected a thrombus vs vegetation on transthoracic echocardiography, but after transesophageal echocardiography, the density was subsequently determined to be cavitation by reviewing the initial images in slow motion.
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Valva Aórtica/diagnóstico por imagem , Ecocardiografia/métodos , Próteses Valvulares Cardíacas , Microbolhas , Trombose Coronária/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Estresse MecânicoRESUMO
BACKGROUND: Prophylactic exclusion of the left atrial appendage (LAA) is often performed during cardiac surgery ostensibly to reduce the risk of stroke. However, the clinical impact of LAA closure in humans remains inconclusive. METHODS: Of 10 633 adults who underwent coronary artery bypass grafting and valve surgery between January 2000 and December 2005, 9792 patients with complete baseline characteristics, surgery procedure, and follow-up data were included in this analysis. A propensity score-matching analysis based on 28 pretreatment covariates was performed and 461 matching pairs were derived and analyzed to estimate the association of LAA closure with early postoperative atrial fibrillation (POAF) (atrial fibrillation ≤30 days of surgery), ischemic stroke, and mortality. RESULTS: In the propensity-matched cohort, the overall incidence of POAF was 53.9%. In this group, the rate of early POAF among the patients who underwent LAA closure was 68.6% versus 31.9% for those who did not undergo the procedure (P<0.001). LAA closure was independently associated with an increased risk of early POAF (adjusted odds ratio, 3.88; 95% confidence interval, 2.89-5.20), but did not significantly influence the risk of stroke (adjusted hazard ratio, 1.07; 95% confidence interval, 0.72-1.58) or mortality (adjusted hazard ratio, 0.92; 95% confidence interval, 0.75-1.13). CONCLUSIONS: After adjustment for treatment allocation bias, LAA closure during routine cardiac surgery was significantly associated with an increased risk of early POAF, but it did not influence the risk of stroke or mortality. It remains uncertain whether prophylactic exclusion of the LAA is warranted for stroke prevention during non-atrial fibrillation-related cardiac surgery.
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Apêndice Atrial/cirurgia , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Acidente Vascular Cerebral/etiologia , Idoso , Fibrilação Atrial/fisiopatologia , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Estudos de Coortes , Feminino , Humanos , Masculino , Acidente Vascular Cerebral/fisiopatologia , Análise de SobrevidaRESUMO
Importance: Surgical occlusion of the left atrial appendage (LAAO) may be performed during concurrent cardiac surgery. However, few data exist on the association of LAAO with long-term risk of stroke, and some evidence suggests that this procedure may be associated with subsequent development of atrial fibrillation (AF). Objective: To evaluate the association of surgical LAAO performed during cardiac surgery with risk of stroke, mortality, and development of subsequent AF. Design, Setting, and Participants: Retrospective cohort study using a large US administrative database that contains data from adult patients (≥18 years) with private insurance or Medicare Advantage who underwent coronary artery bypass graft (CABG) or valve surgery between January 1, 2009, and March 30, 2017, with final follow-up on March 31, 2017. One-to-one propensity score matching was used to balance patients on 76 dimensions to compare those with vs without LAAO, stratified by history of prior AF at the time of surgery. Exposures: Surgical LAAO vs no surgical LAAO during cardiac surgery. Main Outcomes and Measures: The primary outcomes were stroke (ie, ischemic stroke or systemic embolism) and all-cause mortality. The secondary outcomes were postoperative AF (AF within 30 days after surgery among patients without prior AF) and long-term AF-related health utilization (event rates of outpatient visits and hospitalizations). Results: Among 75â¯782 patients who underwent cardiac surgery (mean age, 66.0 [SD, 11.2] years; 2â¯2091 [29.2%] women, 25â¯721 [33.9%] with preexisting AF), 4374 (5.8%) underwent concurrent LAAO, and mean follow-up was 2.1 (SD, 1.9) years. In the 8590 propensity score-matched patients, LAAO was associated with a reduced risk of stroke (1.14 vs 1.59 events per 100 person-years; hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]; P = .03) and mortality (3.01 vs 4.30 events per 100 person-years; HR, 0.71 [95% CI, 0.60-0.84]; P < .001). LAAO was associated with higher rates of AF-related outpatient visits (11.96 vs 10.26 events per person-year; absolute difference, 1.70 [95% CI, 1.60-1.80] events per person-year; rate ratio, 1.17 [95% CI, 1.10-1.24]; P < .001) and hospitalizations (0.36 vs 0.32 event per person-year; absolute difference, 0.04 [95% CI, 0.02-0.06] event per person-year; rate ratio, 1.13 [95% CI, 1.05-1.21]; P = .002). In patients with prior AF (6438/8590 [74.9%]) with vs without LAAO, risk of stroke was 1.11 vs 1.71 events per 100 person-years (HR, 0.68 [95% CI, 0.50-0.92]; P = .01) and risk of mortality was 3.22 vs 4.93 events per 100 person-years (HR, 0.67 [95% CI, 0.56-0.80]; P < .001), respectively. In patients without prior AF (2152/8590 [25.1%]) with vs without LAAO, risk of stroke was 1.23 vs 1.26 events per 100 person-years (HR, 0.95 [95% CI, 0.54-1.68]), risk of mortality was 2.30 vs 2.49 events per 100 person-years (HR, 0.92 [95% CI, 0.61-1.37]), and risk of postoperative AF was 27.7% vs 20.2% events per 100 person-years (HR, 1.46 [95% CI, 1.22-1.73]; P < .001). The interaction term between prior AF and LAAO was not significant (P = .29 for stroke and P = .16 for mortality). Conclusions and Relevance: Among patients undergoing cardiac surgery, concurrent surgical LAAO, compared with no surgical LAAO, was associated with reduced risk of subsequent stroke and all-cause mortality. Further research, including from randomized clinical trials, is needed to more definitively determine the role of surgical LAAO.
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Apêndice Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Cardiopatias/mortalidade , Cardiopatias/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , Acidente Vascular Cerebral/etiologiaRESUMO
AIMS: von Willebrand factor (VWF) is an independent risk factor for adverse events in patients with non-valvular atrial fibrillation (NVAF). However, it is unclear if VWF level remains elevated and predictive of stroke during entire course of NVAF. METHODS AND RESULTS: In order to determine if VWF is a time-dependent blood variable, VWF antigen measured by latex immunoassay in 425 NVAF patients and 100 controls with normal sinus rhythm (NSR) was analyzed according to NVAF duration (<1 month: n = 76, 1-12 months: n = 98, and >12 months: n = 251). The mean VWF antigen level in NVAF patients with <1-month duration (167 ± 59%) was not different compared to those with 1-12 months (157 ± 50%, P = .24) and >12 months duration (156 ± 54%, P = .11) but higher compared to NSR controls (143 ± 48%, P = .003). Higher VWF level correlated with higher CHADS2 scores and with progressing intensity of blood stasis in the left atrium and thrombus formation in all three time periods of atrial fibrillation duration. Patients not treated with warfarin had VWF 30% higher in the first month compared to following months. CONCLUSIONS: von Willebrand Factor is steadily elevated throughout the course of dysrhythmia in NVAF patients treated with warfarin and in those with higher intensity of left atrium blood stasis.
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Fibrilação Atrial/sangue , Biomarcadores/sangue , Fator de von Willebrand , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/etiologia , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
Among patients undergoing cardioversion for atrial fibrillation, the presence of left ventricular thrombus is a relatively uncommon and challenging clinical dilemma. While left atrial appendage thrombus is a contraindication to cardioversion, there is paucity of data regarding the safety of cardioversion in with the presence of left ventricular apical thrombus. Also, thrombus characteristics such as protrusion and mobility on echocardiography are known risk factors for systemic embolism. In this article, we present a case highlighting the management of atrial fibrillation in the setting of left ventricular dysfunction, acute heart failure, and echocardiographic evidence of acute left ventricular apical thrombus.
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Fibrilação Atrial/terapia , Trombose Coronária/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Cardioversão Elétrica/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Doença Aguda , Idoso , Fibrilação Atrial/complicações , Trombose Coronária/complicações , Trombose Coronária/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Fatores de Risco , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia that leads to hospitalizations for complications and adverse events each year. Despite significant improvement in our therapeutic approaches in the past decade, management of AF remains a difficult task. Novel therapies have failed to terminate AF and prevent its recurrence, and patients with AF continue to have thromboembolic complications. With the increasingly aging population and associated conditions, the prevalence of AF is expected to progressively increase, becoming a public health problem. Most patients with AF have multiple comorbidities and are of advanced age, making long-term anticoagulation challenging. This article provides an overview of the current pharmacological therapies for the management of AF, with particular emphasis on the emerging agents.
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Fibrilação Atrial/tratamento farmacológico , Antiarrítmicos/classificação , Antiarrítmicos/uso terapêutico , Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Fibrilação Atrial/complicações , Humanos , Inibidores da Agregação Plaquetária/uso terapêuticoRESUMO
BACKGROUND: Left atrial appendage emptying flow velocity (LAAEV) depends largely on left atrioventricular compliance and may play a role in mediating the perpetuation of atrial fibrillation (AF) and AF-related outcomes. METHODS: We identified 3,251 consecutive patients with sustained AF undergoing first-time successful transesophageal echocardiography (TEE)-guided electrical cardioversion who were enrolled in a prospective registry between May 2000 and March 2012. Left atrial appendage emptying flow velocity was stratified into quartiles: ≤20.2, 20.3-33.9, 34-49.9, and ≥50 cm/s. Multivariate Cox regression models were used to identify independent predictors of AF recurrence, ischemic stroke, and all-cause mortality. RESULTS: The mean (SD) age was 69 (12.6) years and 67% were men. Compared with the fourth quartile, patients in the first-third quartiles were significantly older, had higher CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack [TIA], vascular disease, age 65-74 years, sex category) scores, greater frequency of atrial spontaneous echo contrast, and AF of longer duration. Kaplan-Meier analysis showed a decreased probability of event-free survival with decreasing quartiles of LAAEV. Five-year cumulative event rates across first-fourth quartiles were 83%, 80%, 73%, and 73% (P < .001) for first AF recurrence; 7.5%, 7.0%, 4.1%, and 4.0%, for stroke (P = .01); and 31.3%, 26.1%, 24.1%, and 19.4%, for mortality (P < .001), respectively. Multivariate Cox regression analysis revealed an independent association of the first and second quartiles with AF recurrence (P < .001 and P < .001, respectively) and stroke (P = .03, and P = .04, respectively), and of the first quartile with mortality (P = .003). CONCLUSIONS: Patients with decreased LAAEV have an increased risk of AF recurrence, stroke, and mortality after successful electrical cardioversion. Real-time measurement of LAAEV by TEE may be a useful physiologic biomarker for individualizing treatment decisions in patients with AF.
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Apêndice Atrial/fisiopatologia , Fibrilação Atrial/fisiopatologia , Velocidade do Fluxo Sanguíneo/fisiologia , Cardioversão Elétrica , Monitorização Fisiológica/métodos , Acidente Vascular Cerebral/epidemiologia , Idoso , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Intervalo Livre de Doença , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Estudos Prospectivos , Recidiva , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. Data are lacking on the long-term prognostic implications of POAF. We hypothesized that POAF, which reflects underlying cardiovascular pathophysiologic substrate, is a predictive marker of late AF and long-term mortality. METHODS: We identified 603 Olmsted County, Minnesota, residents without prior documented history of AF who underwent coronary artery bypass graft and/or valve surgery from 2000 to 2005. Patients were monitored for first documentation of late AF or death at >30 days postoperatively. Multivariate Cox regression models were used to assess the independent association of POAF with late AF and long-term mortality. RESULTS: After a mean follow-up of 8.3 ± 4.2 years, freedom from late AF was less with POAF than no POAF (57.4% vs 88.9%, P < .001). The risk of late AF was highest within the first year at 18%. Univariate analysis demonstrated that POAF was associated with significantly increased risk of late AF [hazard ratio (HR), 5.09; 95% CI, 3.65-7.22] and long-term mortality (HR, 1.79; 95% CI, 1.38-2.22). After adjustment for age, sex, and clinical and surgical risk factors, POAF remained independently associated with development of late AF (HR, 3.52; 95% CI, 2.42-5.13) but not long-term mortality (HR, 1.16; 95% CI, 0.87-1.55). Conversely, late AF was independently predictive of long-term mortality (HR, 3.25; 95% CI, 2.42-4.35). Diastolic dysfunction independently influenced the risk of late AF and long-term mortality. CONCLUSIONS: Postoperative atrial fibrillation was an independent predictive marker of late AF, whereas late AF, but not POAF, was independently associated with long-term mortality. Patients who develop new-onset POAF should be considered for continuous anticoagulation at least during the first year following cardiac surgery.
Assuntos
Fibrilação Atrial/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Vigilância da População , Complicações Pós-Operatórias , Medição de Risco , Idoso , Fibrilação Atrial/etiologia , Feminino , Seguimentos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de TempoRESUMO
Background: Direct current (DC) cardioversion is used to terminate cardiac arrhythmias. Current guidelines list cardioversion as a cause of myocardial injury. Objective: This study determined whether external DC cardioversion results in myocardial injury measured by serial changes in high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI). Methods: This was a prospective study of patients undergoing elective external DC cardioversion for atrial fibrillation. hs-cTnT and hs-cTnI were measured precardioversion and at least 6 hours postcardioversion. Myocardial injury was present when there were significant changes in both hs-cTnT and hs-cTnI. Results: Ninety-eight subjects were analyzed. Median cumulative energy delivered was 121.9 (interquartile range [IQR] 102.2-302.7) J. Multiple cases 23 (23.5%) required 300 J or more. Maximum cumulative energy delivered was 2455.1 J. There were small significant changes in both hs-cTnT (median precardioversion 12 [IQR 7-19) ng/L], median postcardioversion 13 [IQR 8-21] ng/L; P < .001) and hs-cTnI (median precardioversion 5 [IQR 3-10) ng/L], median postcardioversion 7 [IQR 3.6-11) ng/L; P < .001). Results were similar in patients with high-energy shocks and did not vary based on precardioversion values. Only 2 (2%) cases met criteria for myocardial injury. Conclusion: DC cardioversion resulted in a small but statistically significant changes in hs-cTnT and hs-cTnI in 2% of patients studied irrespective of shock energy. Patients with marked troponin elevations after elective cardioversion should be assessed for other causes of myocardial injury. It should not be assumed the myocardial injury was from the cardioversion.
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BACKGROUND: High-sensitivity cardiac troponin (hs-cTnT) is often increased in patients with atrial fibrillation/flutter, portending a poor prognosis. The etiologies for these increases have not been systematically investigated. Our aim was to define prevalence/significance of structural cardiac abnormalities in patients with atrial fibrillation/flutter and high-sensitivity cardiac troponin T (hs-cTnT) increases. METHODS: This is a retrospective observational cohort study of patients with atrial fibrillation/flutter diagnosis with hs-cTnT measurements, echocardiograms, and coronary angiograms. Myocardial injury was defined as hs-cTnT >10 ng/L for women and >15 ng/L for men. Cases with myocardial injury were adjudicated according to the Fourth Universal Definition of Myocardial Infarction. RESULTS: Patients with definite causes for increased hs-cTnT (n = 875) were tabulated but not evaluated further; common diagnoses were type 1 myocardial infarction, critical illness, and known heart failure. Of the remaining 401, increased hs-cTnT was present in 336 (84%) patients. Of those, 78% had nonischemic myocardial injury, the remaining (n = 75, 22%) had type 2 myocardial infarction. Patients with elevated hs-cTnT had greater left ventricular mass index, left ventricular filling pressures, and right ventricular systolic pressure. They more frequently had significant coronary artery disease (47% vs 31%, P = .016), especially in type 2 myocardial infarction. With logistic regression, age, sex (F), diabetes, left ventricular mass index, e' medial velocity, and right ventricular systolic pressure were independent determinants of myocardial injury. One-year mortality was higher in patients with myocardial injury. CONCLUSIONS: Structural heart abnormalities are common in patients with atrial fibrillation/flutter and increased hs-cTnT. Causes of myocardial injury should be elucidated in each patient to craft appropriate therapies.
Assuntos
Fibrilação Atrial , Flutter Atrial , Diabetes Mellitus Tipo 2 , Traumatismos Cardíacos , Infarto do Miocárdio , Humanos , Masculino , Feminino , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/diagnóstico , Troponina T , Estudos de Coortes , Biomarcadores , Flutter Atrial/terapia , Infarto do Miocárdio/complicações , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/diagnósticoRESUMO
BACKGROUND: Von Willebrand factor (VWF) elevation correlates with the left atrial blood stasis in nonvalvular atrial fibrillation (NVAF). However, the long-term impact of elevated VWF in patients with NVAF is not well established. METHODS: To assess the impact of VWF and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) in conjunction with echocardiographic measures of left atrium blood stasis on clinical outcomes, 414 NVAF prospectively recruited (October 4, 2007, to April 27, 2009) patients were followed for 3 years. VWF antigen, VWF activity, ADAMTS13 activity, and echocardiographic findings were assessed at baseline. Thromboembolism (TE) (stroke/transient ischemic attack (TIA)), myocardial infarction, or TE of other locations), major bleeding, clinically relevant nonmajor bleeding, and all-cause mortality were assessed by clinical follow-up, questionnaire, or telephone communication. RESULTS: Among 374 patients (mean age, 63.4 ± 12.7 years; 25% females) who had complete follow-up data, there were 33 TE in 32 patients (8.6%), 18 deaths (5.1%), and 33 bleeding events (21 major bleeding and 12 clinically relevant nonmajor bleeding) in 25 patients (6.7%). VWF antigen was predictive of TE in the univariate examination (hazard ratio [HR]: 1.007, 95% confidence interval [CI]: 1.002, 1.013, P = 0.011) but not in multivariate analysis. VWF was an independent predictor of all-cause mortality (HR: 1.011, 95% CI: 1.003, 1.020, P = 0.011) and a composite of TE and all-cause mortality (HR: 1.006, 95% CI: 1.001, 1.012, P = 0.039) in multivariate analysis. ADAMTS13 was not predictive of clinical outcomes in multivariate analysis. CONCLUSIONS: Among patients with NVAF, VWF is an independent predictor of poor outcomes including death and a composite of death and TE. As such, VWF measure may help identify high-risk patients and provide further stratification beyond CHA2DS2-VASc assessment.
CONTEXTE: Une élévation du facteur de Von Willebrand (FVW) concorde avec une stase sanguine dans l'oreillette gauche dans la fibrillation auriculaire non valvulaire (FANV). Les répercussions à long terme d'un taux élevé du FVW chez les patients présentant une FANV ne sont toutefois pas bien établies. MÉTHODOLOGIE: Pour évaluer les répercussions sur les résultats cliniques du FVW et d'une désintégrine et métalloprotéinase de motif type 1 (ADAMTS13) conjointement avec les mesures échocardiographiques de la stase sanguine dans l'oreillette gauche, 414 patients atteints de FANV ont été inscrits de façon prospective (du 4 octobre 2007 au 27 avril 2009) pour faire l'objet d'un suivi de 3 ans. L'antigène du FVW, l'activité du FVW, l'activité d'ADAMTS13, et les résultats de l'échocardiographie ont été évalués au départ. La thromboembolie (TE) (accident vasculaire cérébral/accident ischémique transitoire, infarctus du myocarde, ou TE survenant ailleurs), l'hémorragie majeure, l'hémorragie non majeure pertinente sur le plan clinique et la mortalité toutes causes ont été évaluées au suivi clinique, par questionnaire, ou lors d'un appel téléphonique. RÉSULTATS: Parmi les 374 patients (âge moyen : 63,4 ± 12,7 ans; 25 % de femmes) ayant participé au suivi jusqu'à sa fin, on a relevé 33 TE chez 32 patients (8,6 %), 18 décès (5,1 %) et 33 événements hémorragiques (21 hémorragies majeures et 12 hémorragies non majeures pertinentes sur le plan clinique) chez 25 patients (6,7 %). L'antigène du FW était prédictif d'une TE selon l'analyse univariée (risque relatif [RR] : 1,007; intervalle de confiance [IC] à 95 % : de 1,002 à 1,013; p = 0,011), mais non selon l'analyse multivariée. Le FVW était un facteur prédictif indépendant de la mortalité toutes causes (RR : 1,011; IC à 95 % : de 1,003 à 1,020; p = 0,011) et des événements regroupés de TE et de mortalité toutes causes (RR : 1,006; IC à 95 % : de 1,001 à 1,012; p = 0,039) dans l'analyse multivariée. La protéase ADAMTS13 ne constituait pas un facteur prédictif des résultats cliniques dans l'analyse multivariée. CONCLUSIONS: Parmi les patients présentant une FANV, le FVW était un facteur prédictif indépendant de résultats défavorables, notamment de décès et des événements regroupant les décès et la TE. La mesure du FVW pourrait donc aider à cibler les patients à risque élevé, et permettre une stratification au-delà de l'évaluation du score CHA2DS2-VASc.
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INTRODUCTION: Emerging data suggest that cardioversion for atrial fibrillation (AF) may be associated with acute kidney injury (AKI). However, limited data are available regarding the incidence and risk factors for AKI after direct current cardioversion (DCCV) of AF. METHODS: All patients undergoing DCCV at Mayo Clinic between 2001 and 2012 for AF were prospectively enrolled in a database. All patients with serum creatinine (SCR) values pre- and post-cardioversion were reviewed for AKI, defined as a ≥25% decline in eGFR (estimated glomerular filtration rate) from baseline value within 7 days of the DCCV. RESULTS: Of the 6,427 eligible patients, 1,256 (19.5%) patients had pre- and post-DCCV SCR available and formed the cohort under study. The mean age was 70.4 (SD 11.7) years, and 67.3% were male. During the study period, 131 (10.4%) patients suffered from AKI following DCCV. AKI was independently associated with inpatient status (OR 26.79; 95% CI 3.69-194.52), CHA2DS2-VASc score (OR 1.25; 95% CI 1.11-1.41), prior use of diuretics (OR 1.59; 95% CI 1.03-2.46), and absence of CKD (OR 1.61; 95% CI 1.04-2.49), and was independent of the success of the DCCV. None of the patients required acute dialysis during the study outcome period. CONCLUSION: AKI following DCCV of AF is common, self-limited, and without the need for replacement therapies.
Assuntos
Fibrilação Atrial , Nefropatias , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/terapia , Cardioversão Elétrica , Humanos , Incidência , Masculino , Diálise Renal , Fatores de RiscoRESUMO
Background The prognosis of left ventricular noncompaction (LVNC) remains elusive despite its recognition as a clinical entity for >30 years. We sought to identify clinical and imaging characteristics and risk factors for mortality in patients with LVNC. Methods and Results 339 adults with LVNC seen between 2000 and 2016 were identified. LVNC was defined as end-systolic noncompacted to compacted myocardial ratio >2 (Jenni criteria) and end-diastolic trough of trabeculation-to-epicardium (X):peak of trabeculation-to-epicardium (Y) ratio <0.5 (Chin criteria) by echocardiography; and end-diastolic noncompacted:compacted ratio >2.3 (Petersen criteria) by magnetic resonance imaging. Median age was 47.4 years, and 46% of patients were female. Left ventricular ejection fraction <50% was present in 57% of patients and isolated apical noncompaction in 48%. During a median follow-up of 6.3 years, 59 patients died. On multivariable Cox regression analysis, age (hazard ratio [HR] 1.04; 95% CI, 1.02-1.06), left ventricular ejection fraction <50% (HR, 2.37; 95% CI, 1.17-4.80), and noncompaction extending from the apex to the mid or basal segments (HR, 2.11; 95% CI, 1.21-3.68) were associated with all-cause mortality. Compared with the expected survival for age- and sex-matched US population, patients with LVNC had reduced overall survival (P<0.001). However, patients with LVNC with preserved left ventricular ejection fraction and patients with isolated apical noncompaction had similar survival to the general population. Conclusions Overall survival is reduced in patients with LVNC compared with the expected survival of age- and sex-matched US population. However, survival rate in those with preserved left ventricular ejection fraction and isolated apical noncompaction was comparable with that of the general population.
Assuntos
Cardiopatias Congênitas , Volume Sistólico , Fatores Etários , Ecocardiografia/métodos , Feminino , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/fisiopatologia , Humanos , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Mortalidade , Prognóstico , Estudos Retrospectivos , Fatores Sexuais , Análise de Sobrevida , Estados Unidos/epidemiologia , Função Ventricular EsquerdaRESUMO
Background Recent investigations suggest that inflammation and autoimmunity might have a role in the pathophysiology of atrial fibrillation (AF). Given that abnormal ventriculovascular coupling often coexists with AF, we hypothesize that autoimmune vasculitis plays a significant role in the pathogenetic mechanism of AF. Methods and Results A standardized retrospective population-based case-control study was conducted to evaluate the association between autoimmune vasculitis and AF, and all-cause mortality. The study included 8459 patients with a new diagnosis of AF and 8459 age-, sex-, and registration calendar year-matched controls in Olmsted County, Minnesota, between January 1, 1980 and December 31, 2010. The association of each clinical characteristic, diagnosis, and treatment was assessed using conditional logistic regression to account for the matched case-control study design. Cox proportional hazards regression models and Kaplan-Meier curves were used to detect independent predictors of mortality and examine cumulative survival. Of a total of 16 918 patients (mean age 72.3+14.4 years; 48.7% women), 320 (1.9%) were diagnosed with autoimmune vasculitis before the index date during the 30-year period. Among the cases, the prevalence of any autoimmune vasculitis was 2.3%, whereas the frequency of autoimmune vasculitis in controls was 1.5% (P<0.001). After adjusting for potential confounders, the odds of autoimmune vasculitis in AF cases was 1.5 times higher than in controls (odds ratio, 1.47; 95% CI, 1.04-2.01; P=0.03). Patients with AF and autoimmune vasculitis had worse 5-year survival than those without autoimmune vasculitis or AF (44.7% versus 77.2%; log-rank P<0.001). Conclusions Autoimmune vasculitis is significantly associated with AF and independently confers worse survival. These observations may represent one mechanism linking autoimmunity and inflammation to the pathogenesis and prognosis of AF.
Assuntos
Fibrilação Atrial/etiologia , Doenças Autoimunes/complicações , Vasculite/complicações , Idoso , Fibrilação Atrial/mortalidade , Doenças Autoimunes/mortalidade , Estudos de Casos e Controles , Humanos , Incidência , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Minnesota/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Vasculite/mortalidadeRESUMO
Objective: Previous studies have postulated a causal role of patent foramen ovale (PFO) in the aetiology of embolic stroke in the general population. We hypothesised that the presence of concomitant PFO and atrial fibrillation (AF) will add incremental risk of ischaemic stroke to that linked to AF alone. Methods: We analysed data on 3069 consecutive patients (mean age 69.4±12.2 years; 67.1% men) undergoing transoesophageal echocardiography-guided electrical cardioversion (ECV) for AF between May 2000 and March 2012. PFO was identified by colour Doppler and agitated saline contrast study. All patients were followed up after ECV for first documentation of ischaemic stroke. Outcomes were compared using Cox regression models. Results: The prevalence of PFO was 20.0% and the shunt direction was left-to-right in the majority of patients (71.4%). Patients with PFO had a higher frequency of obstructive sleep apnoea (21.7% vs 17.1%, p=0.01) and higher mean peak left atrial appendage emptying velocity (38.3±21.8 vs 36.1±20.4 cm/s; p=0.04) compared with those without PFO. Otherwise, baseline characteristics were similar between groups. During a mean follow-up period of 7.3±4.6 years, 214 patients (7.0%) had ischaemic stroke. Multivariable analysis showed no significant association between PFO and ischaemic stroke (HR, 0.82 (95% CI 0.57 to 1.18)). PFO shunt direction was strongly associated with stroke: HR, 1.91 (95% CI 1.16 to 3.16) for right-to-left shunt and HR, 0.58 (95% CI 0.36 to 0.93) for left-to-right shunt. Conclusions: The presence of concurrent PFO in this largely anticoagulated group of patients with AF was not associated with increased risk of ischaemic stroke.
Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Forame Oval Patente/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Ecocardiografia Doppler em Cores , Feminino , Forame Oval Patente/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Prevalência , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Although diabetes mellitus (DM) has been established as a risk factor for developing atrial fibrillation (AF) and is a known risk factor for stroke, it is unclear whether the presence or duration of DM is the primary adverse influence on the clinical course of AF. We retrospectively analyzed patients diagnosed with incident AF to examine the impact of DM on ischemic stroke and all-cause mortality. The diagnosis of DM was established by ICD-9 codes and review of medical records. To account for the significant differences in baseline characteristics of patients with and without diabetes, we matched 909 AF patients with DM with 909 AF patients without DM using propensity score matching based on 26 baseline variables. Cox regression analysis was used to identify independent factors associated with ischemic stroke and mortality. The mean age of the propensity matched cohort was 74 ± 11.5 years and 55.4% were male. Over a median follow-up period of 5.4 years (maximum 23.9 years), cumulative survival was significantly lower for patients with DM than those without DM; Log-rank p <0.001. In the propensity-matched comparison, the risk of mortality was significantly higher in the DM group compared with the non-DM group (hazard ratio 1.25; 95% confidence interval 1.12 to 1.69; p <0.001). Likewise, patients with DM had a higher risk of stroke (hazard ratio 1.32; 95% confidence interval 1.02 to 1.69; pâ¯=â¯0.03). Duration of DM was not associated with increased risk for stroke or mortality. In conclusion, the co-morbidity of DM represents an independent predictor of reduced survival and further highlights the excess risk of thromboembolism in patients with AF.
Assuntos
Fibrilação Atrial/etiologia , Complicações do Diabetes/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Causas de Morte , Feminino , Humanos , Masculino , Minnesota , Pontuação de Propensão , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVES: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). METHODS: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. RESULTS: Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. CONCLUSION: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.
Assuntos
Estenose da Valva Aórtica/terapia , Fibrilação Atrial/epidemiologia , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/epidemiologia , Bioprótese , Doenças Cardiovasculares/mortalidade , Causas de Morte , Comorbidade , Tratamento Conservador , Dispneia/epidemiologia , Ecocardiografia Doppler , Feminino , Insuficiência Cardíaca/epidemiologia , Próteses Valvulares Cardíacas , Humanos , Masculino , Insuficiência da Valva Mitral/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Insuficiência Renal/epidemiologia , Índice de Gravidade de Doença , Volume Sistólico , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Disfunção Ventricular Direita/epidemiologiaRESUMO
BACKGROUND: The effect of beta (beta) blockers on the accuracy, particularly the sensitivity, of vasodilator radionuclide myocardial perfusion imaging (MPI) is not entirely clear. This study aimed to further assess the effect of beta-blockers on the ability of MPI to identify significant and high-risk coronary artery disease (CAD). METHODS AND RESULTS: For 555 patients who underwent vasodilator MPI and had coronary angiography within 90 days, global and per-vessel sensitivities and specificities were calculated, and were found to be similar between patients taking beta-blockers and those who were not. beta-blockers did not decrease the ability to detect patients with multivessel disease. Summed stress scores and summed rest scores were likewise similar in both groups. To account in part for catheterization referral bias and the potential of false-negative MPI studies in patients receiving beta-blockers, survival analysis was performed on 2646 patients with normal MPI studies who did not undergo cardiac catheterization and failed to demonstrate significant mortality difference related to the taking of beta-blockers. CONCLUSIONS: beta-blocker therapy does not diminish the ability of vasodilator stress MPI to detect clinically significant CAD, nor hide the mortality risk of patients with normal studies not referred for catheterization.