Impact of Newly Diagnosed Cancer on Bleeding Events in Patients with Atrial Fibrillation Treated with Direct Oral Anticoagulants.

BACKGROUND: In patients with atrial fibrillation (AF), the association between cancer and cardioembolic or bleeding risk during oral anticoagulant therapy still remains unclear. PURPOSE: We aimed to assess the impact of cancer present at baseline (CB) or diagnosed during follow-up (CFU) on bleeding events in patients treated with direct oral anticoagulants (DOACs) for non-valvular AF (NVAF) compared with patients without CB or CFU, respectively. METHODS: All consecutive patients with NVAF treated with DOACs for stroke prevention were enrolled between January 2017 and March 2019. Primary outcomes were bleeding events or cardiovascular death, non-fatal stroke and non-fatal myocardial infarction, and the composite endpoint between patients with and without CB and between patients with and without CB. RESULTS: The study population comprised 1170 patients who were followed for a mean time of 21.6 ± 9.5 months. Overall, 81 patients (6.9%) were affected by CB, while 81 (6.9%) were diagnosed with CFU. Patients with CFU were associated with a higher risk of bleeding events and major bleeding compared with patients without CFU. Such an association was not observed between the CB and no CB populations. In multivariate analysis adjusted for anemia, age, creatinine, CB and CFU, CFU but not CB remained an independent predictor of overall and major bleeding (hazard ratio [HR] 2.67, 95% confidence interval [CI] 1.8-3.89, p < 0.001; HR 3.02, 95% CI 1.6-3.81, p = 0.001, respectively). CONCLUSION: During follow-up, newly diagnosed primitive or metastatic cancer in patients with NVAF taking DOACs is a strong predictor of major bleeding regardless of baseline hemorrhagic risk assessment. In contrast, such an association is not observed with malignancy at baseline. Appropriate diagnosis and treatment could therefore reduce the risk of cancer-related bleeding.

Echocardiographic Markers in the Diagnosis of Cardiac Masses.

BACKGROUND: The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown. The aim of this study was to identify and integrate the echocardiographic features of CMs that can accurately predict malignancy. METHODS: An observational cohort study was conducted among 286 consecutive patients who underwent standard echocardiographic assessment for suspected CM at Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histologic examination or, in the case of cardiac thrombi, with radiologic evidence of thrombus resolution after appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of six echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numeric score, ranging from 0 to 6, with a cutoff of ≥3 balancing sensitivity and specificity with respect to the histologic diagnosis of malignancy. Classification tree analysis was used to determine the ability of echocardiographic parameters to discriminate subgroups of patients with differential risk for malignancy. RESULTS: Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (P < .001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (P < .001). Infiltration, moderate to severe pericardial effusion, nonleft localization, sessile implantation, polylobate shape, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted score of ≥3 was very high (>0.90) and similar to that of the previously published weighted score. Classification tree analysis generated an algorithm in which infiltration was the best discriminator of malignancy, followed by nonleft localization and sessile implantation. The percentage correctly classified by classification tree analysis as malignant was 87.5%. Agreement between observer readings and CM histology ranged between 85.1% and 91.5%. The presence of at least three echocardiographic parameters was associated with lower survival. CONCLUSIONS: In the approach to CMs, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

Bypass grafting with coronary endarterectomy: immediate and long-term results.

BACKGROUND: Increased morbidity and mortality have been associated with coronary artery bypass grafting when an adjunctive coronary endarterectomy is performed. In this study we retrospectively reviewed our experience with coronary bypass and endarterectomy to evaluate the early and late outcome and to determine the independent predictors of early mortality and morbidity of this procedure. METHODS: Between May 1989 and December 2000, 107 patients underwent myocardial revascularization with coronary endarterectomy to achieve a complete revascularization. There were 90 men and 17 women; the mean age was 64 +/- 8.1 years. Sixty-three (58.9%) patients had a previous myocardial infarction, and 29 (27.1%) were operated on on an emergency basis. An ejection fraction of less than 30% was present in 9 (8.4%) patients. The most frequently endarterectomized vessel was the left coronary artery (74.8%). Follow-up information was obtained from 97 patients (100% of the long-term survivors). RESULTS: There were 5 (4.7%) early deaths. The 72-month survival was 91.2% +/- 4.9%. Seventy-seven (83.7%) of the survivors were symptom free, and 15 (16.3%) were in Canadian Cardiovascular Society class II to III. An improvement of the ejection fraction after the operation was shown in the 97 patients who underwent echocardiographic control (P =.03) and angiography. The 30.4-month patency rate of the endarteriectomized coronary arteries was 72% +/- 11%. CONCLUSION: Coronary endarterectomy is a safe and effective procedure for achieving a complete revascularization in patients with end-stage coronary disease.