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1.
Artigo em Inglês | MEDLINE | ID: mdl-31579995

RESUMO

INTRODUCTION: The aim of the present study was to evaluate the role of high-sensitivity cardiac troponin I, N terminal pro-B-type natriuretic peptide (NT-proBNP), creatine kinase-MB mass concentration (CK-MB mass) and copeptin (CP) in predicting incident atrial fibrillation (AF) in myotonic dystrophy type 1 (DM1) patients. MATERIALS AND METHODS: The study enrolled 60 consecutive DM1 patients (age 50.3 ± 7.3 years, 34 male) who underwent pacemaker (PM) implantation for cardiac rhythm abnormalities and 60 PM recipients whose age and sex matched served as control group. All DM1 patients underwent a 12-lead electrocardiogram, 2D color Doppler echocardiogram, biomarkers measurements and device interrogation at implantation, 1 month after and every 6 months thereafter for a minimum of 2-year follow-up. RESULTS: The study population was divided into two groups according to the presence of AF (AF group vs non-AF group). The AF group was older (47.3 ± 8 vs 38.6 ± 7 years, P = .03) and showed higher serum levels of NT-proBNP (151 ± 38.4 vs 107.3 ± 24.2 pg/mL, P < .001) and CP (18.9 ± 4.5 vs 7 ± 2.3 P < .001) than non-AF Group. NT-proBNP (P < .001) and CP (P < .001) were found to be an independent predictor of AF. Based on the receiver-operating characteristics curve analysis, the cut-off value for NT-proBNP that best predicted AF event in DM1 patients was 123 pg/ml (sensitivity of 83.3% and specificity of 86.5%); the cut-off value for CP that best predicted AF event in DM1 patients was 9 pmol/L (sensitivity of 89% and specificity of 87%). CONCLUSION: NT-proBNP and CP represent two independent predictors of AF onset in DM1 population with conduction disturbances underwent PM implantation.

3.
Europace ; 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31603196

RESUMO

AIMS: Recently, three randomized trials reported that dual antithrombotic treatments (DATs) including non-vitamin K antagonist oral anticoagulants (NOACs) and a P2Y12 inhibitor without aspirin were associated with significantly less bleeding than vitamin K antagonist (VKA)-based triple antithrombotic therapy (TAT) in atrial fibrillation (AF) patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). We conducted an analysis of pooled data from these trials. METHODS AND RESULTS: A meta-analysis of the PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials considering major bleeding [International Society on Thrombosis and Haemostasis (ISTH) and Thrombolysis in Myocardial Infarction], clinically relevant non-major bleeding, all-cause/cardiovascular death, stroke, myocardial infarction (MI), and stent thrombosis. Treatment effect is reported as odds ratio (OR) and 95% confidence interval. Among 9463 patients (53% with ACS), DAT regimens were associated with significantly less bleeding than TAT (OR 0.598, 0.491 -0.727; P < 0.001 for ISTH major bleeding), as were NOAC-based vs. VKA-based regimens (OR 0.577, 0.477 -0.698; P < 0.001). Stroke and mortality rates were similar, but there was statistically non-significant trend towards greater risk of MI (OR 1.211, 0.955 -1.535; P = 0.115) and significantly higher risk for stent thrombosis (OR 1.672, 1.022 -2.733, P = 0.041) with DAT vs. TAT (but not NOAC- vs. VKA-based regimens). This was mainly driven by Dabigatran 110 mg; the trends were lower with full-dose NOAC or Rivaroxaban 15 mg-based DATs. CONCLUSION: Our findings support the use of full-dose NOAC (Apixaban 5 mg, Dabigatran 150 mg) or Rivaroxaban 15 mg-based treatments in most AF patients with ACS or undergoing PCI. Notwithstanding the better safety of DAT, an initial course of NOAC-based TAT may be desirable in most AF patients.

4.
Circulation ; 2019 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-31557056

RESUMO

Background: The safety and efficacy of antithrombotic regimens may differ between patients with atrial fibrillation (AF) who have acute coronary syndromes (ACS), treated medically or with percutaneous coronary intervention (PCI), and those undergoing elective PCI. Methods: Using a 2×2 factorial design we compared apixaban with vitamin K antagonists (VKA) and aspirin with placebo in patients with AF who had ACS or were undergoing PCI and were receiving a P2Y12 inhibitor. We explored bleeding, death, and hospitalization as well as death and ischemic events by antithrombotic strategy in three pre-specified subgroups: patients with ACS treated medically, ACS treated with PCI, and those undergoing elective PCI. Results: Of 4614 patients enrolled, 1097 (23.9%) had ACS treated medically, 1714 (37.3%) had ACS treated with PCI, and 1784 (38.8%) had elective PCI. Apixaban compared with VKA reduced ISTH major or CRNM bleeding in patients with ACS treated medically (HR 0.44, 95% CI 0.28-0.68), ACS treated with PCI (HR 0.68, 95% CI 0.52-0.89), and undergoing elective PCI (HR 0.82, 95% CI 0.64-1.04) (pinteraction=0.052); and reduced death or hospitalization in ACS treated medically (HR 0.71, 95% CI 0.54-0.92), ACS treated with PCI (HR 0.88, 95% CI 0.74-1.06), and elective PCI (HR 0.87, 95% CI 0.72-1.04) (pinteraction=0.345). Compared with VKA, apixaban resulted in a similar effect on death and ischemic events in the ACS treated medically, ACS treated with PCI, and elective PCI groups (pinteraction=0.356). Compared with placebo, aspirin had a higher rate of bleeding than placebo in patients with ACS treated medically (HR 1.49, 95% CI 0.98-2.26), ACS treated with PCI (HR 2.02, 95% CI 1.53-2.67) and elective PCI groups (HR 1.91, 95% CI 1.48-2.47) (pinteraction=0.479). For the same comparison, there was no difference in outcomes among the three groups for the composite of death or hospitalization (pinteraction=0.787) and death and ischemic events (pinteraction=0.710). Conclusions: An antithrombotic regimen consisting of apixaban and a P2Y12 inhibitor without aspirin provides superior safety and similar efficacy in patients with AF who have ACS, whether managed medically or with PCI, or those undergoing elective PCI than regimens that include VKAs, aspirin, or both. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02415400.

6.
Europace ; 2019 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-31501852

RESUMO

Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.

7.
Panminerva Med ; 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31508925

RESUMO

The Brugada syndrome is an inherited cardiac ion channel disorder associated with increased risk of ventricular arrhythmias and mortality. Diagnosis is based on a characteristic electrocardiographic (ECG) pattern of coved type ST-segment elevation >2 mm followed by a negative T-wave in ≥1 of the right precordial leads V1 to V3. Since the first description of Brugada syndrome, the definition of disease and underlying pathophysiological mechanisms have been significantly improved in recent years. Also, significant progress has been made in the field of genetic testing in these patients. Still, there are several open questions regarding the management and outcome of these patients. There is more information about patients who would need an implantable cardiac defibrillator for the primary prevention of sudden cardiac death (that is, those with spontaneous Type I Brugada ECG pattern and arrhythmia-related syncope), but currently published data concerning asymptomatic patients with Brugada ECG pattern and other less-well defined presentations are conflicting. Whereas the role of cardiac defibrillator in patients with Brugada syndrome is clear, optimal use of catheter ablation and antiarrhythmic drug therapy needs to be further investigated. In this review, we summarize current evidence and contemporary management of patients with Brugada syndrome.

9.
Artigo em Inglês | MEDLINE | ID: mdl-31327104

RESUMO

PURPOSE: Cryoballoon ablation (CBA) is an effective technique for pulmonary vein isolation (PVI). To date, there are no risk models to predict very late recurrence of atrial fibrillation (VLRAF) after CBA. METHODS: Retrospective analysis of a single-center database was performed. Inclusion criteria included PVI using CBA for atrial fibrillation (AF) without additional ablation targets, follow-up > 365 days, and no recurrent AF between 90 and 365 days after procedure. The primary endpoint was recurrent AF > 30 s > 12 months post-CBA. A risk model was created using clinical variables. RESULTS: Of 674 CBA performed from 2011 to 2016, 300 patients (200 male, 62.0 ± 9.9 years) met inclusion criteria. Of these, 159 (53.0%) patients had paroxysmal AF. Patients had an average of 9.5 ± 2.7 cryoballoon freezes, and no patients required additional radiofrequency ablation lesion sets. Over a follow-up of 995 ± 490 days, 77/300 (25.7%) patients exhibited VLRAF. Univariate and multivariate analyses demonstrated that Structural heart disease (1 point), Coronary artery disease (3 points), left Atrial diameter > 43 mm (1 point), Left bundle branch block (3 points), Early return of AF (4 points), and non-paroxysmal AF (3 points) were risk factors for VLRAF. Combining these variables into a risk model, SCALE-CryoAF, (min 0; max 15) predicted VLRAF with an area under the curve of 0.73. CONCLUSION: SCALE-CryoAF is the first risk model to specifically predict first recurrence of AF beyond 1 year, VLRAF, after CBA. Model discrimination demonstrates that SCALE-CryoAF predicts VLRAF after CBA significantly better than other risk models for AF recurrence.

10.
11.
Arch Cardiovasc Dis ; 112(6-7): 420-429, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31133543

RESUMO

INTRODUCTION: Chronic kidney disease (CKD) has been associated with incident atrial fibrillation (AF) and its complications, but data from Asian cohorts are limited. AIM: To explore the relationship of AF recurrence after catheter ablation (CA) with eGFR as a continuous variable, and with different renal function categories (normal: estimated glomerular filtration rate [eGFR] ≥90mL/min/1.73 m2; mild CKD: eGFR 60-89mL/min/1.73 m2; moderate CKD: eGFR 45-59mL/min/1.73 m2; severe CKD: <45mL/min/1.73 m2), using data from the Guangzhou Atrial Fibrillation Ablation Registry. METHODS: We studied consecutive symptomatic adult patients with non-valvular AF, refractory to at least one antiarrhythmic drug and eligible for CA, in Guangdong General Hospital between June 2011 and August 2015. RESULTS: Data were available from 1407 consecutive patients (mean age 57.3±11.5 years; 68% men) with non-valvular AF undergoing radiofrequency or cryoballoon ablation. During a mean follow-up of 20.7±8.8 months, 18.6% of patients with paroxysmal AF and 50.5% with non-paroxysmal AF had AF recurrence. On multivariable analysis, eGFR (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.96-0.97) was an independent risk factor for AF recurrence, with a good predictive value (area under the curve 0.74, 95% CI 0.72-0.77; P<0.01). In the normal renal function, and mild, moderate and severe CKD categories, AF recurrence rates were 11.5%, 29.3%, 72.0% and 93.3%, respectively. Compared with normal renal function, there were stepwise increased risks of AF recurrence with mild CKD (HR 3.30, 95% CI 2.55-4.26; P<0.01), moderate CKD (HR 9.43, 95% CI 6.76-13.16; P<0.01) and severe CKD (HR 12.35, 95% CI 6.93-21.99; P<0.01). CONCLUSIONS: In a large cohort of Asian patients with AF, renal dysfunction increased the risk of AF recurrence after CA. AF recurrence gradually increased with worsening kidney function in this cohort.

13.
Europace ; 21(7): 1116-1125, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-30874724

RESUMO

The management of an acute coronary syndrome (ACS) in a patient with existing atrial fibrillation (AF) often presents a management dilemma both in the acute phase and post-ACS, since the majority of AF patients will already be receiving oral anticoagulation (OAC) for stroke prevention and will require further antithrombotic treatment to reduce the risk of in-stent thrombosis or recurrent cardiac events. Current practice recommendations are based largely on consensus option as there is limited evidence from randomized controlled trials. Prior to the launch of the new European Heart Rhythm Association (EHRA) consensus document, a survey was undertaken to examine current clinical management of these patients across centres in Europe. Forty-seven centres submitted valid responses, with the majority (70.2%) being university hospitals. This EHRA survey demonstrated overall the management of ACS in AF patients is consistent with the available guidance. Most centres would use triple therapy for a short duration (4 weeks) and predominantly utilize a strategy of OAC (vitamin K antagonist, VKA or non-vitamin K antagonist oral anticoagulant, NOAC) plus aspirin and clopidogrel, followed by dual therapy [(N)OAC plus clopidogrel] until 12 months post-percutaneous coronary intervention, followed by (N)OAC monotherapy indefinitely. Where NOAC was used in combination with antiplatelet(s), the lower dose of the respective NOAC was preferred, in accordance with current recommendations.

14.
Arch Cardiovasc Dis ; 112(3): 171-179, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30683618

RESUMO

BACKGROUND: Female sex has been linked with worse prognosis in patients with atrial fibrillation (AF). Clinical risk stratification of women with AF may help decision-making before catheter ablation (CA). AIM: To evaluate arrhythmia outcomes and the predictive value of clinical scores for arrhythmia recurrence in a large cohort of Chinese patients with AF undergoing CA. METHODS: A total 1410 of patients (68.1% men) who underwent AF ablation with scheduled follow-up were analysed retrospectively. Baseline characteristics and ablation outcome were compared between men and women. The predictive values of risk scoring systems for AF recurrence were assessed in women. RESULTS: Recurrence, early recurrence and complications after CA were similar in women and men over similar follow-up periods (20.7±8.0 vs 20.7±9.1 months; P>0.05). Compared with men, women with AF recurrence were older and had a larger left atrial diameter (LAD), less paroxysmal AF, lower left ventricular ejection fraction, lower estimated glomerular filtration rate (eGFR) and higher serum concentrations of B-type natriuretic peptide (BNP) and C-reactive protein (CRP) (all P<0.01). Multivariable analysis showed that age, non-paroxysmal AF, body mass index, coronary artery disease, LAD, early recurrence, eGFR, BNP and CRP were independent risk factors with sex differences (all P<0.05) in the whole cohort. In women, only non-paroxysmal AF, early recurrence, BNP, CRP (all P<0.01) and history of stroke/transient ischaemic attack (P=0.016) were independent risk factors. Of the clinical scoring systems tested, MB-LATER, APPLE, CAAP-AF and BASE-AF2 scores (C-indexes 0.73, 0.72, 0.68 and 0.72, respectively; all P<0.01) had a modest predictive value for AF recurrence after CA in women. CONCLUSIONS: CA for AF has similar recurrence risks in women and men, but there are sex differences in the clinical characteristics and risk factors associated with AF recurrence.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Adulto , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
15.
Aging Clin Exp Res ; 31(9): 1219-1226, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30552563

RESUMO

BACKGROUND: Cardiac implantable electronic devices (CIEDs) are widely used to treat bradyarrhythmias or improve the prognosis of patients with heart failure (HF). AIMS: To evaluate age-related (≤ 75 vs. > 75 years) attitudes, worries, psychological effects and needs in an Italian CIEDs population. METHODS: Patients attending their periodical ambulatory evaluation received a questionnaire conceived by the European Heart Rhythm Association Scientific Initiatives Committee as part of a multicenter, multinational snapshot survey. Seven countries participated in the study, and 1646 replies were collected. Of these, 437 (27%) were from Italy. Present results refer to the Italian population only. CIEDs were stratified into devices to treat bradycardia or HF. RESULTS: The use of CIEDs was more common in advanced age. Older patients needed less information about CIEDs than younger ones (p = 0.044), who would prefer to be better informed about CIEDs-related consequences on psychologic profile (p = 0.045), physical (p < 0.001) and sexual (p < 0.001) activities, and driving limitations (p = 0.003). When compared to older subjects, younger individuals experienced more difficulties (p = 0.035), especially in their professional (p < 0.001) and private life (p = 0.033), feeling their existence was limited by the device (p < 0.001). Conversely, quality of life (HRQL) more often improved in the elderly (p = 0.001). Information about what to do with CIEDs at the end of life is scant independently of age. CONCLUSIONS: HRQL after CIEDs implantation improves more frequently in older patients, while the psychological burden of CIEDs is usually higher in younger patients. End of life issues are seldom discussed.


Assuntos
Bradicardia/terapia , Desfibriladores Implantáveis/psicologia , Insuficiência Cardíaca/terapia , Marca-Passo Artificial/psicologia , Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/psicologia , Bradicardia/psicologia , Feminino , Insuficiência Cardíaca/psicologia , Humanos , Comportamento de Busca de Informação , Itália , Masculino , Estudos Prospectivos , Inquéritos e Questionários
19.
Kardiol Pol ; 76(9): 1283-1298, 2018.
Artigo em Polonês | MEDLINE | ID: mdl-30211938

RESUMO

Ponizszy tekst jest streszczeniem drugiej aktualizacji oryginalnego praktycznego przewodnika opublikowanego w 2013 roku. Leki przeciwkrzepliwe niebedace antagonistami witaminy K (NOAC) stanowia cenna alternatywe dla antagonistów witaminy K (VKA) w zapobieganiu udarom u pacjentów z migotaniem przedsionków (AF) i uznano je za leki preferowane, szczególnie dla osób rozpoczynajacych leczenie przeciwkrzepliwe. Zarówno lekarze, jak i pacjenci przyzwyczajaja sie do ich stosowania w praktyce klinicznej, istnieje jednak wiele nierozwiazanych kwestii dotyczacych optymalnego stosowania tych leków w okreslonych sytuacjach klinicznych. Europejskie Stowarzyszenie Zaburzen Rytmu Serca (EHRA, European Heart Rhythm Association) podjelo sie koordynacji opracowania jednolitego sposobu komunikowania sie z lekarzami na temat stosowania róznych preparatów NOAC. Grupa okreslila 20 tematów zawierajacych konkretne scenariusze kliniczne, w odniesieniu do których sformulowano praktyczne wskazówki na podstawie dostepnych dowodów. Do problemów klinicznych naleza: 1) odpowiednia kwalifikacja pacjentów do leczenia; 2) praktyczne schematy rozpoczynania oraz monitorowania terapii za pomoca NOAC; 3) zagwarantowanie przestrzegania zalecen przyjmowania doustnych leków przeciwkrzepliwych; 4) zmiana schematów leczenia przeciwkrzepliwego; 5) farmakokinetyka oraz interakcje lekowe; 6) stosowanie NOAC u osób z przewlekla choroba nerek i zaawansowana choroba watroby; 7) sposoby pomiaru efektu przeciwkrzepliwego NOAC; 8) pomiar stezenia NOAC w surowicy: rzadkie wskazania, srodki ostroznosci, potencjalne "pulapki"; 9) postepowanie w przypadku pomylki w dawkowaniu; 10) postepowanie w przypadku (podejrzenia) przedawkowania bez krwawienia lub badania krzepniecia wskazujace na potencjalne ryzyko krwawienia; 11) postepowanie w przypadku krwawienia w trakcie terapii za pomoca NOAC; 12) postepowanie u pacjentów poddanych planowym zabiegom chirurgicznym, procedurom inwazyjnym czy ablacji; 13) postepowanie u pacjentów wymagajacych pilnej interwencji chirurgicznej; 14) pacjenci z AF oraz choroba wiencowa; 15) unikanie pomylek w dawkowaniu NOAC w róznych wskazaniach; 16) kardiowersja u pacjenta leczonego NOAC; 17) AF u pacjentów z ostrym udarem mózgu leczonych NOAC; 18) NOAC w sytuacjach szczególnych; 19) leczenie przeciwkrzepliwe w przypadku AF u pacjentów z nowotworami zlosliwymi; 20) optymalizacja leczenia za pomoca VKA. Dodatkowe informacje oraz materialy do pobrania, jak równiez karty leczenia przeciwkrzepliwego w kilku jezykach mozna znalezc na stronie internetowej EHRA (www.NOACforAF.eu).

20.
EBioMedicine ; 35: 40-45, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30174278

RESUMO

BACKGROUND: Obesity or overweight is related to worse outcomes in patients with atrial fibrillation (AF) following catheter ablation (CA). The role of being underweight in relation to recurrent arrhythmias post AF ablation is less certain. We conducted a retrospective study to investigate the association of body mass index (BMI) with arrhythmia outcomes in AF patients undergoing CA. METHODS: In a cohort of 1410 AF patients (mean age 57.2 ±â€¯11.6 years; 68% male) undergoing single CA, the association between BMI and AF ablation outcome was analyzed using BMI as a continuous variable and by four BMI categories (<18.5 kg/m2, 18.5-24 kg/m2, 25-29 kg/m2, and ≥ 30 kg/m2). RESULT: We observed a positive association between a cut off value of BMI and risk of AF recurrence post AF ablation. BMI ≥26.36 kg/m2 was related to more AF recurrence (c-statistic 0.55, 95%CI 0.51-0.58; P < 0.01) with 50% increased risk of AF recurrence (HR 1.50, 95% CI 1.22-1.86; P < 0.01). Recurrence rates in the four BMI categories were 33.3%, 23.2%, 27.2 and 41.8%, respectively (P < 0.01). Kaplan-Meier analysis showed that BMI categories of <18.5 kg/m2 and ≥ 30 kg/m2 were all associated with more AF recurrence (P = 0.01). Both underweight (HR 1.85, 95%CI 1.12-3.08; P = 0.02) and obesity (HR 1.78, 95%CI 1.17-2.72; P = 0.01) significantly increased the risk of AF recurrence in a Cox proportional hazard model. CONCLUSION: BMI had good predictive value for AF ablation outcomes with a cut off value of ≥26.36 kg/m2. Apart from being obese/overweight, being underweight might also be a risk factor for AF recurrence post ablation.

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