Long-term outcome and prognostic factors after spontaneous cerebellar hemorrhage.

Cerebellar hemorrhage is the least common type of intracranial hemorrhage (ICH) encountered in clinical practice, and clinical data concerning the long-term outcomes are limited. This study aimed to investigate the long-term outcomes following spontaneous cerebellar hemorrhage in a cohort of Chinese patients. This single-center observational study was carried out between 1996 and 2010 and included 72 consecutive Chinese patients with a first spontaneous cerebellar hemorrhage. Of 440 patients with primary ICH, 72 (16.4%) had primary cerebellar hemorrhage. The mean age was 67.5 ± 12.3 years and patients were predominantly male (54%). The 30-day mortality was 16.7% with Glasgow coma scale ≤ 8 as the only predictor. At 6 months, 56.7% of patients who survived the first 30 days had a persistently poor functional status with modified Rankin scale score >2. After a mean follow-up of 4.7 years, 3.3% of patients had recurrent ICH, a recurrence rate of 7.3 per 1,000 patient-years. Ischemic stroke occurred in 12% of patients, an incidence of 25.5 per 1,000 patient-years. This study provided data on the long-term outcome of post-cerebellar hemorrhage in Chinese patients.

Frequent premature atrial complexes predict new occurrence of atrial fibrillation and adverse cardiovascular events.

AIMS: To investigate the relation between baseline frequency of premature atrial complexes (PACs) and new atrial fibrillation (AF) and adverse cardiovascular events. METHOD AND RESULTS: Four hundred and twenty-eight patients without AF or structural heart disease undergoing 24 h electrocardiography monitoring for palpitations, dizziness, or syncope were recruited. One hundred and seven patients with number of PACs at the top quartile (i.e. > 100PACs/day) were defined to have frequent PACs. After 6.1-year follow-up, 31 patients (29%) with frequent PACs developed AF compared with 29 patients (9%) with PACs ≤ 100/day (P< 0.01). Cox regression analysis revealed that frequent PACs [hazard ratio (HR): 3.22 (95% confidence interval (CI): 1.9-5.5; P< 0.001)], age >75 years (HR: 2.3; 95% CI: 1.3-3.9; P= 0.004), and coronary artery disease (HR: 2.5; 95% CI: 1.4-4.4; P= 0.002) were independent predictors for new AF. Concerning the composite endpoint (ischaemic stroke, heart failure, and death), patients with frequent PACs were more at risk than those without (34.5 vs. 19.3%) (HR: 1.95; 95% CI: 1.37-3.50; P= 0.001). Cox regression analysis showed that age >75 years (HR: 2.2; 95% CI: 1.47-3.41; P< 0.001), coronary artery disease (HR: 2.2, 95% CI: 1.42-3.44, P< 0.001), and frequent PACs (HR: 1.6; 95% CI: 1.04-2.44; P= 0.03) were independent predictors for the secondary composite endpoint. CONCLUSION: Frequent PACs predict new AF and adverse cardiovascular events.

Long-term oral nitrate therapy is associated with adverse outcome in diabetic patients following elective percutaneous coronary intervention.

BACKGROUND: To assess the impact of long-term oral nitrate therapy on clinical outcome following percutaneous coronary intervention (PCI) in patients with type II diabetes. METHODS: The incidence of major adverse cardiovascular events (MACEs) following elective PCI for stable coronary artery disease was evaluated in 108 patients with type II diabetes (age 64.6±10.5 years, 67.7% men). Major adverse cardiovascular events were defined as the need for revascularization, non-fatal myocardial infarction or cardiovascular death. Multivariate Cox regression analysis was used to evaluate the predictive value of MACEs by clinical characteristics and the prescription of long-term nitrate therapy. RESULTS: Isosorbide mononitrate (ISMN) was prescribed to 46 patients with an average dose of 44.3±15.2 mg/day. After a mean follow up of 25.3±25 months, 16 patients developed MACEs. Patients who received ISMN were more likely to suffer from MACEs (26.1% vs. 6.5%, P=0.01), mainly driven by a higher rate of acute coronary syndrome (13.0 vs 0%, P=0.01). Average daily dose of nitrate and other cardiovascular medication was not associated with MACEs. Multivariate Cox regression analysis revealed that prescription of only ISMN (Hazard Ratio 3.09, 95% CI 1.10-10.21, P=0.04) was an independent predictor for the development of MACEs. CONCLUSION: Long-term oral nitrate therapy was associated with MACEs following elective coronary artery revascularization by PCI in patients with type II diabetes.

Are MADIT II criteria for implantable cardioverter defibrillator implantation appropriate for Chinese patients?

BACKGROUND: MADIT-II demonstrated that prophylactic implantation of an implantable cardioverter-defibrillator (ICD) device prevents sudden cardiac death (SCD) in patients with myocardial infarction (MI) and impaired left ventricular ejection fraction (LVEF). It remains unclear whether the MADIT-II criteria for ICD implantation are appropriate for Chinese patients. METHODS AND RESULTS: We compared the clinical characteristics and outcome for a cohort of consecutive Chinese patients who satisfied MADIT-II criteria for ICD implantation with the original published MADIT-II population. Seventy consecutive patients who satisfied MADIT-II criteria but did not undergo ICD implantation (age: 67 years, male: 77%) were studied. Their baseline demographics were comparable with the original MADIT-II cohort with the exception of a higher incidence of diabetes mellitus. After follow-up of 35 months, most deaths (78%) were due to cardiac causes (72% due to SCD). The 2-year SCD rate (10.0%) was comparable with that of the MADIT-II conventional group (12.1%), but higher than the MADIT-II defibrillator group (4.9%). Similarly, the 2-year non-SCD rate was 3.0%, also comparable with the MADIT-II conventional group (4.6%), but lower than the MADIT-II defibrillator group (7.0%). Cox regression analysis revealed that advance NYHA function class (Hazard Ratio [HR]: 3.5, 95% Confidence Interval [CI]: 1.48-8.24, P = 0.004) and the lack of statin therapy (HR: 3.7, 95%CI: 1.35-10.17, P = 0.011) were independent predictors for mortality in the MADIT-II eligible patients. CONCLUSION: Chinese patients who satisfy MADIT-II criteria for ICD implantation are at similar risk of SCD and non-SCD as the original MADIT-II subjects. Implantation of an ICD in Chinese patients is appropriate.

Beta-blocker in post-myocardial infarct survivors with preserved left ventricular systolic function.

BACKGROUND: Long-term beta-blockade therapy is beneficial in post-myocardial infarct (MI) patients with left ventricular (LV) dysfunction; nevertheless, its benefit in post-MI patients with preserved LV function remains unclear. The objective of this study is to investigate the effects of long-term beta-blockade therapy on the clinical outcomes in post-MI patients with preserved LV function. HYPOTHESIS: The beneficial effects of long-term beta-blockade therapy in post-MI patients with impaired LV function may extend to those with preserved LV function. METHODS: Of 617 consecutive post-MI patients referred for cardiac rehabilitation program, 208 patients (age: 62.7 +/- 0.8 years; male: 76%) with preserved LV function (ejection fraction >or= 50%), negative exercise stress test, and on angiotensin-converting enzyme inhibition were studied. RESULTS: Baseline characteristics were comparable between patients on beta-blocker (n = 154) and not on beta-blocker (n = 54). After a mean follow-up of 58.5 +/- 2.7 months, 14 patients not on beta-blocker (26%) and 14 patients on beta-blocker (9%) died with hazard ratio (HR) of 2.5 (95% confidence interval [CI]: 1.25-6.42, P = 0.01). Likewise, patients not on beta-blocker had a higher incidence of cardiac death (HR: 3.0, 95% CI: 1.07-12.10, P = 0.04), and non-sudden cardiac death (HR: 10.1, 95% CI: 1.82-89.65, P = 0.01), but not sudden cardiac death compared with patients on beta-blocker (HR: 1.6, 95% CI: 0.34-7.61, P = 0.54). A Cox regression analysis revealed that only advanced age (>or=75 years; HR: 2.55, 95% CI: 1.18-5.49, P = 0.02) and the absence of beta-blocker (HR: 2.41, 95% CI: 1.14-5.09, P = 0.02) were independent predictors for mortality. CONCLUSION: beta-blocker use was associated with a decrease in overall mortality and cardiac death in post-MI patients with preserved LV function.

Use of aspirin in Chinese after recovery from primary intracranial haemorrhage.

Intracranial haemorrhage (ICH) accounts for ~35% of all strokes in Chinese. Anti-platelet agent is often avoided after an index event due to the possibility of recurrent ICH. This single-centered observational study included 440 consecutive Chinese patients with a first spontaneous ICH surviving the first month performed during 1996-2010. The subjects were identified, and their clinical characteristics, anti-platelet therapy after ICH, and outcomes including recurrent ICH, ischaemic stroke, and acute coronary syndrome were checked from hospital records. Of these 440 patients, 56 patients (12.7%) were prescribed aspirin (312 patient-aspirin years). After a follow-up of 62.2 ± 1.8 months, 47 patients had recurrent ICH (10.7%, 20.6 per 1,000 patient years). Patients prescribed aspirin did not have a higher risk of recurrent ICH compared with those not prescribed aspirin (22.7 per 1,000 patient-aspirin years vs. 22.4 per 1,000 patient years, p=0.70). Multivariate analysis identified age > 60 years (hazard ratio [HR]: 2.0, 95% confidence interval [CI]: 1.07-3.85, p=0.03) and hypertension (HR: 2.0, 95% CI: 1.06-3.75, p=0.03) as independent predictors for recurrent ICH. In a subgroup analysis including 127 patients with standard indications for aspirin of whom 56 were prescribed aspirin, the incidence of combined vascular events including recurrent ICH, ischaemic stroke, and acute coronary syndrome was statistically lower in patients prescribed aspirin than those not prescribed aspirin (52.4 per 1,000 patient-aspirin years, vs. 112.8 per 1,000 patient-years, p=0.04). In conclusion, we observed in a cohort of Chinese post-ICH patients that aspirin use was not associated with an increased risk for a recurrent ICH.

Long-term clinical outcomes after intravascular brachytherapy for instent restenosis and de novo coronary artery lesions in percutaneous coronary intervention.

BACKGROUND: We examined the long term clinical outcomes after administration of intravascular brachytherapy (IVBT) for instent restenosis (ISR) and de novo coronary artery lesions in percutaneous coronary intervention (PCI). METHODS AND MATERIALS: From May 2000 to August 2004, 129 symptomatic patients with ISR and de novo coronary artery lesions were treated with intravascular beta radiation after successful PCI. The primary end-point was major adverse cardiac event (MACE), i.e., a composite of all-cause death, myocardial infarction and target lesion revascularization (TLR) within 5 years of follow-up. RESULTS: The mean age of patients was 64+10 years with a male predominance (78%). The majority of patients had diffuse bare metal instent restenotic lesions and 19 patients (15%) had de novo coronary artery lesions. From hospital discharge to follow-up at 5 years (mean follow-up period 75.3+17.7 months), the annual consecutive MACE rates were 16.3%, 13.4%, 8%, 12.2% and 6.6% respectively and were mainly driven by the need for TLR. Left anterior descending artery (LAD) as target vessel of PCI was an independent predictor of long term MACE (OR: 3.5; 95% confidence interval:1.2-10.6; P=.03). There were six cases of stent thrombosis (cumulative incidence of 4.7%) with case fatality rate of 33% (2/6). CONCLUSION: MACE rates remained high post IVBT at 5 years of follow-up and were mainly driven by the need for TLR. LAD as target vessel of PCI was an independent predictor of long term MACE.

Long-term clinical outcomes of drug-eluting stents vs bare-metal stents in Chinese patients.

BACKGROUND: There is limited data on the magnitude of the problem of drug-eluting stent (DES) thrombosis in the Asian population. HYPOTHESIS: We evaluated the long-term clinical outcomes of DES vs bare metal stents (BMS) in Chinese patients. METHODS: From January 2002 to October 2005, 1236 consecutive patients underwent percutaneous coronary intervention with DES or BMS coronary stent implantation at our institution. We analyzed major clinical end points like all-cause mortality, cardiovascular death, myocardial infarction, target lesion revascularization (TLR), and stent thrombosis. RESULTS: The 3-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction were significantly lower in the DES group (3.4%, 0.9%, 3.6%) when compared with the BMS group (7.5%, 4.4%, 6.2%; P < .05). No significant differences were found in the 3-year cumulative rates for TLR or stent thrombosis when comparing the DES group (8.3%, 1.63%) vs the BMS group (9.6%, 1.6%; P > .05). However, after 1 year, there were 8 episodes of stent thrombosis in the DES group vs 1 episode of stent thrombosis in the BMS group (P = .04). CONCLUSION: Drug-eluting stents are associated with a significant reduction in the 3-year cumulative rates of all-cause mortality, cardiovascular death, and myocardial infarction when compared to BMS. However, there were no significant differences in the cumulative rates of TLR or stent thrombosis at 3 years. Stent thrombosis after 1 year was more common in the DES group, but this did not translate to increased mortality. The suggestion that DES might confer a mortality benefit should be interpreted with caution as there could be several confounding factors that were not identified in our study.

Comparison of atrial fibrillation recurrence rates after successful electrical cardioversion in patients with hyperthyroidism-induced versus non-hyperthyroidism-induced persistent atrial fibrillation.

Hyperthyroidism-induced atrial fibrillation (AF) often spontaneously reverts to sinus rhythm after the return of euthyroid state, but a significant number of patients remain in persistent AF, which requires electrical cardioversion. The long-term outcome of hyperthyroidism-induced persistent AF after successful cardioversion remains unclear. The study group consisted of 58 patients with hyperthyroidism-induced persistent AF (mean age 57 +/- 2 years, 72% men) who had undergone successful electrical cardioversion. The AF recurrence rate was prospectively studied and compared with age- and gender-matched controls with persistent AF of nonthyroid origins. After a 24-month follow-up period, 34 patients (59%) had developed AF recurrence, significantly fewer than among controls (83%) (hazard ratio 0.64, 95% confidence interval 0.39 to 0.97, p = 0.04). Cox regression analysis showed that long AF duration was the only predictor of AF recurrence in patients with hyperthyroidism-induced persistent AF. In conclusion, hyperthyroidism-induced persistent AF carries a lower recurrence rate after conversion to sinus rhythm than non-hyperthyroidism-induced persistent AF, and early electrical cardioversion should be considered.

Risk of ischemic stroke after new-onset atrial fibrillation in patients with hyperthyroidism.

BACKGROUND: Hyperthyroidism is one of the most common reversible causes of atrial fibrillation (AF); nevertheless, the risk of ischemic stroke in patients with hyperthyroidism who present with new-onset AF is unclear. OBJECTIVE: This study sought to investigate the clinical outcome of hyperthyroidism-induced AF with regard to risk of ischemic stroke risk. METHODS: We prospectively studied the incidence, time course, and clinical predictors for ischemic stroke in patients with hyperthyroidism-induced AF (n = 160). They were compared with age- and sex-matched cohorts of hyperthyroid patients without AF (n = 160) and AF patients without hyperthyroidism (n = 160). RESULTS: Baseline characteristics were comparable among the 3 groups. At 1 year, 86 hyperthyroid patients with AF (54%) and 92 patients with nonthyroid AF (58%) had spontaneous or pharmacological sinus conversion (P = .20). Ischemic stroke was observed in 15 hyperthyroid patients with AF (9.4%) versus 5 patients with nonthyroid AF (3.1%, P = .02), and 1 hyperthyroid patient without AF (0.6%, P < .001). Furthermore, the majority of ischemic stroke (>70%) in patients with AF occurred within the first 30 days of presentation, whereas AF was still present. Cox regression analysis showed that hyperthyroidism (hazard ratio [HR]: 3.5, 95% confidence interval [CI]: 1.15 to 10.42, P = .03) and persistent AF (HR: 13.0, 95% CI: 2.88 to 58.80, P < .01) predicted the occurrence of ischemic stroke; warfarin therapy reduced the risk of ischemic stroke (HR: 0.17, 95% CI: 0.04 to 0.79, P = .02). CONCLUSION: In hyperthyroid patients who presented with new-onset AF, there was an increased risk of ischemic stroke clustering during the initial phase of presentation. This should prompt early use of anticoagulation therapy in hyperthyroid patients with AF.