Cost-effectiveness analysis of left atrial appendage occlusion compared with pharmacological strategies for stroke prevention in atrial fibrillation.

BACKGROUND: Transcatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. This study evaluated the cost-effectiveness of LAAO for stroke prophylaxis in NVAF. METHODS: A Markov decision analytic model was used to compare the cost-effectiveness of LAAO with 7 pharmacological strategies: aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban. Outcome measures included quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs). Base-case data were derived from ACTIVE, RE-LY, ARISTOTLE, ROCKET-AF, PROTECT-AF and PREVAIL trials. One-way sensitivity analysis varied by CHADS2 score, HAS-BLED score, time horizons, and LAAO costs; and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations was conducted to assess parameter uncertainty. RESULTS: LAAO was considered cost-effective compared with aspirin, clopidogrel plus aspirin, and warfarin, with ICER of US$5,115, $2,447, and $6,298 per QALY gained, respectively. LAAO was dominant (i.e. less costly but more effective) compared to other strategies. Sensitivity analysis demonstrated favorable ICERs of LAAO against other strategies in varied CHADS2 score, HAS-BLED score, time horizons (5 to 15 years) and LAAO costs. LAAO was cost-effective in 86.24 % of 10,000 simulations using a threshold of US$50,000/QALY. CONCLUSIONS: Transcatheter LAAO is cost-effective for prevention of stroke in NVAF compared with 7 pharmacological strategies. The transcatheter left atrial appendage occlusion (LAAO) is considered cost-effective against the standard 7 oral pharmacological strategies including acetylsalicylic acid (ASA) alone, clopidogrel plus ASA, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban for stroke prophylaxis in non-valvular atrial fibrillation management.

Assessment of aortic elastic properties in patients with sarcoidosis.

BACKGROUND: Sarcoidosis is an inflammatory granulomatous disease of unknown etiology that involves multiple organ systems. Many studies have shown a strong relationship between inflammation and atherosclerosis. The aim of this study is to investigate the relationship between elastic properties of the aorta and the duration of the disease in patients with sarcoidosis. METHOD: The study population included 52 patients with sarcoidosis (22 men, mean age = 42.7 ± 10.7 years, and mean disease duration = 38.8 ± 10.8 months) and 50 healthy control subjects (18 men, and mean age = 42.0 ± 8.0 years). Aortic stiffness (ß) index, aortic strain (AoS) and aortic distensibility (AoD) were calculated from the aortic diameters measured by transthoracic echocardiography and blood pressure obtained by sphygmomanometer. Cardiac functions were determined by using routine echocardiographic evaluation consist of standard two-dimensional and conventional Doppler and tissue Doppler imaging. RESULTS: The conventional echocardiographic parameters were similar between patients and controls. There were significant differences between the control and the patient groups in ß index (1.63 ± 0.55 vs 2.44 ± 1.54, p = 0.001), AoS (15.61 ± 5.69 vs 10.93 ± 4.11%, p < 0.001) and AoD (6.35 ± 2.64 vs 4.66 ± 1.98, 10 (-6) cm(2)/dyn, p = 0.001). There were statistically significant negative correlations between the disease duration and AoD (r = -0.46, p = 0.01) and AoS (r= -0.44, p = 0.002), whereas there was a positive correlation between the disease duration and ß index (r = 0.37, p = 0.01). In multivariate analysis, disease duration was significantly related with AoD, AoS and ß index (respectively, RR = 3.28, p = 0.002; RR = 3.03, p = 0.004; RR = 2.39, p = 0.02). CONCLUSION: We observed that elastic properties of the aorta alter in patients with sarcoidosis. We also have demonstrated a statistically significant correlation between aortic elastic properties and the disease duration.

Assessment of red cell distribution width (RDW) in patients with coronary artery ectasia.

OBJECTIVES: Coronary artery ectasia (CAE) is characterized by an abnormal dilatation of the coronary arteries. Red cell distribution width (RDW) is a measure of heterogeneity in the size of red blood cell. In this study, we aimed to investigate RDW levels in patients with CAE. METHODS: The study population included 54 patients with CAE (28 males; mean age, 59 ± 12) and 40 individuals comprising the control group who had normal coronary arteries (17 males; mean age, 56 ± 10). Admission RDW was measured as part of the automated complete blood count. RESULTS: The RDW was significantly higher in the CAE group than the control (P < .001). Also, high-sensitive C-reactive protein (hs-CRP) levels in patients with CAE were significantly higher as compared with controls (P < .001). CONCLUSION: This study demonstrates that RDW and hs-CRP were higher in the CAE group compared with the control group. These results show that RDW is a reliable, simple, and inexpensive marker for patients with CAE.

Assessment of atrial conduction time in patients with systemic lupus erythematosus.

OBJECTIVES: Systemic lupus erythematosus (SLE) is an autoimmune disorder resulting in multisystemic inflammatory damage. Recent articles report that 20% to 30% of deaths in patients with SLE have cardiovascular origin. The aim of this study was to investigate the atrial conduction time in patients with SLE by using high-usefulness tissue Doppler echocardiography (TDI). METHODS: The study population included 56 patients with SLE (49 women; mean [SD] age, 46.2 [12.2] years, and mean [SD] disease duration, 30.7 [10.9] months) and 45 healthy subjects as control group (39 women; mean [SD] age, 45.8 [12.3] years). P-wave dispersion (PWD) was calculated by using 12-lead electrocardiogram. The timing of atrial contractions (PA) was measured as the interval between the onset of P wave on electrocardiogram and the beginning of A wave on TDI. Atrial electromechanical delay (EMD) was calculated from the lateral (PA lateral), septal (PA septal) mitral annulus, and lateral tricuspid annulus (PA tricuspid). RESULTS: Lateral mitral annulus and PA septal were significantly longer in the patients with SLE than in the control subjects (66.7 [15.9] vs 56.5 [13.7], P = 0.001, and 53.5 [15.0] vs 45.0 [15.1] milliseconds, P = 0.006, respectively). Interatrial (PA lateral - PA tricuspid) and intra-atrial (PA septal - PA tricuspid) EMD were significantly higher in SLE groups (25.5 [9.7] vs 19.9 [8.3], P = 0.003 and 13.3 [7.7] vs 8.4 [8.0] milliseconds, P = 0.002, respectively). Similarly, maximum P-wave duration and PWD were significantly longer in the patients with SLE than in the control subjects (104.9 [13.5] vs 98.1 [15.1], P = 0.021 and 24.6 [7.4] vs 20.0 [8.1] milliseconds, P = 0.004, respectively). There were significant positive correlations between the disease duration and interatrial EMD (r = 0.611, P < 0.001) and intra-atrial EMD (r = 0.565, P < 0.001). Positive correlation was also present between the disease duration and PWD (r = 0.457, P < 0.001). CONCLUSION: Atrial EMD is prolonged in patients with SLE. We have also shown that PWD, intra-atrial EMD, and interatrial EMD were significantly correlated with disease duration. This study calls attention to the following: the measurement of atrial conduction time may be clinically helpful in the definition of cardiac involvement.

Assessment of atrial conduction time in patients with sarcoidosis.

OBJECTIVES: Sarcoidosis is an inflammatory granulomatous disease of unknown cause that involves multiple organ systems. Myocardial involvement is usually associated with poor prognosis, but diagnosis of cardiac sarcoidosis is frequently difficult. The aim of this study was to investigate the atrial conduction time in patients with sarcoidosis by using high-usefulness tissue Doppler echocardiography. METHODS: The study population included 49 patients with sarcoidosis (19 men; mean age, 40.5 ± 9.8 years; mean disease duration, 35.7 ± 15.3 months) and 45 healthy control subjects (17 men; mean age, 40.7 ± 7.2 years). From the 12-lead electrocardiogram, P wave dispersion (PWD) was calculated. The timing of atrial contractions (PA) was measured as the intervals between the onset of P wave on electrocardiogram and the beginning of A-wave on TDI, and atrial electromechanical delay (EMD) was calculated from the lateral (PA lateral) and septal (PA septal) mitral annulus and lateral tricuspid annulus (PA tricuspid). RESULTS: Both PA lateral and PA septal were significantly longer in patients with sarcoidosis than control subjects (67.9 ± 16.1 vs 56.3 ± 13.1, P < 0.001; and 54.8 ± 15.2 vs 45.1 ± 14.2 ms, P = 0.002, respectively). Intra-atrial (PA septal-PA tricuspid) and interatrial (PA lateral-PA tricuspid) EMD were significantly higher in sarcoidosis groups (12.6 ± 7.5 vs 8.0 ± 7.1, P = 0.003; and 25.7 ± 9.8 vs 19.3 ± 7.7 ms, P = 0.001, respectively). Similarly, maximum P-wave duration and PWD were significantly longer in patients with sarcoidosis than control subjects (105.2 ± 11.8 vs 96.7 ± 15.4, P = 0.004 and 24.7 ± 5.6 vs 19.7 ± 7.1 ms, P = 0.001, respectively). There were significant positive correlations between the disease duration and interatrial EMD (r = 0.56, P < 0.001) and intra-atrial EMD (r = 0.66, P < 0.001). Positive correlation also was present between the disease duration and PWD (r = .62, P < 0.001). CONCLUSIONS: Atrial EMD was found prolonged in patients with sarcoidosis. We also have demonstrated that PWD, interatrial and intra-atrial EMD were significantly correlated with disease duration. This study calls attention to measurement of atrial conduction time that may be clinically helpful in the recognition of cardiac involvement.

Assessment of heart rate recovery index in patients with familial Mediterranean fever.

Heart rate recovery after exercise is a function of vagal reactivation, and its impairment is an independent prognostic indicator for cardiovascular and all-cause mortality. The aim of our study was to evaluate heart rate recovery in patients with familial Mediterranean fever (FMF). The study population included 38 patients with FMF (14 men; mean age, 36.2 ± 12.1 years, and mean disease duration = 11.3 ± 6.5 years) and 35 healthy control subjects (12 men; mean age = 34.1 ± 9.9 years). Basal electrocardiography, echocardiography, and treadmill exercise testing were performed in all patients and control participants. The heart rate recovery index was defined as the reduction in the heart rate from the rate at peak exercise to the rate 1st-minute (HRR(1)), 2nd-minute (HRR(2)), 3rd-minute (HRR(3)), and 5th-minute (HRR(5)) after the cessation of exercise stress testing. There are significant differences in HRR(1) and HRR(2) indices between patients with FMF and control group (26.4 ± 7.4 vs. 35.0 ± 8.0; P = 0.001 and 47.3 ± 11.8 vs. 54.8 ± 10.3; P = 0.002, respectively). Similarly, HRR(3) and HRR(5) indices of the recovery period were lower in patients with FMF, when compared with indices in the control group (56.0 ± 14.0 vs. 63.7 ± 11.2; P = 0.01 and 64.1 ± 14.7 vs. 71.5 ± 12.7; P = 0.02, respectively). There were also remarkably positive correlations between the disease duration and HRR(1) (r = 0.31, P = 0.02), and HRR(2) (r = 0.26, P = 0.04). The heart rate recovery index impaired in patients with FMF compared to control subjects. When the prognostic significance of the heart rate recovery index is considered, a useful, simple, and noninvasive test may be clinically helpful in the recognition of high-risk patients with FMF.

An assessment of the elastic properties of the aorta in nonobese women with polycystic ovary syndrome.

In this study, we determined that aortic stiffness was lower and aortic distensibility was higher in nonobese women with polycystic ovary syndrome (PCOS) who had similar characteristics with the control group in terms of lipid profile and insulin resistance. In the absence of traditional cardiovascular risk factors, it seems that there is no predisposition to atherosclerosis in nonobese women with PCOS.

The assessment of atherosclerosis on vascular structures in patients with acute coronary syndrome.

INTRODUCTION: Endothelial dysfunction plays a crucial role in the process of atherosclerotic diseases and has been accepted as an early stage of atherosclerosis. Carotid intima-media-thickness (CIMT) and flow-mediated-dilatation (FMD) of the brachial artery have been recommended as noninvasive methods to assess endothelial structure and function. Angiographic properties of patients with acute coronary syndrome (ACS) are closely associated with cardiovascular events. In this study, we investigated the relation of atherosclerotic properties of coronary, brachial and carotid arteries with CIMT, FMD and coronary angiography in patients with ACS. METHODS: We enrolled 133 patients who were diagnosed with ACS into this study. Exclusion criteria were known coronary artery disease, diabetes mellitus and hypertension. Coronary angiography, CIMT and FMD were measured in all patients. The numbers of major stenotic coronary vessels with > or = 50% or > or = 70% were defined as diseased vessel. Gensini score was used to evaluate the severity of atherosclerosis. Morphologic properties of stenotic lesion were defined. Cutoff levels were 7% for FMD and 0.9 mm for CIMT. RESULTS: Mean age was 59.7 + or - 11.8 years. FMD, CIMT and Gensini score were 8.3 + or - 5.9%, 0.80 + or - 0.19 mm and 7.8 + or - 3.5, respectively. Only 44% of patients with ACS had impaired FMD. Gensini score, number of diseased vessels and number of critical lesions were higher in patients with impaired FMD. (Gensini: 8.7 + or - 3.6 vs. 7.0 + or - 3.1, p = 0.009, diseased vessels: 2.7 + or - 0.4 vs. 2.3 + or - 0.7, p < 0.0001, critical lesions: 3.0 + or - 2.1 vs. 2.2 + or - 1.4, p = 0.02). Increased CIMT was found in only 33% of patients. Gensini score and number of diseased vessels were significantly higher in patients with increased CIMT. Significant but weak correlations were found between CIMT, FMD and angiographic severity of coronary atherosclerosis. Angiographic properties and lesion morphology were similar between CIMT and FMD groups. CONCLUSION: There appears to be a relationship between CIMT, FMD and severity of coronary atherosclerosis in patients with ACS. However, in patients with ACS, morphologic properties of stenotic lesions are not associated with CIMT and FMD in brachial artery.

Assessment of aortic wall stiffness in patients with Familial Mediterranean Fever.

INTRODUCTION: To evaluate aortic wall stiffness and its relation between the aortic stiffness and the left ventricular function in patients with Familial Mediterranean Fever (FMF). METHODS: The study population was composed of 31 patients with FMF in attack-free period (12 men, 19 women; mean age: 36+/-7 years) and 27 healthy subjects (10 men, 17 women; mean age: 34+/-7 years) who had volunteered to participate. Aortic stiffness indices, aortic strain and distensibility, were calculated from the aortic diameters measured by echocardiography and blood pressure obtained by sphygmomanometry. RESULTS: There were significant differences between the control and the patient group in aortic strain (mean (SD), 7.23+/-2.14 versus 4.91+/-1.66%, p=0.01) and distensibility (4.02+/-1.42 versus 2.84+/-1.46, 10(-6)cm(2)dyn(-1), p=0.001). Although there was no correlation between the aortic stiffness parameters and the left ventricular function parameters, there were significant negative correlations between the disease duration and aortic strain index (r=-0.29, p<0.001), and between the disease duration and distensibility (r=-0.32, p<0.001). CONCLUSION: Aortic stiffness measurements were found abnormal in patients with FMF. We have also demonstrated that there were significant correlations between aortic stiffness parameters and disease duration.

Assessment of left ventricular systolic and diastolic function by tissue Doppler analysis in patients with hypertension with or without hyperuricemia.

OBJECTIVE: Hyperuricemia (HU) is a well-recognized risk factor for cardiovascular diseases. The independence of this association from other confounding factors has remained controversial. The possible contributory effect of HU to myocardial impairment produced by hypertension (HT), however, has not been clarified yet. The study was designed to assess the left ventricular (LV) systolic and diastolic function in patients with HT with or without HU. Tissue Doppler imaging (TDI) was used for detailed analysis as this method was superior to other conventional echocardiographic techniques. METHODS: The study participants consisted of 27 patients (men 56%, mean age+/-SD; 55+/-10 years) with HT without HU, and 27 patients with HT with HU (men 62%, mean age+/-SD; 56+/-9 years), and 27 age-matched healthy control participants (men 57%, mean age+/-SD; 53+/-11 years). Cardiac functions were determined using echocardiography, comprising standard two-dimensional and conventional Doppler and TDI. Peak systolic myocardial velocity at mitral annulus (Sm), mitral inflow velocities and early diastolic mitral annular velocity (Em), late diastolic mitral annular velocity (Am), peak systolic mitral annular velocity, Em/Am, and myocardial performance index were calculated by TDI. RESULTS: Mitral inflow velocities and tissue Doppler-derived mitral annular diastolic velocities were significantly different in the patient groups (HT without HU and HT with HU) compared with the control cases. Tissue Doppler-derived myocardial performance index (LV-MPI) was significantly impaired in the patient groups compared with those of the control's (0.48+/-0.09, 0.53+/-0.07, and 0.39+/-0.07, respectively, P<0.001). Significant differences were also observed between the patients who had HT without HU and the patients who had HT with HU regarding LV-MPI. Significant correlations were observed between the serum uric acid levels and LV function parameters.

The assessment of cardiac functions by tissue Doppler-derived myocardial performance index in patients with Behcet's disease.

Vascular involvement is one of the major characteristics of Behcet's disease (BD). However, there are controversial findings regarding cardiac involvement in BD. Although early reports demonstrated that there is diastolic dysfunction in BD, conflicting results were found in the following trials. Hence, a new method for more objectively estimating the cardiac functions is needed. For this aim, we used high-usefulness tissue Doppler echocardiography for detailed analysis of cardiac changes in BD patients because this method was superior to other conventional echocardiographic techniques. The study population included 42 patients with BD (19 men, 23 women; mean age, 35 +/- 10 years, mean disease duration, 2.7 +/- 1.6 years) and 30 healthy subjects (14 men, 16 women; mean age, 38 +/- 7 years). Cardiac functions were determined using echocardiography, comprising standard two-dimensional and conventional Doppler and tissue Doppler imaging (TDI). Peak systolic myocardial velocity at mitral annulus, early diastolic mitral annular velocity (Em), late diastolic mitral annular velocity (Am), Em/Am, and myocardial performance index (MPI) were calculated by TDI. The conventional echocardiographic parameters and tissue Doppler measurements were similar between the groups. Tissue Doppler derived mitral relaxation time was longer (75 +/- 13 vs 63 +/- 16 msn, p = 0.021) in patients with BD. There was statistically significant difference between the two groups regarding left ventricular MPI (0.458 +/- 0.072 vs 0.416 +/- 0.068%, p = 0.016), which were calculated from tissue Doppler systolic time intervals. There was also significant correlation between the disease duration and MPI (r = 0.38, p = 0.017). We have demonstrated that tissue Doppler-derived myocardial left ventricular relaxation time and MPI were impaired in BD patients, although systolic and diastolic function parameters were comparable in the patients and controls.

The detailed assessment of left and right ventricular functions by tissue Doppler imaging in patients with familial Mediterranean fever.

In the contrary to other rheumatologic disorders, there have been limited numbers of studies investigating the cardiac involvement in patients with familial Mediterranean fever (FMF), although the disease may carry a potential for cardiovascular disorders because of sustained inflammation during its course. In the present study, we used high usefulness tissue Doppler echocardiography for detailed analysis of cardiac changes in FMF patients. The study population included 30 patients with FMF (11 men, 19 women; mean age, 35 +/- 7 years, mean disease duration, 15.4 +/- 7.6 years) and 30 healthy subjects as controls (12 men, 18 women; mean age, 33 +/- 7 years). The diagnosis of FMF was established according to the Tell-Hashomer criteria. Left and right ventricular functions were measured using echocardiography comprising standard two-dimensional, M-mode, and conventional Doppler as well as tissue Doppler imaging. The conventional echocardiographic paratemeters were similar apart from left ventricular relaxation time was longer (107 +/- 25 vs 85 +/- 10 ms, p < 0.001, respectively) in patients with FMF. According to the tissue Doppler measurements, while systolic velocities of both ventricles were not different, diastolic filling velocities of left ventricle including E'(m) (12.6 +/- 3.4 vs 14.7 +/- 3.3 cm/s, p = 0.04), A'(m) (10.1 +/- 2.6 vs 8.6 +/- 2.0 cm/s, p = 0.015), and E'(m)/ A'(m) (1.24 +/- 0.4 vs 1.71 +/- 0.5 cm/s, p = 0.012) values were statistically different between the groups. Left ventricular myocardial performance indices and right ventricular diastolic functions were found similar between two groups. In addition, there were no significant correlations between the disease duration, clinical features, and echocardiographic parameters. In conclusion, we have demonstrated that although systolic functions were comparable in the patients and controls, left ventricular diastolic function indices were impaired in FMF patients by using tissue Doppler analysis.