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1.
J Am Heart Assoc ; 8(21): e011194, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31672100

RESUMO

Background Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide-ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients. Methods and Results TTS patients from the International Takotsubo Registry were included in this study. Cut-off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In-hospital outcomes and 1-year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P=0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P=0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1-year outcome compared with patients with early recovery (P=0.003). On multiple logistic regression, male sex, LV ejection fraction <45%, and acute neurologic disorders were associated with the absence of early recovery. Conclusions TTS patients without early LV recovery have different clinical characteristics and less favorable 1-year outcome compared with patients with early recovery. The factors associated with the absence of early recovery included male sex, reduced LV ejection fraction, and acute neurologic events. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.

4.
Arterioscler Thromb Vasc Biol ; : ATVBAHA119313491, 2019 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-31766870

RESUMO

OBJECTIVE: Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, which can contribute to intraventricular thrombus and embolism. Still, prevalence and clinical impact of thrombus formation and embolic events on outcome of TTS patients remain unclear. This study aimed to investigate clinical features and outcomes of patients with and without intraventricular thrombus or embolism. Additionally, factors associated with thrombus formation and embolism, as well as predictors for mortality, were identified. Approach and Results: TTS patients enrolled in the International Takotsubo Registry at 28 centers in Australia, Europe, and the United States were dichotomized according to the occurrence/absence of intraventricular thrombus or embolism. Patients with intraventricular thrombus or embolism were defined as the ThrombEmb group. Of 1676 TTS patients, 56 (3.3%) patients developed intraventricular thrombus and/or embolism following TTS diagnosis (median time interval, 2.0 days [range, 0-38 days]). Patients in the ThrombEmb group had a different clinical profile including lower left ventricular ejection fraction, higher prevalence of the apical type, elevated levels of troponin and inflammatory markers, and higher prevalence of vascular disease. In a Firth bias-reduced penalized-likelihood logistic regression model apical type, left ventricular ejection fraction ≤30%, previous vascular disease, and a white blood cell count on admission >10×103 cells/µL emerged as independent predictors for thrombus formation and embolism. CONCLUSIONS: Intraventricular thrombus and embolism occur in 3.3% of patients in the acute phase of TTS. A simple risk score including clinical parameters associated with intraventricular thrombus formation and embolism identifies patients at increased risk. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.

5.
J Am Heart Assoc ; 8(20): e012554, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31590581

RESUMO

Background The incidence and predictors of atrial fibrillation (AF) progression are currently not well defined, and clinical AF progression partly overlaps with rhythm control interventions (RCIs). Methods and Results We assessed AF type and intercurrent RCIs during yearly follow-ups in 2869 prospectively followed patients with paroxysmal or persistent AF. Clinical AF progression was defined as progression from paroxysmal to nonparoxysmal or from persistent to permanent AF. An RCI was defined as pulmonary vein isolation, electrical cardioversion, or new treatment with amiodarone. During a median follow-up of 3 years, the incidence of clinical AF progression was 5.2 per 100 patient-years, and 10.9 per 100 patient-years for any RCI. Significant predictors for AF progression were body mass index (hazard ratio [HR], 1.03; 95% CI, 1.01-1.05), heart rate (HR per 5 beats/min increase, 1.05; 95% CI, 1.02-1.08), age (HR per 5-year increase 1.19; 95% CI, 1.13-1.27), systolic blood pressure (HR per 5 mm Hg increase, 1.03; 95% CI, 1.00-1.05), history of hyperthyroidism (HR, 1.71; 95% CI, 1.16-2.52), stroke (HR, 1.50; 95% CI, 1.19-1.88), and heart failure (HR, 1.69; 95% CI, 1.34-2.13). Regular physical activity (HR, 0.80; 95% CI, 0.66-0.98) and previous pulmonary vein isolation (HR, 0.69; 95% CI, 0.53-0.90) showed an inverse association. Significant predictive factors for RCIs were physical activity (HR, 1.42; 95% CI, 1.20-1.68), AF-related symptoms (HR, 1.84; 95% CI, 1.47-2.30), age (HR per 5-year increase, 0.88; 95% CI, 0.85-0.92), and paroxysmal AF (HR, 0.61; 95% CI, 0.51-0.73). Conclusions Cardiovascular risk factors and comorbidities were key predictors of clinical AF progression. A healthy lifestyle may therefore reduce the risk of AF progression.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31625613

RESUMO

BACKGROUND: Due to high failure rates, Medtronic withdrew the Sprint Fidelis lead (SFL) from the market. Passive fixation lead models exhibited better survival than active models, but most studies have limited follow-up. Aim of this study was to give insights into passive lead survival with a follow-up of 10 years. METHODS: In two large Swiss centers, patients with passive SFLs were identified and data from routine implantable cardioverter defibrillator (ICD) follow-ups were collected. Patients were censored at time of death, last device interrogation (if lost to follow-up), time of lead revision (in non-SFL-related problems), or at database closure (31th December 2017). We defined lead failure as any of the following: lead fracture with inappropriate discharge; sudden increase in low-voltage impedance to >1500 or high-voltage impedance to >100 Ω; >300 nonphysiological short VV-intervals. RESULTS: We identified 145 patients. Age at implant was 60 ± 12 years with a median follow-up of 10.2 (interquartile range [IQR]: 5.0-11.2) years. Thirty-five percent of patients died after 5.4 ± 2.7 years. A total of 19 leads (13%) failed after 6.7 ± 3.2 years (range: 1.2-12.0). Overt malfunction with shocks existed in four patients (3%). Cumulative lead survival was 93.1% at 6, 88.2% at 8, 83.8% at 10, and 77.6% at 11 years, respectively, with 35% of implanted leads under monitoring at 10 years. Lead survival fits best a Weibull distribution with accelerating failure rates (k = 1.95, 95% CI 1.32-2.87, P < 0.001). CONCLUSIONS: During very long-term follow-up, failure rate of the passive SFL shows an increase resulting in an impaired lead survival of 84% at 10 years.

7.
Can J Cardiol ; 35(10): 1332-1343, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31492491

RESUMO

BACKGROUND: Atrial fibrillation (AF) is associated with multiple comorbidities and various adverse outcome events, suggesting a high risk of hospital admissions in this patient population. However, its exact incidence and potential underlying causes are not well defined. The objective of this systematic review was to investigate the incidence and risk factors for hospital admissions in patients with AF. METHODS: We systematically searched MEDLINE, EMBASE, and CENTRAL for studies providing information on all-cause hospital admissions. Studies were included if they provided information on the incidence of all-cause hospital admissions in ≥ 100 patients with AF, and had ≥ 1 year of follow-up. Incidence estimates were pooled using random-effects models. Meta-regression analysis was performed to identify characteristics associated with between-study heterogeneity. RESULTS: Thirty-five studies (n = 311,314 patients) were included. The pooled incidence of all-cause hospital admissions was 43.7 (95% confidence interval [CI], 38.5-48.9; I2 = 99.9%) per 100 person-years. In 24 studies (n = 234,028 patients) that provided information on admission causes, cardiovascular hospitalizations were more common than noncardiovascular hospitalizations (pooled incidence 26.3 [95% CI, 22.7-29.9; I2 = 99.9%] vs 15.7 [95% CI, 12.5-18.9; I2 = 99.8%] per 100 person-years). In meta-regression analyses, older age (ß = 1.4 [95% CI, 0.33-2.53], P = 0.01, R2 = 15.7%) and prevalence of chronic pulmonary disease (ß = 1.5 [95% CI, 0.57-2.45], P = 0.005, R2 = 49.8%) were associated with an increased rate of all-cause hospital admissions. CONCLUSIONS: Patients with AF have a very high risk of being admitted to the hospital, both for cardiovascular and noncardiovascular causes. The development and implementation of preventive strategies should be a public health priority.

8.
Heart ; 2019 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-31422362

RESUMO

OBJECTIVE: The prognostic value of left atrial (LA) dimensions may differ between patients with and without atrial fibrillation (AF). METHODS: MEDLINE and EMBASE were searched for studies that investigated the association between LA echocardiographic parameters measured by transthoracic echocardiography and cardiovascular outcomes in patients with or without AF. Data were independently abstracted by two reviewers and pooled using random-effects meta-analysis. The primary outcome was incident stroke or thromboembolic events. Secondary outcomes were heart failure, all-cause mortality and major adverse cardiac events (MACE). RESULTS: Twenty-three studies of patients with AF (14 939 patients) and 68 studies of patients without AF (50 720 patients) in this systematic review. Increasing LA diameter was significantly associated with stroke and thromboembolic events in patients without AF (risk ratio (RR) 1.38, 95% CI 1.02 to 1.87; p=0.03), but not in patients with AF (RR 1.02, 95% CI 0.98 to 1.07; p=0.27; p for difference=0.05). Increasing LA diameter index was significantly associated with MACE in patients with AF (RR 1.13, 95% CI 1.09 to 1.17; p<0.001) and in patients without AF (RR 2.98, 95% CI 1.90 to 4.66; p<0.001), with stronger effects in non-AF populations (p for difference <0.001). Greater LA volume index was significantly associated with the risk of MACE in patients with AF (RR 1.01, 95% CI 1.00 to 1.02; p=0.03) and in non-AF populations (RR 1.08, 95% CI 1.05 to 1.10; p<0.001), the association being stronger in individuals without AF (p for difference <0.001). CONCLUSIONS: Larger LA parameters were associated with various adverse cardiovascular events. Many of these associations were stronger in individuals without AF, highlighting the potential importance of LA myopathy.

9.
Europace ; 21(11): 1750-1754, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31384937

RESUMO

AIMS: We aimed to assess the novel concept of using the paced PR interval (PRI) on the surface electrocardiogram (ECG) to prove trans-isthmus block after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFl). METHODS AND RESULTS: Consecutive patients with AFl underwent linear radiofrequency ablation of the inferior CTI (6 o'clock). After AFl termination and/or presumed completion of the CTI line, CTI block was proven by atrial pacing by the ablation catheter medial (5 o'clock) and lateral to the line (7 and 9 o'clock). Corresponding PRIs were measured on the surface ECG. CTI block was assumed, if a sudden increase in the PRI was observed by moving the pacing site from 5 to 7 o'clock, and if the latter was longer than at 9 o'clock. Afterwards, bidirectional CTI block was confirmed by differential pacing. Thirty-one patients (mean age 67 ± 16 years, 81% male) underwent CTI ablation, and 18/31 (58%) were in AFl at the time of ablation (cycle length 249 ± 31 ms). Successful CTI block as defined by the PRI method was achieved in 31/31 (100%), and the mean PRIs during pacing at 5, 7, and 9 o'clock were 203 ± 56 ms, 329 ± 70 ms, and 296 ± 66 ms, respectively. Cavotricuspid isthmus block was confirmed in all patients (100%) by coronary sinus pacing with a reversal of the local activation sequence lateral to the isthmus line. CONCLUSION: The method of PRI analysis on the surface ECG to guide CTI ablation is easy to apply and highly accurate in confirming CTI block. This simple technique enables the novel concept of CTI ablation and proof of block with a single catheter.

11.
J Am Heart Assoc ; 8(15): e010881, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31311438

RESUMO

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short- and long-term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short- and long-term mortality. A subanalysis was performed comparing long-term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long-term mortality was higher in patients with malignancy (P<0.001), while short-term outcome was comparable (P=0.17). In a subanalysis, long-term mortality was comparable between TTS patients with malignancies and ACS patients with malignancies (P=0.13). Malignancy emerged as an independent predictor of long-term mortality. Conclusions A substantial number of TTS patients show an association with malignancy. History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients. Clinical Trial Registration URL: http://www.clinicaltrial.gov. Unique identifier: NCT01947621.

13.
Biochem Med (Zagreb) ; 29(2): 020902, 2019 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-31223266

RESUMO

Introduction: Difference between high-sensitivity cardiac troponin T concentrations (hs-cTnT) before and after ablation procedure (delta concentration) reflects the amount of myocardial injury. The aim of the study was to investigate hs-cTnT prognostic power for predicting atrial fibrillation (AF) recurrence after repeat pulmonary vein isolation (PVI) procedure. Materials and methods: Consecutive patients with paroxysmal AF undergoing repeat PVI using a focal radiofrequency catheter were included in the study. Hs-cTnT was measured before and 18-24 hours after the procedure. Standardized 3, 6 and 12-month follow-up was performed. Cox-regression analysis was used to identify predictors of AF recurrence. Results: A total of 105 patients undergoing repeat PVI were analysed (24% female, median age 61 years). Median (interquartile range) hs-cTnT delta after repeat PVI was 283 (127 - 489) ng/L. After a median follow-up of 12 months, AF recurred in 24 (23%) patients. A weak linear relationship between the total radiofrequency energy delivery time and delta hs-cTnT was observed (Pearson R2 = 0.31, P = 0.030). Delta Hs-cTnT was not identified as a significant long-term predictor of AF recurrence after repeated PVI (P = 0.920). Conclusion: This was the first study evaluating the prognostic power of delta hs-cTnT in predicting AF recurrence after repeat PVI. Delta hs-cTnT does not predict AF recurrence after repeat PVI procedures. Systematic measurement of hs-cTnT after repeat PVI does not add information relevant to outcome.


Assuntos
Fibrilação Atrial , Doenças Cardiovasculares/sangue , Veias Pulmonares/metabolismo , Troponina T/sangue , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
14.
Heart ; 105(20): 1559-1567, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31142594

RESUMO

OBJECTIVE: Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician. METHODS: We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction. RESULTS: Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%-12%) but high specificity (95%-100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%). CONCLUSION: Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB. TRIAL REGISTRATION NUMBER: APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.

15.
Heart ; 105(18): 1423-1431, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31018955

RESUMO

OBJECTIVE: Assess the relative incidence and compare characteristics and outcome of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). DESIGN: Two independent prospective multicentre diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30 days and 1 year. RESULTS: 8992 patients were enrolled at 11 centres. UA was adjudicated in 8.9%(95% CI 8.0 to 9.7) and 2.8% (95% CI 2.3 to 3.3) patients in APACE and High-STEACS, respectively, and NSTEMI in 15.1% (95% CI 14.0 to 16.2) and 13.4% (95% CI 12.4 to 14.3). Coronary artery disease was pre-existing in 73% and 76% of patients with UA. At 30 days, all-cause mortality in UA was substantially lower as compared with NSTEMI (0.5% vs 3.7%, p=0.002 in APACE, 0.7% vs 7.4%, p=0.004 in High-STEACS). Similarly, at 1 year in UA all-cause mortality was 3.3% (95% CI 1.2 to 5.3) vs 10.4% (95% CI 7.9 to 12.9) in APACE, and 5.1% (95% CI 0.7 to 9.5) vs 22.9% (95% CI 19.3 to 26.4) in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, 95% CI 7.8 to 14.6 and 7.9%, 95% CI 5.7 to 10.2), and higher than in NCCP (0.6%, 95% CI 0.2 to 1.0). CONCLUSIONS: The relative incidence and mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar.

16.
Eur Heart J Acute Cardiovasc Care ; : 2048872619842988, 2019 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-31008655

RESUMO

AIM: Exercise stress testing is used to detect myocardial ischaemia, but is limited by low sensitivity and specificity. The authors investigated the value of the analysis of high-frequency QRS components as a marker of abnormal depolarization in addition to standard ST-deviations as a marker of abnormal repolarization to improve the diagnostic accuracy. METHODS AND RESULTS: Consecutive patients undergoing bicycle exercise stress nuclear myocardial perfusion imaging were prospectively enrolled. Presence of myocardial ischaemia, the primary diagnostic endpoint, was adjudicated using MPI and coronary angiography. Automated high-frequency QRS analysis was performed in a blinded fashion. The prognostic endpoint was major adverse cardiac events (MACEs) during two years of follow-up. Exercise-induced ischaemia was detected in 147/662 patients (22%). The sensitivity of high-frequency QRS was similar to ST-deviations (46% vs. 43%, p=0.59), while the specificity was lower (75% vs. 87%, p<0.001). The combined use of high-frequency QRS and ST-deviations classified 59% of patients as 'rule-out' (both negative), 9% as 'rule-in' (both positive) and 32% in an intermediate zone (one test positive). The sensitivity for 'rule-out' and the specificity for 'rule-in' improved to 63% and 97% compared with ST-deviation analysis alone (both p<0.001). MACE-free survival was 90%, 80% and 42% in patients in the 'rule-out', intermediate and 'rule-in' groups ( p<0.001). After adjustment for age, gender, ST-deviations and clinical post-test probability of ischaemia, high-frequency QRS remained an independent predictor for the occurrence of MACEs. CONCLUSION: The use of high-frequency QRS analysis in addition to ST-deviation analysis improves the diagnostic accuracy during exercise stress testing and adds independent prognostic information.

17.
J Am Coll Cardiol ; 73(9): 989-999, 2019 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-30846109

RESUMO

BACKGROUND: Patients with atrial fibrillation (AF) have an increased risk of cognitive decline, potentially resulting from clinically unrecognized vascular brain lesions. OBJECTIVES: This study sought to assess the relationships between cognitive function and vascular brain lesions in patients with AF. METHODS: Patients with known AF were enrolled in a multicenter study in Switzerland. Brain magnetic resonance imaging (MRI) and cognitive testing using the Montreal Cognitive Assessment (MoCA) were performed in all participants. Large noncortical or cortical infarcts (LNCCIs), small noncortical infarcts (SNCIs), microbleeds, and white matter lesions were quantified by a central core laboratory. Clinically silent infarcts were defined as infarcts on brain MRI in patients without a clinical history of stroke or transient ischemic attack. RESULTS: The study included 1,737 patients with a mean age of 73 ± 8 years (28% women, 90% taking oral anticoagulant agents). On MRI, LNCCIs were found in 387 patients (22%), SNCIs in 368 (21%), microbleeds in 372 (22%), and white matter lesions in 1715 (99%). Clinically silent infarcts among the 1,390 patients without a history of stroke or transient ischemic attack were found in 201 patients with LNCCIs (15%) and 245 patients with SNCIs (18%). The MoCA score was 24.7 ± 3.3 in patients with and 25.8 ± 2.9 in those without LNCCIs on brain MRI (p < 0.001). The difference in MoCA score remained similar when only clinically silent LNCCIs were considered (24.9 ± 3.1 vs. 25.8 ± 2.9; p < 0.001). In a multivariable regression model including all vascular brain lesion parameters, LNCCI volume was the strongest predictor of a reduced MoCA (ß = -0.26; 95% confidence interval: -0.40 to -0.13; p < 0.001). CONCLUSIONS: Patients with AF have a high burden of LNCCIs and other brain lesions on systematic brain MRI screening, and most of these lesions are clinically silent. LNCCIs were associated with worse cognitive function, even among patients with clinically silent infarcts. Our findings raise the question of MRI screening in patients with AF.

18.
J Cardiol ; 74(1): 53-59, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30711378

RESUMO

BACKGROUND: Catheter ablation of atrial fibrillation (AF) by means of pulmonary vein isolation (PVI) focuses on the PVs as the putative trigger of AF. However, which classification should be used to identify patients that are most suitable for PVI is uncertain. The aim of the study was to evaluate rhythm-, burden-, and anatomically-based classification schemes to predict success rates after up to two procedures of an ablation strategy strictly aimed at isolation of the PVs. METHODS: Patients with paroxysmal or non-longstanding persistent AF undergoing PVI-only ablation with the option of one repeat PVI in case of AF recurrence were included. An AF burden score (AFB) was determined based on frequency, episode duration, and number of previous cardioversions and then categorized as minimal, mild, moderate, or severe. Two- and three-dimensional anatomical assessment of the left atrium (LA) was performed based on pre-interventional imaging by computed tomography or magnetic resonance imaging. RESULTS: Of 195 patients analyzed, 24 presented with recurrence after the last intervention (12%, median follow up: 16±11 months). In multivariable analysis, a more than 6-fold increase of risk for AF recurrence was identified for patients with a severe compared to a mild AFB [hazard ratio: 6.241 (95% confidence interval: 1.914-20.167, p=0.002)]. In contrast to univariable analysis, no other parameter was associated with recurrence in multivariable analysis. CONCLUSIONS: Burden-based (AFB) classification was identified as a significant predictor for AF recurrence even after repeat PVI, while neither anatomical parameters nor the established rhythm-based classification of paroxysmal and persistent AF did.

19.
Heart Rhythm ; 16(7): 1057-1064, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30710738

RESUMO

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected heart failure patients, but decision-making regarding selection of CRT-defibrillator or CRT-pacemaker is an ongoing debate. OBJECTIVE: The purpose of this study was to construct predictive models and scoring systems for implantable cardioverter-defibrillator (ICD) therapy and death without ICD therapy (prior death). METHODS: We pooled 2 prospective cohorts of CRT-D patients with primary prevention indication and used Fine and Gray models to develop independent prognostic models for time to first ICD therapy (event of interest) or death without prior ICD therapy (competing event). We defined CRT-D benefit as a high probability of ICD therapy combined with moderate/low probability of prior death. RESULTS: Seven hundred twenty patients were included. Median follow-up was 7.2 years, and 247 patients (34%) died. Cumulative incidence of ICD therapy/prior death at 5 years was 24%/17%. In multivariable models, higher New York Heart Association classes, diuretic use, and ischemic cardiomyopathy were predictors of ICD therapy (hazard ratio 1.89 [1.30-2.75], 1.91 [1.12-3.24], and 1.40[1.02-1.92], respectively) but not of prior death. Males with comorbidities (cancer, renal failure, peripheral artery disease, body mass index >30) or systolic blood pressure ≤100 were at higher risk for prior death. Higher age was associated with lower risk of ICD therapy but higher risk of prior death. One-quarter of patients had low predicted benefit from CRT-D implantation using a scoring system for the dual prediction of appropriate ICD therapy and death without appropriate ICD-therapy. CONCLUSION: Different factors predict ICD therapy or prior death in CRT-D patients using competing risk models. Scoring allows identifying patients with predicted low benefit of CRT-D (low chance of ICD therapy, high chance of prior death).

20.
PLoS One ; 14(1): e0210821, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30645635

RESUMO

BACKGROUND: Dual antiplatelet therapy (DAPT) prevents thrombotic events after coronary stent implantation but may induce bleedings, specifically in elderly patients. However, a competitive risk analysis is lacking. OBJECTIVES: To assess the determinants of major bleeding and the balance between the competing risks of major bleeding and thrombotic events during prasugrel-based DAPT after stent implantation. METHODS: Overall, 2,291 patients randomized to drug-eluting or bare metal stents and treated with prasugrel 10mg/day for 1 year were followed over 2 years for major bleeding (BARC 3/5) and thrombotic events (cardiac death, myocardial infarction, definitive/probable stent thrombosis). Prasugrel dose was reduced to 5mg in patients >75 years and/or <60kg. Predictors of major bleeding and competing risks of major bleeding and thrombotic events were assessed. RESULTS: Two-year rates of major bleeding and thrombotic events were 2.9% and 9.0%, respectively. The only independent predictor of major bleeding was age (hazard ratio per year increase 1.05 [1.02,1.07], p<0.001). The relationship between major bleeding and age was non-linear, with lowest hazard ratios at 57 years and an exponential increase only above 65 years. In contrast, the relationship between thrombotic events and age was linear and continuously increasing with older age. While the competing risk of thrombotic events was higher than that of major bleeding in younger patients, the two risks were similar in older patients. After discontinuation of prasugrel, bleeding events leveled off in all patients, while thrombotic events continued to increase. CONCLUSIONS: In prasugrel-based DAPT, age is the strongest risk factor for major bleeding, increasing exponentially >65 years. In younger patients, thrombotic events represent a higher risk than bleeding, while thrombotic and bleeding risks were similar in older patients. Important clinical implications relate to prasugrel dose in the elderly, duration of DAPT and the competing risk balance necessitating individualized treatment decisions.


Assuntos
Stents Farmacológicos/efeitos adversos , Hemorragia/etiologia , Inibidores da Agregação de Plaquetas/administração & dosagem , Cloridrato de Prasugrel/administração & dosagem , Stents/efeitos adversos , Trombose/etiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
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