Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals.

BACKGROUND: The precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata. METHODS AND FINDINGS: A systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people ≥65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in ≥65-year-olds was 1.44% (95% CI, 1.13%-1.82%) and 0.41% (95% CI, 0.31%-0.53%) for <65-year-olds. New AF detection rate increased progressively with age from 0.34% (<60 years) to 2.73% (≥85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 (<60 years) to 3.9 (≥85 years); 72% of ≥65 years had ≥1 additional stroke risk factor other than age/sex. All new AF ≥75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for ≥65 years, 926 for 60-64 years; and 1,089 for <60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples. CONCLUSIONS: People with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and >70% have ≥1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and strong dependence for NNS-RX on the age distribution of the population to be screened: essential information for precise cost-effectiveness calculations.

Evidence Basis for a Point-of-Care Ultrasound Examination to Refine Referral for Outpatient Echocardiography.

BACKGROUND: Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) examination in the outpatient setting to assist diagnosis of significant cardiac disease. Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS examination for cardiac application and model its potential use for prognostication and cost-effective echo referral. METHODS: For POCUS examination derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS "signs" contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior vena cava plethora, and lung apical B-lines. The corresponding formal echo reports were then queried for any significant abnormality. The optimal POCUS examination for identifying an abnormal echo was determined. We then reviewed 244 consecutive outpatient echo studies from another institution for associations between the optimal POCUS examination, clinical variables, and referral source with major adverse cardiac events and all-cause mortality in univariate and multivariate models. Assuming a referral model where the absence of POCUS signs or variables would negate initial echo referral, theoretical cost savings were expressed as a percentage in reduction of echo studies. RESULTS: In the derivation cohort, the combination of two signs, denoting left atrial enlargement and inferior vena cava plethora resulted in the highest accuracy of 72% [95% CI: 65%, 78%] in detecting an abnormal echocardiogram. In the validation cohort, mortality at 5.5 years was 14.6% overall, 23% in patients with the left atrial enlargement sign (OR 3.5 [1.6, 7.6]), 25% with inferior vena cava plethora sign (OR 2.2 [0.8, 6.0]), and 8.0% (OR 0.3 [0.2, 0.7]) in those lacking both signs. After adjusting for age, both diabetes (OR 4.8 [2.0, 11.6]), and the left atrial enlargement sign (OR 2.4 [1.1, 5.4]) remained independently associated with mortality (p<0.05). In the referral model, patients younger than 65 years of age without diabetes and without the left atrial enlargement sign would not have received echo referral, resulting in a 33% reduction in total echo cost and would have constituted a low-risk group with a 1.2% 5.5-year mortality. CONCLUSIONS: A quick-look sign for left atrial enlargement is associated with 5-year mortality and could function as an easily obtained outpatient POCUS examination to help in identifying patients in need of echo referral.

Self-reported physical activity and myocardial flow reserve in postmenopausal women at risk for cardiovascular disease.

BACKGROUND: Regular exercise protects against coronary heart disease (CHD) events and improves vascular reactivity. Exercise effects on myocardial flow reserve (MFR) are not well studied. METHODS: We performed dynamic N-13 ammonia positron emission tomography (PET) in 16 postmenopausal women (60 +/- 6 years) to measure myocardial blood flow (MBF) and MFR. We also obtained information from each woman on her self-reported physical activity. RESULTS: Of the 16 patients, 6 reported moderate regular physical activity, and 10 did not. Women who reported regular, at least moderate physical activity had a higher percentage increase in adenosine MBF from rest compared with women who did not exercise (268% vs. 129%, p = 0.04) and had a significantly higher mean maximal MFR (3.68 vs. 2.29, p = 0.04). CONCLUSIONS: These findings provide further mechanistic support for the beneficial cardiovascular effects of exercise.

Weight changes and obesity predict impaired resting and endothelium-dependent myocardial blood flow in postmenopausal women.

BACKGROUND: Obesity has been associated with impaired endothelial function, but the influence of lifetime weight patterns on endothelial function has not been studied. HYPOTHESIS: We hypothesized that coronary vascular reactivity would be diminished in postmenopausal women with a history of obesity and frequent weight swings. METHODS: We performed dynamic N-13 ammonia positron emission tomography in 18 postmenopausal women with cardiac risk factors. Myocardial blood flow (MBF) was measured at rest, after the cold pressor test (CPT), and after adenosine infusion in order to determine baseline and endothelium-dependent and -independent flows, respectively. Myocardial blood flow was corrected for cardiac work by normalizing to the rate-pressure product. Weight history was obtained by standardized questionnaire. RESULTS: Normalized rest (n-rest) MBF correlated negatively with current weight (r = -0.52, p = 0.026) and weight at age 18 (r = -0.47, p = 0.047). Normalized CPT (n-CPT) MBF correlated inversely with current weight (r = -0.55, p = 0.018), weight at age 18 (r = -0.605, p = 0.008), and highest weight (r = -0.62, p = 0.006). Higher waist circumference predicted lower n-rest MBF (r = -0.52, p = 0.028) and n-CPT MBF (r = -0.48, p = 0.04). The same association was found with hip circumference (r = -0.52, p = 0.028; r = -0.49, p = 0.038, respectively), whereas higher body mass index (BMI) predicted lower n-CPT MBF (r = -0.53, p = 0.02). Women with at least four significant weight swings had lower MBF during rest, CPT, and n-CPT (0.88 vs. 1.19 ml/g/min, p = 0.008; 0.76 vs. 1.23 ml/g/min, p < 0.001; 0.74 vs. 1.10 ml/g/min, p = 0.009, respectively). CONCLUSIONS: Increased waist and hip circumference, weight, and frequent weight swings are associated with impaired resting and endothelium-dependent MBF in postmenopausal women. These data suggest that lifetime weight patterns may influence cardiovascular risk in women.

The sinotubular junction does not progressively dilate four years after modified subcoronary freestyle stentless tissue aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Aortic root dilation at the sinotubular junction (STJ) results in aortic regurgitation associated with normal valves and with a complete subcoronary stentless aortic bioprosthesis. The study aim was to assess for progressive aortic root dilation following modified subcoronary Freestyle aortic valve replacement (AVR), and to compare for differences between implant techniques. METHODS: Aortic root diameter was measured at the annulus, sinuses of Valsalva, STJ and tubular aorta on post-pump transesophageal echocardiograms and on early (3-month) and late (>2 years) transthoracic echocardiograms among 16 patients after modified subcoronary Freestyle valve replacement, 16 after root inclusion, and three after total root replacement. RESULTS: Mean follow up was 3.9 +/- 0.8, 3.3 +/- 0.7 and 3.5 +/- 1.1 years for modified subcoronary, root inclusion and total root patients, respectively. The aortic annulus, sinuses and STJ increased in diameter to similar extents between surgery and three months after modified subcoronary and root inclusion surgery, with no further increase at late follow up (modified subcoronary STJ 18.4 +/- 3.7, 21.1 +/- 3.7 and 20.5 +/- 4.4 mm on intraoperative, early and late echocardiography, respectively; root inclusion STJ 21.8 +/- 3.9, 25.4 +/- 4.6 and 24.4 +/- 4.4 mm, respectively). There were no changes in aortic root diameter after total root replacement (STJ 23.7 +/- 1.2 and 25.7 +/- 6.0 on intraoperative and late follow up, respectively). Aortic regurgitation prevalence was low, and similar between groups. CONCLUSION: Small but significant increases in aortic root dimensions were seen during the first three months after modified subcoronary and root inclusion surgery, with no subsequent change. The early changes were likely caused by resorption of paravalvular edema and hematoma transiently affecting aortic root measurements in the perioperative period. There was no evidence of progressive STJ dilation at 3.9 years after modified subcoronary Freestyle AVR.