Clinical impact of diabetes mellitus on 2-year clinical outcomes following PCI with second-generation drug-eluting stents; Landmark analysis findings from patient registry: Pooled analysis of the Korean multicenter drug-eluting stent registry.

BACKGROUND: Patients with diabetes mellitus are at an increased risk for adverse clinical events following percutaneous coronary interventions (PCI). However, the clinical impact of diabetes mellitus (DM) on second-generation drug-eluting stent (DES) implantation is not well-known. The aim of the current analysis was to examine the clinical impact of DM on clinical outcomes and the time sequence of associated risks in patients treated with second-generation DES. METHODS: Using patient-level data from two stent-specific, all-comer, prospective DES registries, we evaluated 1,913 patients who underwent PCI with second-generation DES between Feb 2009 and Dec 2013. The primary outcomes assessed were two-year major cardiac adverse events (MACE), composite endpoints of death from any cause, myocardial infarction (MI), and any repeat revascularization. We classified 0-1 year as the early period and 1-2 years as the late period. Landmark analyses were performed according to diabetes mellitus status. RESULTS: There were 1,913 patients with 2,614 lesions included in the pooled dataset. The median duration of clinical follow-up in the overall population was 2.0 years (interquartile range 1.9-2.1). Patients with DM had more cardiovascular risk factors than patients without DM. In multivariate analyses, the presence of DM and renal failure were strong predictors of MACE and target-vessel revascularization (TVR). After inverse probability of treatment weighting (IPTW) analyses, patients with DM had significantly increased rates of 2-year MACE (HR 2.07, 95% CI; 1.50-2.86; P <0.001). In landmark analyses, patients with DM had significantly higher rates of MACE in the early period (0-1 year) (HR 3.04, 95% CI; 1.97-4.68; P < 0.001) after IPTW adjustment, but these findings or trends were not observed in the late period (1-2 year) (HR 1.24, 95% CI; 0.74-2.07; P = 0.41). CONCLUSIONS: In the second-generation DES era, the clinical impact of DM significantly increased the 2-year event rate of MACE, mainly caused by clinical events in the early period (0-1 year). Careful observation of patients with DM is advised in the early period following PCI with second-generation DES.

NOAC Adherence of Patients with Atrial Fibrillation in the Real World: Dosing Frequency Matters?

BACKGROUND AND OBJECTIVES: Nonvitamin K antagonist oral anticoagulants (NOACs) require stricter medication adherence. We investigated the NOACs adherence in real-world practice. METHODS: We screened all patients in our cardiology department the day before their outpatient appointment, over a 5-month period. We enrolled 719 consecutive patients who were taking NOACs for atrial fibrillation. The patients were contacted by phone or text to bring the remnant pills with them without any information why. Adherence was measured by the percentage of prescribed doses taken (PDT) (number of doses taken/number of doses expected to be taken from the last prescription × 100 [%]) and the Morisky Medication Adherence Scale (MMAS)-8. RESULTS: All 4 NOACs (apixaban 47.8%, dabigatran 21.2%, rivaroxaban 18.4%, and edoxaban 12.6%) were prescribed. The mean duration that the patients had been taking NOACs was 7.2 ± 5.7 months. The PDT was 95.4 ± 9.1% in the once-daily dosing group and 93.4 ± 12.7% in the twice-daily group, and the difference was statistically significant (p = 0.017). The mean MMAS was 2.6 ± 0.8. The proportion of patients with a PDT < 80% was 7.8%. They had a significantly higher MMAS than the PDT ≥ 80% group (3.4 vs. 2.5; p = 0.000). CONCLUSION: Most patients who were taking NOACs had excellent adherence regardless of the dosing frequency. An MMAS ≥ 3 could be used as a simple screening tool for a poor NOAC adherence.

The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography.

PURPOSE: The exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography. METHODS: Consecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax - LAVmin]/LAVmax. RESULTS: Ninety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m2. CONCLUSION: In our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients.

Novel method for the prediction of para-Hisian premature ventricular complexes from the electrocardiogram.

BACKGROUND: Catheter ablation of para-Hisian (PH) premature ventricular complexes (PVCs) has a high risk of heart block. This study aimed to find the electrocardiographic (ECG) predictors of PH-PVCs. METHODS: We enrolled 47 patients who underwent an electrophysiologic study for catheter ablation of PVCs and analyzed the ECG characteristics, retrospectively. RESULTS: The PVC locations were the PH in 14, right ventricular (RV) outflow tract (OT) in 11, left ventricular (LV) OT in 16, LV septum in 5, and LV summit in 1. The QRS width of the PH-PVCs was significantly narrower than that of the rest of PVCs (140.9 ± 17.1 ms vs. 158.9 ± 19.4 ms, P = 0.004). Precordial transition of the PH-PVCs related to sinus rhythm was not helpful in predicting the location. Lead I had monophasic R waves in 100% and lead aVR QS waves in 100%. In aVL, 13 of 14 patients had monophasic R waves, and 1 had biphasic (rS) waves with an initial positive polarity. Among the study cohort, 15 patients had a QS in aVR and R in aVL, including 13 PH-PVCs and 2 PVCs coming from the RVOT septum and LVOT septum, respectively. The QS in aVR and monophasic R in aVL had a sensitivity of 92.8%, specificity of 93.9%, positive predictive value of 86.7%, and negative predictive value of 96.9% for localizing PH-PVCs. CONCLUSIONS: A PVC morphology with a QS in aVR and monophasic R in aVL and QRS width <143 msec, could be used as a reliable parameter for predicting the PH location.

The incidence of left atrial appendage thrombi on transesophageal echocardiography after pretreatment with apixaban for cardioversion in the real-world practice.

The risk of thromboembolisms during the post-cardioversion period is high. For patients with persistent atrial fibrillation (AF), anticoagulation with warfarin (INR 2.0~3.0) is recommended for at least three weeks prior and four weeks after cardioversion. We aimed to evaluate the efficacy of apixaban in preventing thromboembolic events during post-cardioversion. We enrolled 127 consecutive persistent AF patients (83 persistent, 44 longstanding persistent AF), scheduled to undergo cardioversion and were pretreated with apixaban. All patients underwent transesophageal echocardiography (TEE) to rule out thrombi in the left atrium (LA) or LA appendage (LAA) after anticoagulation with apixaban. The median duration of anticoagulation before the TEE was 37 (interquartile range [IQR] 34, 50) days. There were 7 patients (5.5%) with visible thrombi in the LAA. A spontaneous echo contrast was noted in 24 (18.9%) patients. Cardioversion was attempted in 117 patients, and they were prescribed amiodarone before the elective DC cardioversion. Sinus rhythm was achieved in 37 patients (31.6%) by amiodarone itself. DC cardioversion was attempted in 80 patients and was successful in 73 (91.3%). None of the cardioverted patients had any thromboembolic events within one month. Transient ischemic attacks were observed in one patient during a median follow up period of 202 days (IQR 143, 294). In conclusion, apixaban could be used as an anticoagulant for patients scheduled for cardioversion. However, the incidence of thrombi was not negligible. TEE or other imaging modalities should be considered before cardioversion or other invasive procedures.

Usefulness of the Doppler flow of the ophthalmic artery in the evaluation of carotid and coronary atherosclerosis.

BACKGROUND AND OBJECTIVES: There is little information about the relationship between the Doppler flow of the ophthalmic artery (OA) and carotid and coronary atherosclerosis. The aim of the investigation was to assess the clinical usefulness of the Doppler flow of the OA to estimate the severity of carotid and coronary atherosclerosis. SUBJECTS AND METHODS: The study was a retrospective analysis of the findings in 140 patients (mean age: 60 years, male: 64%) who underwent coronary angiography (CA) for the evaluation of typical angina between July 2010 and October 2011 in our single center. The severity of coronary artery stenosis was based on the Gensini score (GS). Significant coronary artery disease (CAD) was defined as the obstruction of over 75% of the major coronary arteries confirmed with CA. The pulsed Doppler flow of the OA and carotid ultrasound were performed before CA. RESULTS: The mean systolic velocity/mean diastolic velocity (MSV/MDV), pulsatile index and resistance index in the Doppler flow of the OA were identified as significant and independent correlations with carotid intima-media thickness, and MSV/MDV was identified to have a significant and independent correlation with the GS. MSV/MDV >2.1 was the independent predictor for significant CAD {odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p=0.005} and carotid plaque (OR 2.8, 95% CI 1.1-7.0, p=0.028), after adjustment for CAD-associated factors. CONCLUSION: The Doppler flow of the OA might be a useful predictor of the severity of carotid and coronary atherosclerosis.