OCT-Derived Plaque Morphology and FFR-Determined Hemodynamic Relevance in Intermediate Coronary Stenoses.

BACKGROUND: optical coherence tomography (OCT) might allow identifying lesion features reportedly associated with plaque vulnerability and increased risk of clinical events. Previous studies on correlation between OCT and functional lesion significance indices reported contradictory results, yet integration of complementary information from both modalities is gaining increased interest. The aim of the study was to compare plaque morphology using OCT in hemodynamically relevant vs. non-relevant lesions by fractional flow reserve (FFR). METHODS: consecutive patients with intermediate grade coronary stenoses by angiography were evaluated by both FFR and OCT in this single-center study. Stenoses were labeled hemodynamically relevant in case of the FFR ≤ 0.80. Minimal lumen area (MLA), fibrous cap thickness (FCT), minimal cap thickness over the calcium, angle of the calcium, and necrotic core within the lesions were evaluated. RESULTS: a total of 105 patients (124 vessels) were analyzed. Of them, 65 patients were identified with at least one lesion identified as hemodynamically relevant by FFR (72 vessels, 58.1%). Lesions with FFR ≤0.80 presented with lower mean and minimal lumen area (3.46 ± 1.29 vs. 4.65 ± 2.19, p =0.001 and 1.84 ± 0.97 vs. 2.66 ± 1.40, p = 0.001) compared to patients with FFR > 0.80. No differences were found between groups in the mean and minimal FCT, mean, and maximal necrotic core, calcium angle, as well as the overall rate of calcified and lipid plaques. CONCLUSION: hemodynamic relevance of intermediate grade lesions correlated moderately with the luminal assessment by OCT. No differences were identified in the plaque morphology between relevant and non-relevant coronary stenoses by FFR.

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ±â€Š1.2 vs 1.2 ±â€Š0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ±â€Š4.4 vs 3.7 ±â€Š2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.

District versus academic hospitals: differences in the clinical characteristics of patients with atrial fibrillation without valvular heart disease treated with oral anticoagulants

INTRODUCTION Atrial fibrillation (AF) is the most common cardiac arrhythmia with a significant risk of morbidity and mortality. Non-vitamin K antagonist oral anticoagulants are the first­line drugs in stroke prevention in patients with AF. Oral anticoagulant (OAC) therapy may differ between medical centers. OBJECTIVES We compared the clinical characteristics of AF patients treated with OAC in a district and an academic hospital. PATIENTS AND METHODS We analyzed 3528 patients from the multicenter retrospective CRAFT study: 2666 patients from the academic hospital and 862 patients from the district hospital. Their baseline clinical characteristics were compared. RESULTS Patients treated in the district hospital were older (mean [SD] age, 73.9 [10.3] years vs 66.0 [13.4] years; P <0.001) and more likely female (49.1% vs 37.4%; P <0.001). Patients treated in the academic hospital more frequently had paroxysmal AF, while those in the district hospital, permanent AF. The latter group was also more likely to have comorbidities and a higher frequency of previous bleeding episodes or anemia. The groups did not differ regarding kidney function. In both groups, patients were significantly more likely to be on rivaroxaban than on dabigatran. The group treated in the district hospital were at higher risk of thromboembolic events than the other gruop (mean [SD] CHA2DS2VASc score, 4.6 [1.7] vs 3.05 [2.0]; P <0.001), as well as of hemorrhagic events (mean [SD] HASBLED score, 0.6 [0.7] vs 0.4 [0.6]; P <0.001). CONCLUSIONS Patients with AF treated with OACs in the district and academic hospitals have different clinical characteristics. Patients treated in the district hospital were older, had more comorbidities, more frequently had permanent AF, and were at higher risk of thromboembolic and bleeding events than patients treated in the academic hospital.

Comparison of clinical characteristics of real-life atrial fibrillation patients treated with vitamin K antagonists, dabigatran, and rivaroxaban: results from the CRAFT study.

BACKGROUND: The first-line drugs for the treatment of non-valvular atrial fibrillation (AF) are non-vitamin K antagonist oral anticoagulants (NOACs), which are preferred over vitamin K antagonists (VKAs). There is some evidence that there are dis-crepancies between everyday clinical practice and the guidelines. AIM: The study aimed to compare the characteristics of patients on VKAs, dabigatran, and rivaroxaban in everyday practice (i.e. baseline characteristics, drug doses, risk factors for bleeding and thromboembolic events). Additionally, we assessed the frequency of prescription of different oral anticoagulants (OACs) in recent years. METHODS: This study consisted of data from the multicentre CRAFT (MultiCentre expeRience in AFib patients Treated with OAC) study (NCT02987062). This was a retrospective analysis of hospital records of AF patients (hospitalised in the years 2011-2016) treated with VKAs (acenocoumarol, warfarin) and NOACs (dabigatran, rivaroxaban). A total of 3528 patients with non-valvular AF were enrolled in the CRAFT study. RESULTS: The total cohort consisted of 1973 patients on VKA, 504 patients on dabigatran, and 1051 patients on rivaroxaban. Patients on rivaroxaban were older (70.5 ± 13.1 years) and more often female (47.9%), compared with those on VKAs (67.0 ± 12.8 years, p < 0.001; 35.5%, p < 0.001) and on dabigatran (66.0 ± 13.9 years, p < 0.001; 38.9%, p = 0.001). Among NOACs, patients with persistent and permanent AF were more likely to receive rivaroxaban (54.7% and 73.4%, re-spectively) than dabigatran (45.3%, p < 0.001 and 26.6%, p = 0.002, respectively). Patients on rivaroxaban had higher risk of thromboembolic events (CHA2DS2VASc 3.9 ± 2.0, CHADS2 2.2 ± 1.4) than those on VKAs (3.3 ± 2.0, 1.9 ± 1.3) and on dabigatran (3.1 ± 2.0, 1.8 ± 1.3). Patients on rivaroxaban had also a higher rate of prior major bleeding (11.2%) than those on VKAs (6.7%, p < 0.001) and on dabigatran (7.3%, p = 0.02). Patients on lower doses of dabigatran and rivaroxaban had a significantly higher risk of thromboembolic and bleeding events. Use of VKAs in the year 2011 was reported in over 96% of patients on OACs, but this proportion decreased to 34.6% in 2016. In the last analysed year (2016) AF patients were treated mainly with NOACs - dabigatran (24.2%) and rivaroxaban (41.3%). CONCLUSIONS: The prescription of VKAs declined significantly after the introduction of NOACs. Patients treated with different OACs demonstrated a distinct baseline clinical profile. The highest risk of thromboembolic events and incidence of major bleedings was observed in patients on rivaroxaban, in comparison to patients on VKAs and dabigatran. Among NOACs, patients treated with lower doses of dabigatran and rivaroxaban were older and had a significantly higher risk of thromboembolic and bleeding events.

Effectiveness of Medtronic CareLink Express System in identifying patients with high-energy electrotherapy devices requiring clinically significant intervention.

BACKGROUND: The number of patients with implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy and defibrillator (CRT-D) is growing. This results in high workloads for centers performing standard controls (SC) of these systems. Medtronic CareLink Express® (MCLE) is a solution enabling remote controls (RC) of implantable devices. In cases of detecting arrhythmias or device malfunctioning, it automatically generates alarms transmitted to the controlling physician. The objective of the study was to evaluate the effectiveness of alarms generated by MCLE in identification of patients that require clinically significant intervention during SC. METHODS: A total of 119 patients (age 64 ± 14, 17 women) implanted with ICD/CRT-D were included in the trial. Device reprogramming or pharmacological treatment modifications during SC were as-sessed as significant if they were required for optimal clinical management of the patient (effectiveness of antiarrhythmic and resynchronization therapy, also patient safety). Analysis of generated alarms was then performed to assess the effectiveness (sensitivity and specificity) of MCLE in identifying patients that require changes in therapy. RESULTS: Data from 129 transmissions and 129 subsequent SCs were analyzed. 179 alarms were recorded during 96 (74%) transmissions. A total of 333 program changes of implanted devices took place during 107 (83%) SCs. Device reprogramming was considered clinically significant in 27 cases Additionaly, 13 pharmacological treatment modifications were performed. Sensitivity and specificity of alarms generated by MCLE with regards to identification of patients requiring clinically significant intervention was 87% and 31%, respectively. Finally, a statistically significant difference was observed in the number of clinically significant interventions among patients with and without MCLE alarms (33 [86.8%] vs. 5 [13.2%], p = 0.037). CONCLUSIONS: Medtronic CareLink Express® is an RC system enabling high-sensitivity supervision of patients with cardiac.

Comparison of different oral anticoagulant regimens in patients with atrial fibrillation undergoing ablation or cardioversion.

INTRODUCTION    Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative to vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF). OBJECTIVES    The aim of the study was to assess the incidence of left atrial appendage (LAA) thrombus and dense spontaneous echo contrast (SEC), as well as to compare the clinical characteristics of patients with AF treated with different anticoagulant regimens. PATIENTS AND METHODS    We studied 1033 consecutive patients with AF, who underwent transesophageal echocardiography (TEE) before AF ablation or cardioversion. We excluded 174 patients without any prior oral anticoagulation or who underwent bridging with heparin before TEE. RESULTS    In the study group of 859 patients (median age, 61 years; men, 66%), 437 patients (50.9%) received VKAs; 191 (22.2%), dabigatran; 230 (26.8%), rivaroxaban; and 1 patient (0.1%), apixaban. There were no differences in baseline characteristics or the incidence of LAA thrombus (VKAs, 6.9%; NOACs, 5.5%; P = 0.40) and dense SEC (VKAs, 5.3%; NOACs, 3.3%; P = 0.18) between patients on VKAs and those on NOACs. Compared with patients treated with dabigatran, those on rivaroxaban more often had paroxysmal AF, higher ejection fraction, LAA emptying velocity, and platelet count, as well as lower left ventricular end­diastolic dimension and hematocrit. The frequency of LAA thrombus in patients receiving dabigatran and those receiving rivaroxaban was comparable (6.8% vs 4.4%; P = 0.29), while dense SEC occurred more often in patients treated with dabigatran (5.2% vs 1.7%; P = 0.06). In a logistic regression analysis, none of the oral anticoagulation regimens predicted LAA thrombus in TEE, whereas maximal LAA emptying velocity was the only parameter independently associated with the presence of thrombus. CONCLUSIONS    In the studied group of patients with AF, the choice of anticoagulation did not depend on thromboembolic or bleeding risk.

[Coordinated care after myocardial infarction. The statement of the Polish Cardiac Society and the Agency for Health Technology Assessment and Tariff System]. / Opieka koordynowana po zawale serca. Stanowisko Polskiego Towarzystwa Kardiologicznego oraz Agencji Oceny Technologii Medycznych i Taryfikacji.

The in-hospital mortality following myocardial infarction has decreased substantially over the last two decades in Poland. However, according to the available evidence approximately every 10th patient discharged after myocardial infarction (MI) dies during next 12 months. We identified the most important barriers (e.g. insufficient risk factors control, insufficient and delayed cardiac rehabilitation, suboptimal pharmacotherapy, delayed complete myocardial revascularisation) and proposed a new nation-wide system of coordinated care after MI. The system should consist of four modules: complete revascularisation, education and rehabilitation programme, electrotherapy (including ICDs and BiVs when appropriate) and periodical cardiac consultations. At first stage the coordinated care programme should last 12 months. The proposal contains also the quality of care assessment based on clinical measures (e.g. risk factors control, rate of complete myocardial revascularisation, etc.) as well as on the rate of cardiovascular events. The wide implementation of the proposed system is expected to decrease one year mortality after MI and allow for better financial resources allocation in Poland.

Cardiac pacing in 21 patients with Emery-Dreifuss muscular dystrophy: a single-centre study with a 39-year follow-up.

BACKGROUND: Emery-Dreifuss muscular dystrophy (EDMD) is a genetic condition associated with cardiac arrhythmias. The patients typically develop early, asymptomatic bradyarrhythmia, which may lead to sudden death, preventable with a cardiac implantable electronic device (CIED). EDMD may be characterised by atrial electrical silence. Intra-operative electrophysiological evaluation of the myocardium helps ultimately determine the true nature of the disorder and select an appropriate CIED. AIM: To analyse permanent electrotherapy procedures in EDMD patients: atrial pacing limitations that stem from the electrophysiological properties of the myocardium and long-term follow-up of implanted devices. METHODS: A total of 21 EDMD patients (mean age 29 ± 9 years) with a CIED implanted (1976-2014) due to bradyarrhythmia were included in the study. The implantation procedures and factors determining the CIED type selection were analysed. RESULTS: CIEDs were implanted in five women and in 16 men with EDMD types 1 and 2 (mean follow-up: 11 ± 8 years). Intra-operatively assessed atrial electrophysiology resulted in changing the planned CIED type during the procedure in three men with EDMD type 1. Eventually, we implanted: eight DDD, one VDD, 11 VVI, and one CD-DR device, with four of the patients' devices switched later from DDD to VVI mode in response to electrophysiological changes in the atria. CONCLUSIONS: Intra-operative assessment of atrial electrophysiological properties resulted in changing the planned DDD mode for VVI in 19% of patients with EDMD type 1. Progression of the underlying disease over a 39-year follow-up resulted in a later change of the initially selected pacing mode from DDD to VVI in 40% of cases.

Ex vivo effects of an Oenothera paradoxa extract on the reactive oxygen species generation and neutral endopeptidase activity in neutrophils from patients after acute myocardial infarction.

Oxidative stress induced by reactive oxygen species (ROS) is considered to play an important part in the aetiology of coronary heart disease. Apart from ROS, neutrophils are a source of neutral endopeptidase (NEP) that inactivates protective natriuretic peptides. The aim of the present study was to evaluate the in vitro ROS generation and inhibition of NEP activity in neutrophils obtained from healthy volunteers and from patients after acute myocardial infarction (AMI) by an aqueous extract of Oenothera paradoxa. Neutrophils isolated from AMI patients showed two-fold higher ROS generation compared with cells from healthy donors, especially in the lucigenin-enhanced luminescence model, which suggests intensive O2⁻ generation. The addition of O. paradoxa extract at concentrations of 0.2, 2 and 20 µg/mL resulted in a significant reduction in ROS generation. The extracellular NEP activity was higher in patients after AMI compared with healthy individuals (15.0 ± 0.9 versus 10.3 ± 0.5 nmol AMC/10(6) cells/60 min; p = 0.001). The addition of O. paradoxa extract at concentrations of 20, 50 and 100 µg/mL resulted in a significant reduction in NEP activity in both groups. O. paradoxa extract appears to be an interesting candidate for supplementation in the prevention of cardiovascular diseases.

The dubious value of echocardiographic and plasma ANP measurements in predicting outcome of cardioversion in patients with persistent atrial fibrillation.

UNLABELLED: Atrial fibrillation (AF) is a common arrhythmia with important therapeutic and prognostic implications. An attempt to restore sinus rhythm is considered in most patients with AF. The aim of this study was to assess the value of echocardiographic examination and plasma atrial natriuretic peptide (ANP) evaluation in predicting the outcome of cardioversion and maintenance of sinus rhythm in patients with persistent AF. METHODS: Eighty-one consecutive patients, aged 62+/-9 years, with AF of duration 4.7 months were subjected to an echocardiography examination and ANP assessment before cardioversion. The patients were predominantly hypertensive men with moderately enlarged left atrium and ejection fraction of left ventricle of about 50%. All patients were in controlled AF and had normalized blood pressure. In order to predict the outcome of cardioversion, and maintenance of sinus rhythm over a 1 month period, a multivariate logistic regression method was performed using the following variables: left atrial and left ventricular dimensions, left ventricular ejection fraction and plasma ANP levels. RESULTS: Sixty-nine out of the 81 patients were successfully converted to sinus rhythm. At 1 month 57 patients remained in sinus rhythm. There were no statistical differences between sinus rhythm and AF group in baseline ANP levels (59.4 vs 64.2 pg/ml, consecutively), clinical and echocardiographic characteristics. In logistic regression analysis neither baseline echocardiographic variable nor ANP level, predicts successful cardioversion over a 1-month period of observation. CONCLUSION: Echocardiographic data and ANP level should not be included as an important variable when considering patients for cardioversion.