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1.
Kardiologiia ; 60(7): 108-114, 2020 Aug 11.
Artigo em Russo | MEDLINE | ID: mdl-33155949

RESUMO

Atrial fibrillation is one of the most common concomitant diseases in patients with diabetes mellitus (DM). Meta-analyses of multiple studies have shown that the risk of AF is higher for diabetic patients with impaired glucose homeostasis than for patients without DM. Patients with AF and DM were younger, more frequently had arterial hypertension, chronic kidney disease, heart failure, and ischemic heart disease, and stroke and were characterized with a more severe course of AF. The article discusses possible mechanisms of the mutually aggravating effects of DM and AF, scales for evaluating the risk of bleeding (CHADS2, CHA2DS2­VASc, HAS-BLED), and the role of anticoagulants. A meta-analysis of 16 randomized clinical studies, including 9 874 patients, has demonstrated the efficacy of oral anticoagulants in prevention of stroke with an overall decrease in the relative risk by 62 % compared to placebo (95% confidence interval, from 48 to 72 ). For prevention of complications in patients with AF and DM, current antithrombotic therapies can be used, specifically the oral factor Xa inhibitor, rivaroxaban, which is the best studied in patients with AF and DM and represents a possible alternative to warfarin in such patients.


Assuntos
Fibrilação Atrial , Diabetes Mellitus , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Diabetes Mellitus/tratamento farmacológico , Humanos , Fatores de Risco , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêutico
2.
Turk Kardiyol Dern Ars ; 48(7): 656-663, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33034573

RESUMO

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is an infectious disease that was first reported in December 2019 in Wuhan, China, and has since spread rapidly around the world, resulting in the ongoing COVID-19 pandemic. The CHA2DS2-VASc score is a well-validated risk stratification tool for predicting stroke in atrial fibrillation (AFib), as well as morbidity and mortality in several entities. The aim of this study was to evaluate the relationship between the CHA2DS2-VASc score and in-hospital mortality in patients with COVID-19, regardless of AFib. METHODS: This multicenter, retrospective study included a total of 349 patients with COVID-19 who were hospitalized between March 15 and April 15, 2020. The CHA2DS2-VASc score of each patient was calculated. Mortality outcomes were followed up until April 25, 2020. RESULTS: The CHA2DS2-VASc score was significantly higher in non-survivor COVID-19 patients than in survivor COVID-19 patients (p<0.001). Forward stepwise logistic regression analysis demonstrated that a CHA2DS2-VASc score of ≥3 (odds ratio [OR]: 12.613, 95% confidence interval [CI]: 3.092-51.451; p<0.001), and the leukocyte count (OR: 1.327, 95% CI: 1.145-1.538; p<0.001), C-reactive protein level (OR: 1.010, 95% CI: 1.002-1.018; p=0.012), and ferritin level (OR: 1.005, 95% CI: 1.003-1.007; p<0.001) on admission were independent predictors of in-hospital mortality of COVID-19 patients. CONCLUSION: The CHA2DS2-VASc score predicted in-hospital mortality in patients with COVID-19, regardless of AFib.


Assuntos
Infecções por Coronavirus/mortalidade , Pneumonia Viral/mortalidade , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Fibrilação Atrial/epidemiologia , Betacoronavirus , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Medição de Risco
3.
JAMA ; 324(9): 871-878, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32870297

RESUMO

Importance: Outcomes of postoperative atrial fibrillation (AF) after noncardiac surgery are not well defined. Objective: To determine the association of new-onset postoperative AF vs no AF after noncardiac surgery with risk of nonfatal and fatal outcomes. Design, Setting, and Participants: Retrospective cohort study in Olmsted County, Minnesota, involving 550 patients who had their first-ever documented AF within 30 days after undergoing a noncardiac surgery (postoperative AF) between 2000 and 2013. Of these patients, 452 were matched 1:1 on age, sex, year of surgery, and type of surgery to patients with noncardiac surgery who were not diagnosed with AF within 30 days following the surgery (no AF). The last date of follow-up was December 31, 2018. Exposures: Postoperative AF vs no AF after noncardiac surgery. Main Outcomes and Measures: The primary outcome was ischemic stroke or transient ischemic attack (TIA). Secondary outcomes included subsequent documented AF, all-cause mortality, and cardiovascular mortality. Results: The median age of the 452 matched patients was 75 years (IQR, 67-82 years) and 51.8% of patients were men. Patients with postoperative AF had significantly higher CHA2DS2-VASc scores than those in the no AF group (median, 4 [IQR, 2-5] vs 3 [IQR, 2-5]; P < .001). Over a median follow-up of 5.4 years (IQR, 1.4-9.2 years), there were 71 ischemic strokes or TIAs, 266 subsequent documented AF episodes, and 571 deaths, of which 172 were cardiovascular related. Patients with postoperative AF exhibited a statistically significantly higher risk of ischemic stroke or TIA (incidence rate, 18.9 vs 10.0 per 1000 person-years; absolute risk difference [RD] at 5 years, 4.7%; 95% CI, 1.0%-8.4%; HR, 2.69; 95% CI, 1.35-5.37) compared with those with no AF. Patients with postoperative AF had statistically significantly higher risks of subsequent documented AF (incidence rate 136.4 vs 21.6 per 1000 person-years; absolute RD at 5 years, 39.3%; 95% CI, 33.6%-45.0%; HR, 7.94; 95% CI, 4.85-12.98), and all-cause death (incidence rate, 133.2 vs 86.8 per 1000 person-years; absolute RD at 5 years, 9.4%; 95% CI, 4.9%-13.7%; HR, 1.66; 95% CI, 1.32-2.09). No significant difference in the risk of cardiovascular death was observed for patients with and without postoperative AF (incidence rate, 42.5 vs 25.0 per 1000 person-years; absolute RD at 5 years, 6.2%; 95% CI, 2.2%-10.4%; HR, 1.51; 95% CI, 0.97-2.34). Conclusions and Relevance: Among patients undergoing noncardiac surgery, new-onset postoperative AF compared with no AF was associated with a significant increased risk of stroke or TIA. However, the implications of these findings for the management of postoperative AF, such as the need for anticoagulation therapy, require investigation in randomized trials.


Assuntos
Fibrilação Atrial/complicações , Ataque Isquêmico Transitório/etiologia , Complicações Pós-Operatórias/etiologia , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Operatórios , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Ataque Isquêmico Transitório/epidemiologia , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia
4.
Medicine (Baltimore) ; 99(36): e22054, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899067

RESUMO

BACKGROUND: Anticoagulant therapy is used for stroke prevention and proved to be effective and safe in the long term. The study aims to analyse the cost-effectiveness relationship of using of direct-acting oral anticoagulants vs vitamin K antagonists to prevent ischaemic stroke in patients with nonvalvular atrial fibrillation, including all the active ingredients marketed in Spain, prescribed for 2 years in the Primary Care service of the Institut Català de la Salut. METHODS: Population-based cohort study, in which the cost of the 2 treatment groups will be evaluated. Direct costs (pharmacy, primary care, emergency and hospitalization) and indirect costs (lost productivity) will be included from a social perspective. Effectiveness (assessed as the occurrence of a health event, the 1 of primary interest being stroke) will be determined, with a 2-year time horizon and a 3% discount rate. The average cost of the 2 groups of drugs will be compared using a regression model to determine the factors with the greatest influence on determining costs. We will carry out a univariate ('one-way') deterministic sensitivity analysis. DISCUSSION: We hope to provide relevant information about direct and indirect costs of oral anticoagulants, which, together with aspects of effectiveness and safety, could help shape the consensual decision-making of evaluating bodies.


Assuntos
Acenocumarol/economia , Anticoagulantes/economia , Fibrilação Atrial/tratamento farmacológico , Isquemia Encefálica/patologia , Ensaios Clínicos Pragmáticos como Assunto/métodos , Varfarina/economia , Acenocumarol/administração & dosagem , Acenocumarol/uso terapêutico , Administração Oral , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Isquemia Encefálica/prevenção & controle , Análise Custo-Benefício , Inibidores do Fator Xa , Humanos , Atenção Primária à Saúde/organização & administração , Segurança , Espanha/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento , Vitamina K/antagonistas & inibidores , Varfarina/administração & dosagem , Varfarina/uso terapêutico
6.
Int Heart J ; 61(5): 1059-1069, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921666

RESUMO

Because of its rigidity and non-steerability, the presence of a horizontal aortic root poses a major anatomical issue during transcatheter aortic valve replacement (TAVR) with Evolut self-expanding valve. Previous studies have elucidated the difficulties of coaxial implantation of the self-expanding valve in patients with horizontal aorta, often resulting in increased complications and a lower device success rate. To date, most patients with extremely horizontal aorta (aortic root angle ≥ 70°) have been excluded from major TAVR clinical trials. Therefore, available data on TAVR with Evolut in this challenging anatomy are limited, and standardized treatment strategies and clinical results remain unknown. Herein, we report a clinical case series of TAVR with Evolut in extremely horizontal aorta. Among seven patients (aged 80-92 years; STS score, 12.6% ± 7.9%) who underwent TAVR with Evolut system, aortic root angle ranged from 71° to 83° (mean, 75.1°± 4.5°). All patients achieved device success with dedicated strategies and were clinically stable at 3-month follow-up. None of the patients had more than mild paravalvular leakage (PVL) at any point during follow-up.Complications in three patients included complete atrioventricular block requiring a permanent pacemaker implantation, cerebral infarction because of atrial fibrillation 3 days after TAVR, and cardiac tamponade requiring pericardiocentesis. In this case series, Evolut self-expanding TAVR in extremely horizontal aorta was effective and feasible with a high device success rate. Based on anatomical features, some dedicated strategies majorly contribute to the success of this procedure. Large-scale multicenter studies are required to confirm our findings.


Assuntos
Aorta Torácica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Aorta Torácica/anatomia & histologia , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Bloqueio Atrioventricular/epidemiologia , Bloqueio Atrioventricular/terapia , Estimulação Cardíaca Artificial , Tamponamento Cardíaco/epidemiologia , Infarto Cerebral/epidemiologia , Infarto Cerebral/etiologia , Angiografia por Tomografia Computadorizada , Feminino , Próteses Valvulares Cardíacas , Humanos , Masculino , Tomografia Computadorizada Multidetectores , Marca-Passo Artificial , Pericardiocentese , Complicações Pós-Operatórias/epidemiologia , Desenho de Prótese , Substituição da Valva Aórtica Transcateter/instrumentação , Resultado do Tratamento
7.
Anesth Analg ; 131(4): 1156-1163, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925336

RESUMO

BACKGROUND: Ideal timing of postoperative ß-blockers is unclear. We hypothesized that patients who do not receive ß-blockers immediately after cardiac surgery would have increased in-hospital mortality (primary outcome) and postoperative hemodynamic, pulmonary, neurologic, or respiratory complications (secondary outcomes). METHODS: We performed a retrospective cohort study evaluating patients who underwent cardiac surgery at our institution from January 1, 2013 to September 30, 2017. We compared outcomes between patients who received ß-blockers by postoperative day (POD) 5 with outcomes in patients who did not receive ß-blockers at any time or received them after POD 5. Inverse probability of treatment weighting was used to minimize confounding. Univariate logistic regression analyses were performed on the weighted sets using absent or delayed ß-blockers as the independent variable and each outcome as dependent variables in separate analyses. A secondary analysis was performed in patients prescribed preoperative ß-blockers. E-values were calculated for significant outcomes. RESULTS: All results were confounder adjusted. Among patients presenting for cardiac surgery, not receiving ß-blockers by POD 5 or at any time was not associated with the primary outcome in-hospital mortality, estimated odds ratio (OR; 99.5% confidence interval [CI]) of 1.6 (0.49-5.1), P = .28. Not receiving ß-blockers by POD 5 or at any time was associated with postoperative atrial fibrillation, estimated OR (99.5% CI) of 1.5 (1.1-2.1), P < .001, and pulmonary complications, estimated OR (99.5% CI) of 3.0 (1.8-5.2), P < .001. E-values were 2.4 for postoperative atrial fibrillation and 5.6 for pulmonary complications. Among patients presenting for cardiac surgery taking preoperative ß-blockers, not receiving ß-blockers by POD 5 or at any time was not associated with the primary outcome mortality, with estimated OR (99.5% CI) of 1.3 (0.43-4.1), P = .63. In this subset, not receiving ß-blockers by POD 5 or at any time was associated with increased adjusted ORs of postoperative atrial fibrillation (OR = 1.6; 99.5% CI, 1.1-2.4; P < .001) and postoperative pulmonary complications (OR = 2.8; 99.5% CI, 1.6-5.2; P < .001). Here, e-values were 2.7 for postoperative atrial fibrillation and 5.1 for pulmonary complications. For the sensitivity analyses for secondary outcomes, exposure and outcome periods overlap. Outcomes may have occurred before or after postoperative ß-blocker administration. CONCLUSIONS: Among patients who undergo cardiac surgery, not receiving postoperative ß-blockers within the first 5 days after cardiac surgery or at any time is not associated with in-hospital mortality and is associated with, but may not necessarily cause, postoperative atrial fibrillation and pulmonary complications.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cuidados Pós-Operatórios , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Fibrilação Atrial/epidemiologia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Resultado do Tratamento
8.
Arch Cardiovasc Dis ; 113(8-9): 551-563, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32753124

RESUMO

Obesity is a major risk factor for atrial fibrillation. It also influences the natural history of the disease, leading to more persistent forms and poorer ablation outcomes. This article reviews atrial fibrillation ablation in the obese population, focusing on outcomes, complications and periprocedural management. Through an analysis of the possible pathophysiological mechanism linking obesity and atrial fibrillation, we identify potential strategies to improve post-ablation outcomes in this challenging population.


Assuntos
Técnicas de Ablação , Fibrilação Atrial/cirurgia , Obesidade/fisiopatologia , Técnicas de Ablação/efeitos adversos , Adiposidade , Animais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Índice de Massa Corporal , Frequência Cardíaca , Humanos , Obesidade/diagnóstico , Obesidade/epidemiologia , Fatores de Risco , Resultado do Tratamento , Ganho de Peso
9.
N Z Med J ; 133(1519): 41-54, 2020 07 31.
Artigo em Inglês | MEDLINE | ID: mdl-32777794

RESUMO

BACKGROUND: Concomitant atrial fibrillation (AF) and acute coronary syndrome (ACS) present the difficult therapeutic dilemma of balancing bleeding, cardio-embolic and coronary thrombotic risks with appropriate combinations of antithrombotic medications. We aim to evaluate current New Zealand practice by identifying the incidence of AF in ACS; describe the population characteristics; and assess our antithrombotic management. METHODS: Consecutive patients ≥18y presenting with ACS who had coronary angiography (2017-2018) were identified from the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. The cohort was divided into three groups: 1) patients with pre-existing AF; 2) new-onset AF; and 3) no AF. Antithrombotic regimens included dual antiplatelet therapy (DAPT), dual antithrombotic therapy (DAT-single antiplatelet plus an oral anticoagulant (OAC)) and triple antithrombotic therapy (TAT). RESULTS: There were 9,489 patients, 9.6% with pre-existing AF, 4.4% new AF and 86% without AF. Both AF groups were older (median 74 vs 71 vs 65y, p=0.001), had poorer renal function, were more likely to present with heart failure (16% vs 19% vs 8%, p=0.001) and have left ventricular ejection fraction <40% (22% vs 28% vs 13%, p<0.001). They received less percutaneous coronary intervention (PCI) (53% vs 59% vs 70%, p=0.001). In the cohort, 25 different combinations of antithrombotic agents were utilised. Ninety-six percent of patients with any AF had a CHA2DS2VASC stroke risk score of ≥2, of whom 48% did not receive OAC. Twenty-four percent received TAT and 19% DAT. OAC use increased slightly with increasing stroke risk but were independent of CRUSADE bleeding risk. Of patients with AF treated with PCI, 53% received DAPT, 11% DAT and 35% TAT. 51% of those at high stroke risk were discharged on DAPT only. In contrast, 19% at low stroke risk received TAT. CONCLUSION: In New Zealand, one in seven patients presenting with ACS have AF, a third being new-onset AF. Antithrombotic management is inconsistent, with underutilisation of anticoagulants, particularly the DAT regimen, and is inadequately informed by stroke and bleeding risk scores.


Assuntos
Síndrome Coronariana Aguda , Fibrilação Atrial , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
10.
Medicine (Baltimore) ; 99(34): e21885, 2020 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-32846847

RESUMO

The use of a drug-eluting stent (DES) in patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention is conventional. However, the effect of DES on new-onset atrial fibrillation (AF) after AMI still remains unclear.By using data from Taiwan's National Health Insurance Research Database, a total of 17,741 patients with ST-elevation myocardial infarction (STEMI) and 17,631 patients with non-ST-elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention were analyzed to investigate the risk of new-onset AF after index admission of AMI.There were 26.5% (N = 4696) of patients with STEMI and 39.5% (N = 6967) of patients with NSTEMI received DES implantation. Upon 1-year follow-up, we observed that DES placement was associated with a reduced 1-year risk of new-onset AF in the patients with NSTEMI (adjusted hazard ratio [aHR] = 0.74, 95% confidence interval [CI] = 0.59-0.93, P = .009) after adjustment for clinical relevant variables. This benefit was consistent with that in the patients with NSTEMI who were ≥75 years old, had a CHA2DS2-VASc score of ≥2, and did not receive intra-aortic balloon pump insertion (aHR = 0.72, 95% CI = 0.53-0.98, P = .039; aHR = 0.73, 95% CI = 0.586-0.92, P = .006; and aHR = 0.71, 95% CI = 0.56-0.90, P = .004; respectively). However, DES placement had a neutral effect on the risk of new-onset AF in the patients with STEMI.Compared with the use of BMS, the use of DES might reduce the risk of new-onset AF in patients with NSTEMI.


Assuntos
Stents Farmacológicos/efeitos adversos , Infarto do Miocárdio/cirurgia , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Estudos de Casos e Controles , Stents Farmacológicos/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio sem Supradesnível do Segmento ST/complicações , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Taiwan/epidemiologia
11.
Stroke ; 51(10): 2918-2924, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32762619

RESUMO

BACKGROUND AND PURPOSE: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. METHODS: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. RESULTS: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92-104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130-136]; P<0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores (P=0.003), lower comorbidity score (P<0.001), and arrived more often by ambulance (P<0.001). Post-SIP, more patients had large vessel occlusions (P=0.03), and there were fewer stroke mimics (P=0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts. CONCLUSIONS: In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.


Assuntos
Infecções por Coronavirus , Mortalidade Hospitalar , Hospitais Comunitários , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/epidemiologia , Telemedicina , Adulto , Idoso , Idoso de 80 Anos ou mais , Ambulâncias , Fibrilação Atrial/epidemiologia , Betacoronavirus , California/epidemiologia , Estudos de Coortes , Comorbidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde , Alta do Paciente , Índice de Gravidade de Doença , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
12.
J Stroke Cerebrovasc Dis ; 29(9): 105034, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807446

RESUMO

BACKGROUND: Data on independent risk factors for stroke recurrence in Japanese patients with nonvalvular atrial fibrillation are limited. METHODS: We performed a subgroup analysis of a postmarketing surveillance study of apixaban (STroke prevention ANticoagulant Drug Apixaban Real-world Data study) in Japanese patients with nonvalvular atrial fibrillation receiving oral apixaban (5 mg/2.5 mg twice daily) in routine clinical practice. Patients were categorized into primary and secondary prevention groups based on the absence or presence of a history of ischemic stroke/transient ischemic attack, respectively. RESULTS: Patients in the secondary prevention group (1101 of 6306 patients [17.5%] analyzed; mean observation period, 15.7 months) had a higher risk of ischemic stroke or hemorrhage than those in the primary prevention group. The incidence rates of major (3.92%/year vs 2.06%/year), intracranial (1.87%/year vs 0.55%/year), and cerebral (1.14%/year vs 0.37%/year) hemorrhage and effectiveness outcomes (ischemic stroke/systemic embolism/transient ischemic attack, 3.25%/year vs 0.57%/year) were significantly higher (all P < 0.001) in the secondary prevention group than in the primary prevention group. Multivariate analysis identified no independent risk factors in the secondary prevention group, while prior major bleeding, alcohol abuse, advanced age, male sex, lower body weight, higher serum creatinine, and antiplatelet drug use were identified as risk factors for major hemorrhage, and advanced age and antiplatelet drug use for effectiveness outcomes in the primary prevention group. CONCLUSIONS: Among Japanese patients with nonvalvular atrial fibrillation who received apixaban, presence of a history of ischemic stroke/transient ischemic attack was associated with higher incidence rates of hemorrhage and thromboembolic events.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Ataque Isquêmico Transitório/prevenção & controle , Prevenção Primária , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Incidência , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Vigilância de Produtos Comercializados , Estudos Prospectivos , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Recidiva , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 29(9): 104934, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807411

RESUMO

BACKGROUND AND PURPOSE: Use of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS. METHODS: We reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection. RESULTS: 389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64-2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33-2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09-0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection. CONCLUSIONS: Older age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.


Assuntos
Fibrilação Atrial/diagnóstico , Embolia/diagnóstico , Tecnologia de Sensoriamento Remoto/instrumentação , Acidente Vascular Cerebral/diagnóstico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Diagnóstico Tardio , Registros Eletrônicos de Saúde , Embolia/epidemiologia , Embolia/fisiopatologia , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Valor Preditivo dos Testes , Prevalência , Prognóstico , Recidiva , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo
14.
Am J Cardiol ; 133: 134-138, 2020 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-32800294

RESUMO

Despite limited options for rate control of atrial fibrillation and for low-output heart failure seen in cardiac amyloidosis (CA), digoxin use is discouraged due to a reported increased risk of sensitivity and toxicity. We present our experience with digoxin use in patients with CA and report the event rate of suspected digoxin-related arrhythmias and toxicity. This is a retrospective study of patients with CA seen at our institution between November 1995 and October 2018. Patients were screened for a history of ≥7 days of continuous digoxin use and stratified based on amyloid precursor protein-transthyretin (ATTR) and immunoglobulin light chain (AL). Medical records were used to identify suspected digoxin-related arrhythmias and toxicity events. Digoxin was used in 69 patients (42 ATTR, 27 AL) for a median duration of 6 months (IQR, 1 to 16). Indication for use was rate control in 64% of patients and symptomatic heart failure management in 36%. Suspected digoxin-related arrhythmias and toxicity events occurred in 12% of patients. No deaths were attributed to digoxin use or toxicity, but 11 patients died while on digoxin-most due to progressive heart failure in the setting of CA. In conclusion, digoxin may be a therapeutic option for rate and symptom control for some patients with AL-CA and ATTR-CA. Rigorous patient selection is recommended, and patients should be closely monitored during digoxin administration.


Assuntos
Neuropatias Amiloides Familiares/complicações , Fibrilação Atrial/induzido quimicamente , Cardiotônicos/uso terapêutico , Digoxina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Amiloidose de Cadeia Leve de Imunoglobulina/complicações , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
15.
Medicine (Baltimore) ; 99(27): e20881, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629677

RESUMO

Atrial fibrillation (AF) is a major independent risk factor of stroke and anticoagulation therapy is needed in patients with AF after ischemic stroke. However, the detection rate of AF is low after ischemic stroke. Developing a prediction model for newly diagnosed AF after ischemic stroke will help to assess the subclinical AF.We identified 98,103 patients with diabetes mellitus (DM) and 261,893 patients without DM, who were not AF history and admitted for newly ischemic stroke from the National Health Insurance Research Database in Taiwan. The prediction model for 3-year incidence of AF after ischemic stroke was derived from multivariate logistic regression and also the accuracy rate of the prediction model was compared with CHA2DS2-VASC and CHADS2 scores as a reference.Four thousand nine hundred seventy six patients in the DM cohort and 16,127 patients in the non-DM cohort developed AF during 3 years of follow-up. The variables in the point-based prediction model for non-DM patients (range: -3-28), included age, heart failure, coronary artery disease, gout, obstructive pulmonary disease, hypertension, female, and statin use, while those for DM patients (range: -2-30) included age, heart failure, coronary artery disease, chronic kidney disease, hypertension, obstructive pulmonary disease, and statin use. Compared to the CHADS2 and CHA2DS2-VASc scoring systems, this scoring system was better at predicting 3-year risk of AF after ischemic stroke in both cohorts.This model might be useful in evaluating the benefit of insertable cardiac monitor implantation and anticoagulation agents in individual patients after ischemic stroke.


Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Diabetes Mellitus/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Fatores Etários , Doenças Cardiovasculares/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Taiwan/epidemiologia
16.
Int Heart J ; 61(4): 705-712, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32727999

RESUMO

There is increasing evidence linking plasma homocysteine levels and atrial fibrillation (AF). The association between an elevated level of plasma homocysteine and AF was examined by meta-analysis in this study.The PubMed and ScienceDirect databases until August 2019 were utilized to collect previous literature on homocysteine and the potential relation to AF. The pooled effects were evaluated depending on standardized mean differences (SMDs) or odds ratios (ORs) with 95% confidence intervals (CIs), and the calculation was performed using Stata 12 software.A total of 11 validated articles were included in the meta-analysis. For pooled effect, the results confirmed that AF patients had higher homocysteine levels than control subjects (SMD: 0.58, 95%CI: 0.09-1.06). Compared with control subjects, homocysteine levels were higher in paroxysmal AF (SMD: 0.45, 95%CI: 0.18-0.72) and persistent AF patients (SMD: 1.21, 95%CI: 0.50-1.92). The pooled analysis suggested that patients with elevated homocysteine levels had markedly higher risk of AF compared with lower homocysteine levels in the categorical variable (OR: 2.21, 95%CI: 1.16-4.21) and continuous variable analyses (OR: 1.13, 95%CI: 1.00-1.27), respectively. In addition, the pooled analysis indicated that recurrent AF patients had significantly higher homocysteine levels than those without recurrence (SMD: 0.65, 95%CI: 0.42-0.88). The pooled analysis of the categorical variables indicated that elevated homocysteine levels were associated with increased risk of AF recurrence (OR: 3.81, 95%CI: 3.11-4.68). However, the association was weak in the pooled analysis of continuous variables (OR: 1.88, 95%CI: 0.74-4.81).Our meta-analysis identified that plasma homocysteine levels were significantly elevated in AF and recurrent AF patients. Elevated homocysteine is associated with increased risk of AF and AF recurrence.


Assuntos
Fibrilação Atrial/sangue , Homocisteína/metabolismo , Hiper-Homocisteinemia/complicações , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/mortalidade , Estudos de Casos e Controles , Humanos , Recidiva , Medição de Risco , Software
17.
Am J Cardiol ; 128: 107-112, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650902

RESUMO

The association between objectively measured physical activity and atrial fibrillation (AF) has not been examined. Therefore, we examined the association between moderate and vigorous physical activity (MVPA) with incident AF in 5,147 participants who completed accelerometer assessment for 4 to 7 consecutive days in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. MVPA was defined as >1,065 counts/minute, and daily mean time spent in MVPA was computed. Incident AF was identified during follow-up by a study-scheduled electrocardiogram and also from self-reported medical history of a physician diagnosis. Logistic regression was used to assess the relation between daily time in MVPA and incident AF. A total of 429 (8.3%) incident AF cases were detected after a median follow-up of 3.5 years following accelerometer assessment. Participants with higher daily time spent in MVPA were less likely to develop AF than those with lower MVPA achievement (Quartile 1 = 12.4%; Quartile 2 = 8.3%; Quartile 3 = 7.1%; Quartile 4 = 5.4%; p-trend <0.001). In a multivariable model adjusted for AF risk factors, the risk of AF decreased with higher levels of daily MVPA (Quartile 1: Ref; Quartile 2: hazard ratio [HR] = 0.77, 95% confidence interval [CI] 0.58 to 1.01; Quartile 3: HR = 0.72, 95% CI 0.53 to 0.98; Quartile 4: HR = 0.62, 95% CI 0.44 to 0.87; p-trend = 0.0056). In conclusion, higher levels of objectively measured daily MVPA are protective against the development of AF suggesting that promotion of MVPA should be encouraged to reduce the risk of AF.


Assuntos
Acelerometria , Fibrilação Atrial/epidemiologia , Exercício Físico , Afro-Americanos/estatística & dados numéricos , Idoso , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de Proteção , Risco , Fatores Sexuais , Estados Unidos/epidemiologia
18.
Am J Cardiol ; 128: 168-173, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650915

RESUMO

The prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT) is assessed controversially. LVHT is associated with other cardiac abnormalities and with neuromuscular disorders (NMD). Aim of the study was to assess cardiac and neurological findings as predictors of mortality rate in adult LVHT-patients. Included were patients with LVHT diagnosed between 1995 and 2019 in 1 echocardiographic laboratory. Patients underwent a baseline cardiologic examination and were invited for a neurological investigation. In January 2020, their survival status was assessed. End points were death or heart transplantation. LVHT was diagnosed by echocardiography in 310 patients (93 female, aged 53 ± 18 years) with a prevalence of 0.4%/year. A neurologic investigation was performed in 205 patients (67%). A specific NMD was found in 33 (16%), NMD of unknown etiology in 123 (60%) and the neurological investigation was normal in 49 (24%) patients. During follow-up of 84 ± 71 months, 59 patients received electronic devices, 105 patients died, and 6 underwent heart transplantation. The mortality was 4.7%/year, the rate of heart transplantation/death 5%/year. By multivariate analysis, the following parameters were identified to elevate the risk of mortality/heart transplantation: increased age (p = 0.005), inpatient (p = 0.001), presence of a specific NMD (p = 0.0312) or NMD of unknown etiology (p = 0.0365), atrial fibrillation (p = 0.0000), ventricular premature complexes (p = 0.0053), exertional dyspnea (p = 0.0023), left bundle branch block (p = 0.0201), and LVHT of the posterior wall (p = 0.0158). In conclusion, LVHT patients should be systematically investigated neurologically since neurological co-morbidity has a prognostic impact.


Assuntos
Fibrilação Atrial/epidemiologia , Bloqueio de Ramo/epidemiologia , Transplante de Coração/estatística & dados numéricos , Miocárdio Ventricular não Compactado Isolado/epidemiologia , Mortalidade , Doenças Neuromusculares/epidemiologia , Adulto , Idoso , Comorbidade , Ecocardiografia , Ecocardiografia Doppler , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Doenças Musculares/epidemiologia , Distrofia Muscular de Duchenne/epidemiologia , Distrofia Miotônica/epidemiologia , Atrofia Óptica Hereditária de Leber/epidemiologia , Síndrome Pós-Poliomielite/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais
19.
Am J Cardiol ; 128: 191-195, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650919

RESUMO

Abnormal P-wave axis may reflect preclinical atrial dysfunction and has been associated with an increased risk of incident atrial fibrillation (AF) in the general population. Patients with diabetes mellitus (DM) have a higher prevalence of AF, but the association of abnormal P-wave axis and the risk of incident AF in those with diabetes has not been previously explored. For this analysis, we included 8,965 eligible participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. P-wave axis was automatically measured on study electrocardiogram and visually confirmed, with the normal range being between 0° and 75°. At baseline, 8% of the study population had an abnormal P-wave axis. During 43,856 person-years of follow-up, there were 145 cases of incident AF. Using multivariable-adjusted Cox proportional hazards models, participants with abnormal P-wave axis had an increased risk of incident AF (hazard ratio 2.65, 95% confidence interval 1.76 to 3.99, p < 0.0001). Findings were similar in prespecified subgroups, without evidence of effect modification. Both left- and right-axis deviation of the P-wave were associated with incident AF. Our results suggest that abnormal P-wave axis is associated with incident AF in those with DM and that this relation is conserved in prespecified subgroups. There may be utility in considering P-wave axis values from routine ECGs in these patients.


Assuntos
Fibrilação Atrial/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Átrios do Coração/fisiopatologia , Idoso , Fibrilação Atrial/fisiopatologia , Comorbidade , Diabetes Mellitus Tipo 2/fisiopatologia , Eletrocardiografia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
20.
Am J Cardiol ; 128: 60-66, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650925

RESUMO

Left atrial calcium (LAC) is often observed in patients who have undergone mitral valve (MV) surgery, but little is known about its characteristics and clinical implications. Therefore, we sought to investigate the structural and hemodynamic significance of LAC and its association with clinical outcomes. We investigated 327 patients with repaired or prosthetic MV who underwent cardiac CT from 2010 to 2017. The degree of LAC was analyzed and classified into three groups: group 1 (no LAC), group 2 (mild-to-moderate LAC), and group 3 (severe LAC). Clinical and echocardiographic characteristics and clinical outcomes were compared in three groups. LAC was seen in 79 (24.2%) patients. Groups 2 and 3 showed more prevalent atrial fibrillation, a rheumatic etiology, a higher number of previous surgeries, a larger LA volume index, and higher pulmonary artery systolic pressure than group 1. Paravalvular leakage of the MV increased progressively according to severity of LAC (15.4% in group 1, 39.3% in group 2, and 66.7% in group 3, p <0.001). Event-free survival rate for major adverse cardiovascular adverse events (log rank p = 0.033) and all-cause mortality (log rank p <0.001) were significantly different according to LAC group. In Cox regression analyses, presence of severe LAC was an independent predictor of all-cause mortality (hazard ratio: 4.44, 95% confidence interval: 1.71 to 11.58, p = 0.002). LAC on cardiac CT is not uncommon and reflects more advanced LA remodeling and a stiff LA. The presence and severity of LAC are associated with a worse clinical outcome after MV surgery.


Assuntos
Calcinose/epidemiologia , Cardiomiopatias/epidemiologia , Átrios do Coração/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral/cirurgia , Estenose da Valva Mitral/cirurgia , Complicações Pós-Operatórias/epidemiologia , Idoso , Fibrilação Atrial/epidemiologia , Calcinose/diagnóstico por imagem , Cardiomiopatias/diagnóstico por imagem , Causas de Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Complicações Pós-Operatórias/diagnóstico por imagem , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Cardiopatia Reumática/cirurgia , Tomografia Computadorizada por Raios X
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