Ivabradine could not decrease mitral regurgitation triggered atrial fibrosis and fibrillation compared with carvedilol.

BACKGROUND: Ivabradine, a medical treatment for heart failure (HF), reduces heart rate (HR) and prolongs diastolic perfusion time. It is frequently prescribed to patients with HF who have a suboptimal response or intolerance to beta-blockers. Degenerative mitral regurgitation (MR) is a valvular heart disease often associated with the development of HF and atrial fibrillation (AF). However, studies comparing the effects of ivabradine and beta-blockers on MR are lacking. Therefore, this study aimed to explore the potential therapeutic effects of ivabradine and carvedilol on MR using a rat model. METHODS AND RESULTS: Using a novel echo-guided mini-invasive surgery, MR was created in 12-weeks-old Sprague-Dawley rats. After 2 weeks, the rats were randomized to receive either ivabradine or carvedilol for 4 weeks. Echocardiography was performed at baseline and at two-week intervals. Following haemodynamic studies, postmortem tissues were analysed. Notably, the MR-induced myocardial dysfunction did not improve considerably after treatment with ivabradine or carvedilol. However, in haemodynamic studies, pharmacological therapies, particularly carvedilol, mitigated MR-induced chamber dilatation (end-systolic volume and end-diastolic volume; MR vs. MR + Carvedilol; P < 0.05) and decreased compliance (end-systolic pressure-volume relationship; MR vs. MR + Carvedilol; P < 0.05). Compared with ivabradine, a shorter duration (MR vs. MR + Carvedilol; P < 0.05) and reduced inducibility (MR vs. MR + Carvedilol and MR vs. MR + Ivabradine; P < 0.05) of AF were observed in MR rats treated with carvedilol. Similarly, reduced cardiac fibrosis and apoptosis were observed in the MR rat model in the treatment groups, especially in those treated with carvedilol (MR vs. MR + Carvedilol; P < 0.01). CONCLUSIONS: Although both ivabradine and carvedilol, at least in part, mitigated MR-induced chamber dilatation and decreased compliance, carvedilol had a better effect on reversing MR-induced cardiac fibrosis, apoptosis, and arrhythmogenesis than ivabradine. When compared with Ivabradine, MR rats treated with carvedilol exhibited a shorter duration and reduced inducibility of AF, thus providing more effective suppression of HCN4. Further investigations are required to validate our findings.

Dapagliflozin protects against doxorubicin-induced nephrotoxicity associated with nitric oxide pathway-A translational study.

Doxorubicin (Dox) is a potent anticancer agent, but its associated organ toxicity, including nephrotoxicity, restricts clinical applications. Dapagliflozin (DAPA), a sodium-glucose cotransporter-2 inhibitor, has been shown to slow the progression of kidney disease in patients with and without diabetes. However, the effect of DAPA to counteract Dox-induced nephrotoxicity remains uncertain. Therefore, in this study, we aimed to elucidate the effects of DAPA in mitigating Dox-induced nephrotoxicity. We analyzed the Taiwan National Health Insurance Database to evaluate the incidence of renal failure among breast cancer patients receiving Dox treatment compared to those without. After adjusting for age and comorbidities, we found that the risk of renal failure was significantly higher in Dox-treated patients (incidence rate ratio, 2.45; confidence interval, 1.41-4.26; p = 0.0014). In a parallel study, we orally administered DAPA to Sprague-Dawley rats for 6 weeks, followed by Dox for 4 weeks. DAPA ameliorated Dox-induced glomerular atrophy, renal fibrosis, and dysfunction. Furthermore, DAPA effectively suppressed Dox-induced apoptosis and reactive oxygen species production. On a cellular level, DAPA in HK-2 cells mitigated Dox-mediated suppression of the endothelial NOS pathway and reduced Dox-induced activities of reactive oxygen species and apoptosis-associated proteins. DAPA improved Dox-induced apoptosis and renal dysfunction, suggesting its potential utility in preventing nephrotoxicity in patients with cancer undergoing Dox treatment.

Robot-assisted endoscopic removal of a huge tricuspid valve myxoma: case report.

BACKGROUND: Cardiac myxoma is the most common benign cardiac tumor. Its tremendous size and fragile character severely bother the surgeons. Several minimal invasive approaches had been applied for radical tumor excision. The wound was forcibly enlarged for en-bloc specimen removal and prevention of debris sputtering. CASE PRESENTATION: We reported a case of huge tricuspid valve (TV) myxoma managed by robot-assisted endoscopic tumor resection and TV repair, with initial presentation of worsening shortness of breath for two months. The tumor was downsized with a morcellator and removed through a keyhole wound (1.1 cm in diameter). The patient recovered uneventfully and was discharged after four days. CONCLUSIONS: With the first morcellator application, this might be the smallest surgical wound reported after the removal of a huge cardiac myxoma. The ICU and hospital stays were shortened. This might be effectively applied to further minimally invasive surgeries for cardiac tumor excision.

Comprehensive comparison between geriatric and nongeriatric patients with trauma.

ABSTRACT: The incidence of geriatric trauma is increasing due to the growing elderly population. Healthcare providers require a global perspective to differentiate critical factors that might alter patients' prognosis.We retrospectively reviewed all adult patients admitted to a trauma center during a 4-year period. We identified 655 adult trauma patients aged from 18 to 64 (nongeriatric group) and 273 trauma patients ≥65 years (geriatric group). Clinical data were collected and compared between the 2 groups.The geriatric group had a higher incidence of trauma and higher Injury Severity Scores than did the nongeriatric group. Fewer geriatric patients underwent surgical treatment (all patients: geriatric vs nongeriatric: 65.9% vs 70.7%; patients with severe trauma: geriatric vs nongeriatric: 27.6% vs 44.5%). Regarding prognosis, the geriatric group exhibited higher mortality rate and less need for long-term care (geriatric vs nongeriatric: mortality: 5.5% vs 1.8%; long-term care: 2.2% vs 5.0%).We observed that geriatric patients had higher trauma incidence and higher trauma mortality rate. Aging is a definite predictor of poor outcomes for trauma patients. Limited physiological reserves and preference for less aggressive treatment might be the main reasons for poor outcomes in elderly individuals.

Clinical Features and Outcomes of Immune Checkpoint Inhibitor-Associated Cardiovascular Toxicities.

BACKGROUND: Despite the increasing prevalence of therapies utilizing immune checkpoint inhibitors (ICIs), the associated cardiovascular complications have been poorly reported. Given the fatality of ICI-related complications, especially myocarditis, optimal risk stratification to predict major adverse cardio- and cerebrovascular events (MACCEs) in patients receiving ICIs is mandatory. METHODS: We collected clinical data from patients receiving ICIs, and the primary outcomes were MACCEs, including myocarditis, heart failure, and ischemic stroke. Other systemic immune responses relating to ICIs were also recorded. The median follow-up duration was 3 years. RESULTS: Among 580 patients, the incidence of MACCEs was 3.9%. Older patients, male patients, and patients with lung cancer, liver cirrhosis, or diabetes had higher risks of MACCEs. There was no significant difference between the use of PD-1/PD-L1 inhibitors or CTLA inhibitors in terms of developing cardiovascular toxicities. The development of ICI-related MACCEs was associated with worse survival. Notably, after re-review by specialists, three patients eventually diagnosed with ICI-related myocarditis had not previously been identified. Only one was treated with pulse steroids, and none survived. The most common concomitant extracardiac immune-related adverse events were myositis/dermatitis, endocrine toxicity and hepatitis. CONCLUSIONS: Collectively, ICIs may lead to severe cardiovascular toxicities and require more attention. Early identification, proper diagnosis, and prompt treatment are pivotal for improving survival.

Comparison of Surgical or Medical Castration-Related Cardiotoxicity in Patients with Prostate Cancer.

PURPOSE: Androgen deprivation therapy (ADT) includes bilateral orchiectomy or long-acting gonadotropin-releasing hormone (GnRH) agonists/antagonists. It remains controversial with respect to ADT associated cardiovascular outcomes. Hereby, we compared the risk of major adverse cardiovascular and cerebrovascular events (MACCEs) in patients with prostate cancer receiving either surgical castration or GnRH therapies. MATERIALS AND METHODS: Using the Taiwan Cancer Registry and Taiwan's National Health Insurance Research Database, we identified 8,413 patients receiving GnRH therapies compared with 694 receiving surgical castration from 2008 to 2017. The median followup duration was 3 years. RESULTS: The crude incidences of 3-year mortality and MACCEs were 19.90% vs 26.51% and 8.23% vs 8.65% in patients receiving GnRH therapies or surgical castration, respectively. After adjusting for age, cancer stage and comorbidities, despite no significant differences in MACCEs between groups there was a slight increase in the incidence of acute myocardial infarction (AMI) in patients receiving surgical castration compared with those receiving GnRH therapies. The mortality adjusted hazard ratios of MACCEs and AMI among patients receiving surgical castration were 1.11- and 1.8-fold higher than those receiving GnRH therapies. Notably, in subgroup analysis regarding cancer stage, patients with cancer stage IV showed the most significantly increasing risk of AMI in those receiving surgical castration compared with GnRH therapies. CONCLUSIONS: Collectively, we indicated an increased risk of AMI in patients with prostate cancer, especially in patients receiving surgical castration rather than those receiving GnRH therapies. Our findings highlight concerns regarding the cardiac safety of surgical castration compared with GnRH therapies.

Ortner syndrome caused by aberrant right subclavian artery: A case report.

INTRODUCTION: Ortner syndrome (cardiovocal hoarseness) is characterized by recurrent laryngeal nerve paralysis secondary to a cardiovascular abnormality. Ortner syndrome caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation is rare, with only 1 case reported in the literature. Cardiovascular abnormalities could be life-threatening and require early diagnosis and treatment. However, such abnormalities are not often considered by clinical practitioners when patients initially present with hoarseness. PATIENT CONCERNS: A 34-year-old woman without any medical history presented to our outpatient department with hoarseness and mild dysphagia for 1 month. DIAGNOSIS: Upon stroboscopic examination, left vocal cord incomplete paralysis was noted. Contrast-enhanced computed tomography revealed an aberrant right subclavian artery arising from the left aortic arch, causing focal compression of the esophagus and, potentially, compression of the left recurrent laryngeal nerve compression. The patient was diagnosed as left recurrent laryngeal nerve paralysis caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation. INTERVENTIONS: The patient was referred to a cardiovascular surgeon for resection and bypass surgery. Both the dysphagia and the hoarseness improved after the surgery. OUTCOMES: Significant improvement of the left vocal cord paralysis and no vocal cord adduction were seen upon stroboscopic examination after 3 months. During the 5-year follow-up period, the patient remained well, and no signs of recurrence were noted. CONCLUSION: This case can increase otolaryngologists' awareness of this etiology of hoarseness and consider it in their differential diagnosis.

Predicting outcomes after trauma: Prognostic model development based on admission features through machine learning.

ABSTRACT: In an overcrowded emergency department (ED), trauma surgeons and emergency physicians need an accurate prognostic predictor for critical decision-making involving patients with severe trauma. We aimed to develope a machine learning-based early prognostic model based on admission features and initial ED management.We only recruited patients with severe trauma (defined as an injury severity score >15) as the study cohort and excluded children (defined as patients <16 years old) from a 4-years database (Chi-Mei Medical Center, from January 2015, to December 2018) recording the clinical features of all admitted trauma patients. We considered only patient features that could be determined within the first 2 hours after arrival to the ED. These variables included Glasgow Coma Scale (GCS) score; heart rate; respiratory rate; mean arterial pressure (MAP); prehospital cardiac arrest; abbreviated injury scales (AIS) of head and neck, thorax, and abdomen; and ED interventions (tracheal intubation/tracheostomy, blood product transfusion, thoracostomy, and cardiopulmonary resuscitation). The endpoint for prognostic analyses was mortality within 7 days of admission.We divided the study cohort into the early death group (149 patients who died within 7 days of admission) and non-early death group (2083 patients who survived at >7 days of admission). The extreme Gradient Boosting (XGBoost) machine learning model provided mortality prediction with higher accuracy (94.0%), higher sensitivity (98.0%), moderate specificity (54.8%), higher positive predict value (PPV) (95.4%), and moderate negative predictive value (NPV) (74.2%).We developed a machine learning-based prognostic model that showed high accuracy, high sensitivity, and high PPV for predicting the mortality of patients with severe trauma.

Minor Traumatic Intracranial Hemorrhage: Identifying Prognostic Factors and Comparing Patients with Favorable and Unfavorable Outcomes.

BACKGROUND: Whether patients with minor traumatic intracranial hemorrhage (MTICH) require intensive care remains uncertain. This study aimed to identify the factors affecting the postinjury neurologic outcomes of patients with MTICH to determine optimal care. METHODS: We retrospectively reviewed the data of all patients with trauma discharged from a tertiary trauma center during a 2-year period and included adult patients with isolated MTICH. Patient Glasgow Outcome Scale (GOS) score at discharge was the primary outcome measurement. A GOS score of 4 or 5 was defined as a favorable outcome, and a score of 1-3 was considered an unfavorable outcome. We compared the clinical data between favorable and unfavorable outcome groups to determine the differences between groups. RESULTS: Of the 11,814 patients considered, we identified 534 patients who met the inclusion criteria. Older adults accounted for 35.4% of the study cohort. Only 4 complications (0.7%) and 1 mortality (0.2%) were observed during hospitalization. The number of patients who requiring brain surgery, transfusion, mechanical ventilation, pressor, or invasive monitor was 5 (0.9%), 5 (0.9%), 3 (5.6%), 0 (0%), and 0 (0%), respectively. After multivariate analysis, we discovered that comorbidities, brain surgery requirement, respiratory rate, and Trauma Injury Severity Score were strongly associated with patient GOS score at discharge. CONCLUSIONS: MTICH rarely resulted in permanent morbidity and mortality. Older patients exhibited higher incidences of MTICH and were at a higher risk for unfavorable outcomes.

Effects of renal impairment on cardiac remodeling and clinical outcomes after myocardial infarction.

How renal function influences post-acute myocardial infarction (AMI) cardiac remodeling and outcomes remains unclear. This study evaluated the impact of levels of renal impairment on drug therapy, echocardiographic parameters, and outcomes in patients with AMI undergoing percutaneous coronary intervention (PCI). A total of 611 patients diagnosed with AMI underwent successful PCI, and two echocardiographic examinations were performed within 1 year after AMI. Patients were categorized according to Group 1: severely impaired estimated glomerular filtration rate (eGFR)<30, Group 2: mildly impaired 30≤eGFR<60, Group 3: potentially at risk 60≤eGFR<90 and normal eGFR≥90 ml/min/1.73 m2. During the 5-year follow-up period, the primary endpoints were cardiovascular mortality and outcomes. Patients with worse renal function (eGFR<30) were older and had a higher prevalence of hypertension and diabetes, but relatively few were smokers or had hyperlipidemia. Despite more patients with lesions of the left anterior descending artery, those with worse renal function received suboptimal guideline-directed medical therapy (GDMT). Notably, patients with worse renal function presented with worse left ventricular function at baseline and subsequent follow-up. Kaplan-Meier analysis revealed increased cardiovascular death, development of heart failure, recurrent AMI and revascularization in patients with worse renal function. Notably, as focusing on patients with ST elevation MI, the similar findings were observed. In multivariable Cox regression, impaired renal function showed the most significant hazard ratio in cardiovascular death. Collectively, in AMI patients receiving PCI, outcome differences are renal function dependent. We found that patients with worse renal function received less GDMT and presented with worse cardiovascular outcomes. These patients require more attention.

Clinical Features and Required Aids of Transferred Severe Trauma Patients.

BACKGROUND: It is crucial to identify the pivotal factors for transferring patients with major trauma. We aim to delineate the clinical features and required aids of severe trauma patients and identify the differences between those who were admitted directly to a trauma center and those transferred from other hospitals. METHODS: We retrospectively reviewed all hospitalized trauma patients discharged from the ward in Chi-Mei Medical Center from January 1, 2017 to December 31, 2018. Of 5,846 patients, we identified 1,061 patients with Injury Severity Score >15, of which 92 patients were transferred from two branch hospitals (branch group), 172 patients were transferred from other hospitals (other group), and 797 patients were admitted directly through the emergency department (control group). We compared the clinical variables between control and the other two groups. RESULTS: The branch group included a high proportion of pediatric patients (control: 1.8%, other: 2.3%, and branch: 6.5%). The branch group demonstrated higher requirements for life-saving interventions and arterial embolization (branch vs. control, life-saving interventions: 26.1% vs. 17.6%, p = 0.046; arterial embolization: 9.8% vs. 3.5%, p = 0.004). However, no statistically significant differences were observed between the control group and other group in terms of requirements of life-saving interventions. The prognoses were similar between the groups. CONCLUSIONS: Our trauma center can provide pediatric trauma care and timely life-saving interventions to help severe trauma patients transferred from other hospitals. The branch hospitals benefit mostly from the aid. Better network connection and information sharing between hospitals might play crucial roles in the management of transferred severe trauma patients.

Differences in injury and trauma management between migrant workers and citizens.

In Taiwan, legal migrant workers and almost all citizens are covered under the National Health Insurance program. Work-related injuries and various traumatic events constitute 2 major reasons for seeking medical care among migrant workers. Therefore, we conducted this retrospective study to delineate the clinical features of migrant workers with trauma and determine differences in trauma management between migrant workers and citizens under the current medical care and insurance system.We retrospectively reviewed the data of all patients with trauma who were discharged from adult wards between January 1, 2015 and December 31, 2016. We identified 5854 citizens and 110 migrant workers during the chart review. Data related to the prehospital period, emergency department, hospital course, and prognosis were collected and compared between migrant workers and citizens.More than half of the traumatic events among migrant workers occurred at factory, farm, or mine locations (migrant workers vs all citizens: 57.3% vs 11.5%), whereas most traumatic events among citizens occurred at street and home or dormitory locations (street: migrant workers vs all citizens: 17.3% vs 52.5%; home or dormitory: migrant workers vs all citizens: 0.9% vs 14.3%). Compared with citizens, migrant workers had lower scores in injury severity scores and new injury severity scores, but higher scores in revised trauma score and trauma and injury severity scores. The hospital course and prognosis were similar between migrant workers and citizens.Compared with citizens, migrant workers had a higher incidence of work-related injury and sustained less severe injuries. Under the coverage of the current health care and insurance system in Taiwan, migrant workers with trauma and work-related injuries receive comparable medical care and prognoses to citizens.

Ibudilast, a Phosphodiesterase Inhibitor and Toll-Like Receptor-4 Antagonist, Improves Hemorrhagic Shock and Reperfusion-Induced Left Ventricular Dysfunction by Reducing Myocardial Tumor Necrosis Factor α.

OBJECTIVES: Rapid loss of blood volume causes ischemic injury to myocardial cells and impairs cardiac function. Subsequent reperfusion, although necessary to revitalize stunned tissues, can induce production of reactive oxygen species and inflammation, causing further tissue damages and weakening cardiac function. Ibudilast, a Toll-like receptor-4 (TLR4) antagonist and an inhibitor of phosphodiesterase-4, possesses antioxidative and anti-inflammatory capacities. In this study, we aim to examine the protective efficacy of ibudilast against hemorrhagic shock and reperfusion (HSR)-induced myocardial injury and cardiac dysfunction. METHODS: Studies were conducted on male Sprague-Dawley rats in 3 groups: sham-operated, HSR with, and HSR without pretreatment of ibudilast. Hemorrhagic shock was induced by withdrawing blood from the femoral artery until the mean aortic pressure dropped to around 40 mm Hg; reperfusion was conducted by replenishing blood after 120 minutes of hemorrhagic shock, and the observation continued for another 240 minutes. The left ventricular (LV) contractility, diastolic suction capacity, and ventricular stiffness were evaluated using simultaneous LV pressure, and volume was recorded during a temporary inferior vena cava constriction at the end of reperfusion. Ibudilast (10 mg/kg) was administered intraperitoneally 3 days and 20 minutes prior to HSR. Serum creatine kinase myocardial band (CK-MB) was examined at the end of both HSR, and serum CK-MB, myocardial TLR4 protein expression, and malondialdehyde (MDA) and tumor necrosis factor (TNF)-α levels at the end of reperfusion. RESULTS: HSR induced an increase in serum CK-MB. Subsequent reperfusion further increased serum CK-MB, upregulated myocardial TLR4 protein expression, and increased tissue levels MDA and TNF-α vs the sham (P < .05). HSR reduced LV contractility, prolonged LV relaxation time, and increased LV diastolic stiffness. Ibudilast pretreatment attenuated HSR-induced TLR4 protein expression, reduced myocardial MDA and TNF-α levels, and protected against cardiac dysfunction. CONCLUSIONS: Ibudilast pretreatment reduced myocardial TLR4 expression, decreased MDA and TNF-α levels, and protected against HSR-induced decrease in LV contractility, prolonged LV relaxation time, and increased diastolic stiffness.

Severe varicose veins and the risk of mortality: a nationwide population-based cohort study.

OBJECTIVE: Varicose veins (VVs) are common and although considered benign may cause morbidity. However, the association between VV severity and cardiovascular and mortality risks remains unknown. The aim of this study was to investigate the factors associated with overall mortality in patients with VV. METHODS: A total of 4644 patients with newly diagnosed VV between 1999 and 2013 were identified from Taiwan's National Health Insurance Database. VV severity was classified from grade 1 to 3 according to the presentation of ulcers or inflammation. Moreover, 9497, 2541 and 5722 age-matched, sex-matched and chronic cardiovascular risk factor-matched controls, as assessed based on propensity score, were separately selected for three grading VV groups. Enrolled patients were analysed using conditional Cox proportional hazards regression analysis to estimate risk of mortality and major adverse cardiovascular events (MACEs) in the VV and control groups. RESULTS: Most patients with VV were free from systemic disease. However, compared with matched controls, patients with VV showed a 1.37 times increased risk of mortality (95% CI 1.19 to 1.57; p<0.0001). Compared with matched controls, older (age ≧65 years) (adjusted HR: 1.38; 95% CI 1.17 to 1.62; p=0.0001) and male patients with VV (adjusted HR 1.41; 95% CI 1.18 to 1.68; p=0.0001) showed increased risk of mortality. Furthermore, compared with controls, patients with VV showed 2.05 times greater risk of MACE. Compared with matched controls, population at grade 3 increased 1.83 times risk of mortality and 2.04 to 38.42 times risk of heart failure, acute coronary syndrome, ischaemic stroke and venous thromboembolism. CONCLUSIONS: This nationwide cohort study demonstrated that patients with VV are at a risk of cardiovascular events and mortality. Our findings suggest that presence of VV warrants close attention in terms of prognosis and treatment.

Right ventricular reserve post mitral valve repair is associated with heart failure hospitalization.

Right ventricular impairment is a predictor of cardiovascular outcomes in patients with degenerative mitral regurgitation. However, the time course of right ventricular functional changes post-surgical mitral valve repair remains largely unknown. Herein, using right ventricular-focused echocardiography, we aimed to investigate right ventricular reserve and its impact on hospitalization for heart failure after mitral valve repair. In this prospective study, we enrolled 108 patients scheduled to undergo surgical repair of degenerative mitral regurgitation. Echocardiography, including right ventricular strain analysis, was performed prior to, and one month and six months post mitral valve repair. Right ventricular strain that improved one month post-surgery was defined as reserved right ventricular. In addition, any cardiovascular outcomes comprising heart failure that required admission were recorded. The median follow-up duration is 31 months. Despite a significant improvement in mitral valve regurgitant volume post-operatively, left ventricular ejection fraction (LVEF) at six months was similar to LVEF at baseline. There was a transient decrease in LV longitudinal strain at one month that was recovered six months post mitral valve repair. Regarding the right ventricular, in contrast with conventional right ventricular parameters, including right ventricular tissue Doppler S', fractional area change and tricuspid annular plane systolic excursion (TAPSE), only resolution of right ventricular strain at one month predicted the subsequent myocardial recovery. Furthermore, patients with reserved right ventricular had a lower risk of hospitalization for heart failure compared to those with non-reserved right ventricular. Collectively, the early resolution of right ventricular strain is associated with the improvement in right ventricular function (measured by TAPSE) and in heart failure hospitalization in patients who had undergone surgical mitral valve repair for degenerative mitral regurgitation.

Influence of warfarin on cardiac and cerebrovascular events following bioprosthetic aortic valve replacement: A nationwide cohort study.

OBJECTIVE: The need for anticoagulation treatment following bioprosthetic aortic valve replacement remains controversial. We investigated the associations of warfarin treatment with the risks of major adverse cardiac and cerebrovascular events, including mortality, bleeding incidents, and reoperation requirement after bioprosthetic aortic valve replacement surgery. METHODS: We identified 1086 patients who received first bioprosthetic aortic valve replacement between 2001 and 2010 using Taiwan's National Health Insurance Database. Patients were excluded for prior use of warfarin, warfarin use for >3 months, dual valve procedures, prior valve surgeries, or concomitant surgeries. Enrolled patients were divided into 2 groups according to whether they were warfarin-naïve or received warfarin for <3 months postsurgery. After propensity score matching, 282 patients not receiving warfarin were matched to 282 patients receiving warfarin for <3 months. Patients were followed-up for minimum 36 months. RESULTS: Patients receiving warfarin were younger and showed less frequent kidney disease than those who did not use warfarin. The warfarin group demonstrated a gross decrease in major adverse cardiac and cerebrovascular events. Patients receiving warfarin for <30 days were at an even lower risk for major adverse cardiac and cerebrovascular events than those treated for ≥30 days. No significant difference in bleeding or reoperation risk was observed between warfarin users and warfarin nonusers. Similar findings remained after propensity-score matching but the benefit of short-term warfarin use diminished in a younger population. CONCLUSIONS: Short-term use of postoperative warfarin (especially <30 days) following bioprosthetic aortic valve replacement may be associated with a reduction in MACCE compared with nonuse.

Risk of ischaemic stroke in thyrotoxic atrial fibrillation.

OBJECTIVE: Atrial fibrillation (AF) is the most common cardiac complication of thyrotoxicosis and is strongly implicated in thromboembolic events. However, the incidence of stroke in thyrotoxic AF remains unclear. Herein, we aimed to investigate the risks of mortality and ischaemic stroke between patients with thyrotoxic AF and nonthyrotoxic AF. DESIGNS AND METHODS: From Taiwan's National Health Insurance Research Database, 1868 patients with the concomitant diagnoses of AF and thyrotoxicosis identified between 2001 and 2010 were compared to 7472 patients with nonthyrotoxic AF using propensity score matching for age, sex and comorbidities. RESULTS: There was no significant difference in either CHA2 DS2 -VASc score or anticoagulant usage between the groups. Alternatively, the thyrotoxic group contained more ß-blocker/digoxin users, whereas the nonthyrotoxic group contained more statin users. Patients with thyrotoxic AF exhibited lower risks of all-cause mortality (HR: 0.66, CI: 0.59-0.73, P < .0001) and ischaemic stroke (HR: 0.73, CI: 0.64-0.84, P < .0001) than those with nonthyrotoxic AF, especially thyrotoxic patients with CHA2 DS2 -VASc scores ≥1. Comorbidities, including diabetes, hyperlipidaemia, hypertension and coronary artery disease, contributed to all-cause mortality in patients with nonthyrotoxic AF; however, this effect was diminished in thyrotoxic AF. CONCLUSIONS: Patients with thyrotoxicosis and AF have a lower risk of stroke than patients with nonthyrotoxic AF. Treatment for thyrotoxicosis is also crucial as the prescription of anticoagulants based on CHA2DS2-VASc scores.