201
|
Sazonova IY, Pondicherry-Harish R, Kadle N, Sharma GK, Figueroa RE, Robinson VJB. Embolic Stroke Diagnosed by Elevated D-Dimer in a Patient With Negative TEE for Cardioembolic Source. J Investig Med High Impact Case Rep 2015; 2:2324709614560907. [PMID: 26425631 PMCID: PMC4528875 DOI: 10.1177/2324709614560907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We report a case of cerebrovascular accident with thromboembolic stroke etiology in a patient who had atrial flutter and negative transesophageal echocardiography (TEE) results. The increased D-dimer levels (1877 ng/mL) initiated referral for magnetic resonance imaging and magnetic resonance angiography of the brain that showed classic recanalization of an embolic thrombus in the angular branch of the left middle cerebral distribution. The D-dimer level of this patient was normalized after 3 months of anticoagulation therapy. Although TEE is considered the gold standard for evaluation of cardiac source of embolism, exclusion of intracardiac thrombus with TEE alone does not eliminate the risk of thromboembolic events. This case highlights the utility of D-dimer as a potential adjunct in the decision-making process to guide investigation of thromboembolism, determine subsequent therapy, and hence reduce the risk of embolic stroke recurrence.
Collapse
|
202
|
Serra W, Li Calzi M, Coruzzi P. Left Atrial Appendage Thrombosis During Therapy with Rivaroxaban in Elective Cardioversion for Permanent Atrial Fibrillation. Clin Pract 2015; 5:788. [PMID: 26664717 PMCID: PMC4653753 DOI: 10.4081/cp.2015.788] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/03/2015] [Accepted: 07/31/2015] [Indexed: 11/29/2022] Open
Abstract
Electric external cardioversion (EEC) for permanent atrial fibrillation (AF) carries a risk of thromboembolic events (TE). The use of transesophageal echocardiography (TEE) to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned. Therapeutic anticoagulation with novel oral anticoagulants (NOAC) is recommended for 3 to 4 weeks before and an anticoagulation life-long therapy is recommended after EEC to reduce TE, in patients with high CHA2DS2-VASc score; however, only few data are currently available about safety of short-term anticoagulation with NOAC in the setting of EEC. Patients with increased risk of thromboembolism have not been adequately studied and the monitoring of anticoagulant effects can also have important benefits in case of drug interactions. We report a case of a 68-year old man with AF from September 2014. Moderate depression of global left ventricular systolic function was detected by echocardiographic exam. On the basis of a high thromboembolic risk, an anticoagulant therapy with rivaroxaban, at the dose of 20 mg/day, was started. TEE showed a thrombus in the left atrial appendage. This case demonstrates the utility of performing TEE prior than EEC in patients with hypokinetic cardiomyopathy other than AF in therapy with NOAC. We underline the presence of significant pharmacodynamic interference of rivaroxaban with other drugs such as oxcarbazepine.
Collapse
Affiliation(s)
- Walter Serra
- Department of Cardiology, University Hospital of Parma , Italy
| | - Mauro Li Calzi
- Department of Cardiology, University Hospital of Parma , Italy
| | | |
Collapse
|
203
|
Kovar FM, Fang IF, Perkmann T, Haslacher H, Slavka G, Födinger M, Endler G, Wagner OF. Subclinical hypothyroidism and mortality in a large Austrian cohort: a possible impact on treatment? Wien Klin Wochenschr 2015; 127:924-30. [PMID: 26373750 DOI: 10.1007/s00508-015-0846-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinical implications of subclinical hypothyroidism (SCH) are still matter of intense debate, resulting in the controversial discussion whether subclinical hypothyroidism should be treated. We performed a cohort study to evaluate the impact of subclinical hypothyroidism on vascular and overall mortality. METHODS Between 02/1993 and 03/2004, a total of 103,135 persons attending the General Hospital Vienna with baseline serum thyrotropin (TSH, thyroid-stimulating hormone) and free thyroxin (fT4) measurements could be enrolled in a retrospective cohort study. Subclinical hypothyroidism was defined by elevated TSH ranging from 4.5 to 20.0 mIU/L and normal fT4 concentration (0.7-1.7 ng/dL). Overall and vascular mortality as primary endpoints were assessed via record linkage with the Austrian Death Registry. RESULTS A total of 80,490 subjects fulfilled inclusion criteria of whom 3934 participants (3.7%) were classified as SCH (868 males and 3066 females, median age 48 years). The mean follow-up among the 80,490 subjects was 4.1 years yielding an observation period of 373,301 person-years at risk. In a multivariate Cox regression model adjusted for age and gender TSH levels showed a dose-dependent association with all-cause mortality. The association between SCH and overall or vascular mortality was stronger in men below 60 years compared to older males or females. CONCLUSION Our data support the hypothesis that SCH might represent an independent risk factor for overall and vascular mortality, especially in men below 60 years. Whether this group would benefit from replacement therapy should be evaluated in interventional studies.
Collapse
Affiliation(s)
- Florian Maria Kovar
- Department for Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - I-Fei Fang
- Central Laboratory, Wilhelminenspital der Stadt Wien, Vienna, Austria
| | - Thomas Perkmann
- Department of Medical and Chemical Laboratory Diagnostics, Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, AKH-Wien Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Helmuth Haslacher
- Department of Medical and Chemical Laboratory Diagnostics, Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, AKH-Wien Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Slavka
- Central Laboratory, Wilhelminenspital der Stadt Wien, Vienna, Austria
| | - Manuela Födinger
- Department of Medical and Chemical Laboratory Diagnostics, Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, AKH-Wien Waehringer Guertel 18-20, 1090, Vienna, Austria
- Central Laboratory, Kaiser Franz Josef-Spital der Stadt Wien, Vienna, Austria
| | - Georg Endler
- Department of Medical and Chemical Laboratory Diagnostics, Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, AKH-Wien Waehringer Guertel 18-20, 1090, Vienna, Austria
- Labors.at, Vienna, Austria
| | - Oswald F Wagner
- Department of Medical and Chemical Laboratory Diagnostics, Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, AKH-Wien Waehringer Guertel 18-20, 1090, Vienna, Austria.
| |
Collapse
|
204
|
Keller K, Prochaska JH, Coldewey M, Gobel S, Ullmann A, Jünger C, Lamparter H, Ariza L, Bickel C, Lauterbach M, Konstantinides S, Rostock T, Münzel T, Wild PS. History of deep vein thrombosis is a discriminator for concomitant atrial fibrillation in pulmonary embolism. Thromb Res 2015; 136:899-906. [PMID: 26376038 DOI: 10.1016/j.thromres.2015.08.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/22/2015] [Accepted: 08/29/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is the consequence of deep vein thrombosis (DVT) in 70% of all cases. Although, PE and DVT are commonly related to risk factors of Virchow's triad, both entities are linked to cardiovascular risk factors, but risk factors seem differently important in both entities. OBJECTIVES We aimed to investigate clinical profile and outcome of patients with PE history stratified by concomitant DVT. PATIENTS/METHODS Data from the observational multi-center thrombEVAL-study were analyzed. RESULTS The sample (N=2,318) comprised 295 PE patients, of whom 69.2% (N=204) had DVT. Individuals without DVT were older and had higher prevalence of concomitant atrial fibrillation (AF), chronic lung diseases, coronary artery disease, heart failure and hypertension. Multivariable regression revealed an independent association of AF (Odds Ratio (OR) 3.17, 95% CI 1.63-6.18, P<0.001) and coronary artery disease (OR 2.31, 95% CI 1.15-4.66, P=0.019) with PE without DVT. There was higher frequency of permanent AF in individuals without DVT, whereas paroxysmal AF was more prevalent in individuals with DVT. All AF subtypes were independently associated with PE without DVT with increasing ORs from paroxysmal to permanent AF. PE patients with and without DVT did not differ in survival (P=0.32) and cost-relevant clinical outcome (P=0.26) during follow-up. AF in PE patients was associated with cost-relevant clinical outcome (Hazard Ratio (HR) 1.78, 95% CI 1.03-3.09, P=0.040), but no significant difference in survival (HR 0.93, 95% CI 0.35-2.50, P=0.88) was observed. CONCLUSIONS History of DVT is a significant discriminator for clinical profile of PE patients. Individuals without DVT had more often cardiac and pulmonary disease with strongest association with AF. Data advocate a potential link between AF and PE. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov, Unique identifier NCT01809015.
Collapse
Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jürgen H Prochaska
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Meike Coldewey
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sebastian Gobel
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Germany
| | - Alexander Ullmann
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Claus Jünger
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Heidrun Lamparter
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Liana Ariza
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Michael Lauterbach
- Department of Internal Medicine III, Hospital of Barmherzige Brüder Trier, Trier, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Rostock
- Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Germany
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis, Mainz, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Germany; Department of Medicine 2, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Germany; Preventive Cardiology and Preventive Medicine, University Medical Center Mainz of Johannes Gutenberg-University Mainz, Mainz, Germany.
| |
Collapse
|
205
|
Davila CD, Pandian NG. Simultaneous Right and Left Atrial Appendage Thrombus in a Patient with Atrial Fibrillation: A Lesson to Remember. Echocardiography 2015; 32:1873-5. [DOI: 10.1111/echo.13044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Carlos D. Davila
- Department of Medicine; Einstein Medical Center; Philadelphia Pennsylvania
| | | |
Collapse
|
206
|
Relationship between body mass index and left atrial appendage thrombus in nonvalvular atrial fibrillation. J Thromb Thrombolysis 2015; 41:613-8. [DOI: 10.1007/s11239-015-1266-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
207
|
Bilateral atrial appendage thrombus formation in a patient with atrial fibrillation. J Echocardiogr 2015. [PMID: 26205432 DOI: 10.1007/s12574-015-0258-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
208
|
Osmanagic A, Möller S, Osmanagic A, Sheta HM, Vinther KH, Egstrup K. Effect of early direct current cardioversion on the recurrence of atrial fibrillation in patients with persistent atrial fibrillation. Am J Cardiol 2015; 116:225-9. [PMID: 25972054 DOI: 10.1016/j.amjcard.2015.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 12/19/2022]
Abstract
In patients with persistent atrial fibrillation (AF), the sinus rhythm (SR) can be restored by direct current cardioversion (DCC), although the recurrence of AF after successful DCC is common. We examined whether transesophageal echocardiography (TEE)-guided early DCC, compared with the conventional approach of DCC after 3 weeks of anticoagulation with dabigatran-etexilat, reduces the recurrence of AF. A total of 126 consecutive patients with persistent AF were randomly assigned to a TEE followed by early DCC (n = 65) or to a conventional treatment with dabigatran-etexilat for 3 weeks followed by DCC (n = 61). None of the patients received any antiarrhythmic treatment other than β blockers, and all the DCCs were successful. Forty-eight-hour Holter monitoring was performed at 28 days and at 3, 6, and 12 months after the DCC. The primary outcome was AF recurrence lasting ≥30 seconds. The analysis was stratified by AF duration <60 (n = 62) or >60 days (n = 64) before DCC. We observed a significant reduction in the AF recurrence risk (p = 0.003) in patients with persistent AF <60 days who received early DCC, but there was no significant benefit of early DCC (p = 0.456) in patients with persistent AF lasting >60 days. The recurrence-free survival probability at 28 days in patients with persistent AF <60 days was 0.27 (95% confidence interval 0.14 to 0.51) in the conventional treatment group compared with 0.69 (95% confidence interval 0.54 to 0.87; p = 0.006) in the early DCC group. A benefit of early DCC persisted throughout 12 months of follow-up. In conclusion, TEE-guided early DCC in patients with persistent AF <60 days results in a significant reduction of AF recurrence.
Collapse
Affiliation(s)
- Armin Osmanagic
- Department of Medical Research, OUH Svendborg Hospital, Svendborg, Denmark.
| | - Sören Möller
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Azra Osmanagic
- Department of Geriatric Medicine, Odense University Hospital OUH, Odense, Denmark
| | - Hussam M Sheta
- Department of Medical Research, OUH Svendborg Hospital, Svendborg, Denmark
| | - Kristina H Vinther
- Department of Medical Research, OUH Svendborg Hospital, Svendborg, Denmark
| | - Kenneth Egstrup
- Department of Medical Research, OUH Svendborg Hospital, Svendborg, Denmark
| |
Collapse
|
209
|
Mont L, Marín F, Dalmau FGB, Martínez MS, Cullere JG. Clinical development of rivaroxaban: emerging new clinical evidences? Future Cardiol 2015; 11:565-83. [PMID: 26111102 DOI: 10.2217/fca.15.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rivaroxaban has proven efficacious in a variety of conditions. In fact, rivaroxaban has been approved for the prevention of venous thromboembolism after elective hip or knee replacement surgery, for the prevention and treatment of deep vein thrombosis and pulmonary embolism, for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the prevention of atherothrombotic events after acute coronary syndrome with elevated cardiac biomarkers. However, clinical development of rivaroxaban is ongoing. Considering published and on-going randomized clinical trials, noninterventional studies and registries, over 275,000 patients are being analyzed. The aim of this review was to update the clinical development of rivaroxaban, including completed and ongoing studies not only randomized clinical trials, but also clinical practice studies.
Collapse
Affiliation(s)
- Luís Mont
- Arrhythmia Section, Institut del Torax, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto de Investigación Biosanitaria Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | | | - Marianela Sánchez Martínez
- Cardiovascular Critical Unit, Department of Cardiology. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jaime Gallego Cullere
- Neurology Department and Stroke Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| |
Collapse
|
210
|
Ferner M, Wachtlin D, Konrad T, Deuster O, Meinertz T, von Bardeleben S, Münzel T, Seibert-Grafe M, Breithardt G, Rostock T. Rationale and design of the RE-LATED AF—AFNET 7 trial: REsolution of Left atrial-Appendage Thrombus—Effects of Dabigatran in patients with Atrial Fibrillation. Clin Res Cardiol 2015; 105:29-36. [DOI: 10.1007/s00392-015-0883-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/09/2015] [Indexed: 11/30/2022]
|
211
|
Galloway A, Li H, Vanderlinde-Wood M, Khan M, Benbrook A, Liles C, Zillner C, Rao V, Cunningham MW, Yu X, Kem DC. Activating autoantibodies to the β1/2-adrenergic and M2 muscarinic receptors associate with atrial tachyarrhythmias in patients with hyperthyroidism. Endocrine 2015; 49:457-63. [PMID: 25500789 PMCID: PMC5810549 DOI: 10.1007/s12020-014-0495-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Abstract
We have previously demonstrated that activating autoantibodies to β1-adrenergic receptor (β1AR) and M2 muscarinic receptor (M2R) facilitate atrial fibrillation (AF) in patients with Graves' disease (GD). The objectives of this expanded study were to examine the prevalence of β1AR, β2AR, and M2R autoantibodies in hyperthyroidism subjects. Sera from 81 patients including 31 with GD and AF, 36 with GD and sinus rhythm, 9 with toxic multinodular goiter, 5 with subacute thyroiditis, and 10 control subjects were examined for these autoantibodies by ELISA. Sera from 20 ELISA-positive GD subjects, 10 with AF and 10 with sinus rhythm, were assayed for autoantibody bioactivity using cell-based bioassays. In patients with GD and AF, 45, 65, and 77 % were ELISA positive for β1AR, M2R, and β2AR autoantibodies, respectively. In patients with GD and sinus rhythm, 17, 39, and 75 % were ELISA positive for β1AR, M2R, and β2AR autoantibodies, respectively. β1AR and M2R autoantibodies were co-present in 39 % of patients with GD and AF compared to 14 % in GD with sinus rhythm (p = 0.026). Patients with toxic multinodular goiter or subacute thyroiditis had a low prevalence of autoantibodies. The mean β1AR and M2R autoantibody activity was elevated in both GD groups but higher in those with AF than those with sinus rhythm. β2AR autoantibody activity was also increased in both groups. In conclusion, β1AR, β2AR, and M2R autoantibodies were elevated in GD. β1AR and M2R autoantibodies appear to be related to concurrent AF, while β2AR autoantibodies were equally prevalent in those with a sinus tachycardia and those with AF.
Collapse
Affiliation(s)
- Allison Galloway
- Endocrinology and the Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center and Veterans Affairs Medical Center, Oklahoma City, OK, 73104, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
212
|
Cresti A, García-Fernández MA, De Sensi F, Miracapillo G, Picchi A, Scalese M, Severi S. Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study. Europace 2015; 18:450-6. [PMID: 26017468 DOI: 10.1093/europace/euv128] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/13/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Prevalence of left appendage thrombosis ranges from 6 to 18% in persistent atrial fibrillation (AF). Few and low sample size studies have assessed left and right atrial thrombosis in persistent atrial flutter (AFL) and a wide variety of frequencies, from 1 to 21%, has been reported. The aim of this study was to evaluate the prevalence of atrial appendage thrombosis in a large population of patients undergoing transoesophageal echocardiography (TEE)-guided cardioversion (CV) for recent AFL onset and compare it with AF. METHODS AND RESULTS From 1999 to September 2014, we collected data of 1081 patients to CV: 877 affected by AF (81.1%) and 204 by AFL (18.9%). The presence of auricular thrombosis was evaluated by TEE in AF or AFL persisting for more than 48 h. The presence of appendage thrombosis, Doppler emptying velocities, and severe spontaneous echo contrast (SEC) was studied. The overall prevalence of atrial thrombosis was 9.62% (104/1081). Frequency of atrial thrombosis in AFL patients was 6.4% (13/204) vs. 10.5% among AF (92/877), P = 0.074. Comparing the two appendages, frequency of left atrial appendage thrombosis was in AFL 5.9% (12/204) vs. 9.9% (87/877) in the AF group, P = 0.07. Right atrial appendage thrombosis was present in 0.5% (1/204) in the AFL group vs. 0.8% (7/877) in the AF group, P = 0.64. Moderate to severe SEC (3+/4+) was present in 28% of AFL patients (57/204) vs. 35% of AF patients (307/877), P = 0.05. CONCLUSION Auricular thrombosis is not an infrequent finding in AFL before CV. Our study suggests the use of TEE screening in AFL, as well as in AF, when patients arrive to clinical attention after more than 48 h from arrhythmia onset.
Collapse
Affiliation(s)
- Alberto Cresti
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Miguel Angel García-Fernández
- Department of Medicine, San Carlos University Hospital, Universidad Complutense, Facultad de Medicina, Madrid, Spain
| | - Francesco De Sensi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Gennaro Miracapillo
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Andrea Picchi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Marco Scalese
- Department of Epidemiology and Health Research, Institute of Clinical Physiology, National Council of Research, F. G. Monasterio, Pisa, Italy
| | - Silva Severi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| |
Collapse
|
213
|
Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CAN J EMERG MED 2015; 12:181-91. [DOI: 10.1017/s1481803500012227] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.Methods:This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.Results:A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.Conclusion:This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
Collapse
|
214
|
Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation. J Interv Card Electrophysiol 2015; 43:227-36. [DOI: 10.1007/s10840-015-0008-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/06/2015] [Indexed: 01/30/2023]
|
215
|
Lip GYH, Merino J, Ezekowitz M, Ellenbogen K, Zamoryakhin D, Lanz H, Jin J, Al-Saadi N, Mercuri M, Goette A. A prospective evaluation of edoxaban compared to warfarin in subjects undergoing cardioversion of atrial fibrillation: The EdoxabaN vs. warfarin in subjectS UndeRgoing cardiovErsion of Atrial Fibrillation (ENSURE-AF) study. Am Heart J 2015; 169:597-604.e5. [PMID: 25965706 DOI: 10.1016/j.ahj.2015.02.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 02/07/2015] [Indexed: 11/29/2022]
Abstract
We designed a prospective, randomized, open-label, blinded end point evaluation parallel group Phase 3b clinical trial comparing edoxaban (a new oral factor Xa inhibitor) with enoxaparin/warfarin followed by warfarin alone in subjects undergoing planned electrical cardioversion of non-valvular atrial fibrillation. The primary efficacy end point is the composite end points of stroke, systemic embolic event, myocardial infarction, and cardiovascular (CV) mortality, from randomization until the end of follow-up (day 56 post cardioversion). The primary safety end point is the composite of major and clinically-relevant non-major bleeding, from the first administration of study drug to end of treatment (Day 28 post cardioversion) +3 days. The primary efficacy analysis will be conducted on the intention-to-treat population whereas the primary safety analysis, on the safety population. The study includes stratification on the following levels: (i) approach to cardioversion (transoesophagel echocardiography or non-transoesophagel echocardiography) as determined by the Investigator; (ii) subject's experience in taking anticoagulants at the time of randomization (anticoagulant-experienced or anticoagulant-naïve); and (iii) assigned edoxaban dose (full 60 mg QD or reduced 30 mg dose QD). A subject with one or more factors (CrCl ≥15 mL/min and ≤50 mL/min, low body weight [≤60 kg], and concomitant use of p-pg inhibitors (excluding amiodarone) will receive a reduced dose (30 mg) of edoxaban if the subject is randomized to the edoxaban group. ENSURE-AF will be the largest prospective randomised trial of anticoagulation for cardioversion, also involving a Non-VKA Oral Anticoagulant-edoxaban.
Collapse
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Aalborg University, Denmark.
| | - Jose Merino
- University Hospital La Paz - IdiPaz, Madrid, Spain
| | - Michael Ezekowitz
- Jefferson Medical College, Cardiovascular Research Foundation, New York, NY
| | | | | | - Hans Lanz
- Daiichi Sankyo Pharma Development, Edison, NJ
| | - James Jin
- Daiichi Sankyo Pharma Development, Edison, NJ
| | | | | | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital, Paderborn and Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| |
Collapse
|
216
|
Selenium and its supplementation in cardiovascular disease--what do we know? Nutrients 2015; 7:3094-118. [PMID: 25923656 PMCID: PMC4446741 DOI: 10.3390/nu7053094] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 04/07/2015] [Accepted: 04/16/2015] [Indexed: 02/07/2023] Open
Abstract
The trace element selenium is of high importance for many of the body’s regulatory and metabolic functions. Balanced selenium levels are essential, whereas dysregulation can cause harm. A rapidly increasing number of studies characterizes the wide range of selenium dependent functions in the human body and elucidates the complex and multiple physiological and pathophysiological interactions of selenium and selenoproteins. For the majority of selenium dependent enzymes, several biological functions have already been identified, like regulation of the inflammatory response, antioxidant properties and the proliferation/differentiation of immune cells. Although the potential role of selenium in the development and progression of cardiovascular disease has been investigated for decades, both observational and interventional studies of selenium supplementation remain inconclusive and are considered in this review. This review covers current knowledge of the role of selenium and selenoproteins in the human body and its functional role in the cardiovascular system. The relationships between selenium intake/status and various health outcomes, in particular cardiomyopathy, myocardial ischemia/infarction and reperfusion injury are reviewed. We describe, in depth, selenium as a biomarker in coronary heart disease and highlight the significance of selenium supplementation for patients undergoing cardiac surgery.
Collapse
|
217
|
Arrigo M, Bettex D, Rudiger A. [Treatment of atrial fibrillation in intensive care units and emergency departments]. Med Klin Intensivmed Notfmed 2015; 110:614-20. [PMID: 25876744 DOI: 10.1007/s00063-015-0006-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 12/08/2014] [Accepted: 12/18/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia in patients hospitalized in intensive care units and emergency departments and is associated with an increased morbidity and mortality. In critically ill patients, atrial fibrillation can cause hemodynamic instability and cardiogenic shock. The mechanisms and the management of atrial fibrillation are significantly different in critically ill patients compared to outpatients. DIAGNOSIS AND TREATMENT The initial management includes the evaluation of the hemodynamic consequences of new-onset atrial fibrillation and the optimization of reversible causes. In patients with hemodynamic instability the rapid restoration of an adequate perfusion pressure is the initial goal. Often, a rapid conversion in sinus rhythm is required to achieve hemodynamic stabilization. Electrical cardioversion, if possible performed after pretreatment with an antiarrhythmic drug to increase the success rate, frequently plays a central role in the conversion to sinus rhythm of hemodynamically unstable patients. Stable patients are initially treated with a short-acting intravenous β-blocker to achieve heart rate control. A conversion to sinus rhythm may be achieved pharmacologically with vernakalant, an atrial-specific multichannel blocker. EVALUATION All patients with atrial fibrillation lasting more than 48 h should be evaluated for anticoagulation in order to reduce cardio-embolic complications. After recovering from the acute illness, atrial fibrillation persists only in a minority of patients.
Collapse
Affiliation(s)
- M Arrigo
- Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz.,Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz
| | - D Bettex
- Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz
| | - A Rudiger
- Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz.
| |
Collapse
|
218
|
Kovacs RJ, Flaker GC, Saxonhouse SJ, Doherty JU, Birtcher KK, Cuker A, Davidson BL, Giugliano RP, Granger CB, Jaffer AK, Mehta BH, Nutescu E, Williams KA. Practical Management of Anticoagulation in Patients With Atrial Fibrillation. J Am Coll Cardiol 2015; 65:1340-1360. [DOI: 10.1016/j.jacc.2015.01.049] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/21/2015] [Accepted: 01/29/2015] [Indexed: 11/16/2022]
|
219
|
Coleman CM, Khalaf S, Mould S, Wazni O, Kanj M, Saliba W, Cantillon D. Novel Oral Anticoagulants for DC Cardioversion Procedures: Utilization and Clinical Outcomes Compared with Warfarin. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:731-7. [PMID: 25721150 DOI: 10.1111/pace.12618] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 02/16/2015] [Accepted: 02/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Novel oral anticoagulant (NOAC) agents dabigatran, rivaroxaban, and apixaban are increasingly utilized as thromboembolic prevention for patients with atrial fibrillation undergoing direct current cardioversion (DCCV) with post hoc analyses of clinical trials suggesting satisfactory safety and efficacy. This study characterizes utilization, effectiveness, and complications of NOAC agents for stroke prophylaxis in the setting of DCCV. METHODS Comparison of warfarin and NOAC agents as periprocedural anticoagulation for DCCV procedures performed at Cleveland Clinic from January 2009 through December 2013. Variables of interest include utilization rates for each NOAC agent stratified by clinical parameters including CHADS2 score, and associated clinical outcomes including cerebrovascular accident (CVA), transient ischemic attack (TIA), peripheral arterial embolism (PAE), and bleeding events during 8 weeks of postprocedure follow-up. RESULTS Among 5,320 DCCV procedures, 673 (12.6%) cases were excluded due to inadequate follow-up. Warfarin was utilized in 3,721 (80.1%), dabigatran in 719 (15.5%), rivaroxaban in 159 (3.4%), and apixaban in 48 (1.0%) with a steady increase in NOAC utilization from 2011 to 2013. There were low rates of CVA/TIA (warfarin: 0.97% vs NOAC 1.62%, P = 0.162) and bleeding (warfarin: 1.02% vs NOAC: 0.5%, P = 0.247) and no significant differences detected between agents. Higher CHADS2 /CHA2 DS2 -VASC scores were associated with thromboembolic and bleeding risk. Increasing age, chronic kidney disease, diabetes, coronary disease, and deep vein thrombosis/pulmonary embolism were associated with increased bleeding risk. CONCLUSION In a high-volume, single-center experience, NOAC utilization has grown to account for over a third of cardioversion procedures, and these agents appear safe and effective compared to warfarin with low rates of thromboembolic and bleeding complications.
Collapse
Affiliation(s)
- Corey M Coleman
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Shaden Khalaf
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Steven Mould
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Oussama Wazni
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mohamed Kanj
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Walid Saliba
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Daniel Cantillon
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
220
|
Lip GYH, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, Morandi E, van Eickels M, Cohen A. Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X-TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J 2015; 169:464-71.e2. [PMID: 25819852 DOI: 10.1016/j.ahj.2014.12.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/04/2014] [Indexed: 12/24/2022]
Abstract
There are still many unresolved issues concerning patient outcomes and prognostic factors in patients with atrial fibrillation (AF) and left atrial/left atrial appendage (LA/LAA) thrombi. Rivaroxaban (Xarelto®), a potent and highly selective oral, direct factor Xa inhibitor, is a new therapeutic option in this setting. The planned study program will consist of a prospective interventional study (X-TRA) and a retrospective observational registry (CLOT-AF). The primary objective of the X-TRA study is to explore the efficacy of rivaroxaban in the treatment of LA/LAA thrombi in patients with nonvalvular AF or atrial flutter, scheduled to undergo cardioversion or AF ablation, in whom an LA/LAA thrombus has been found on transesophageal echocardiography (TEE) before the procedure. The primary end point is the complete LA/LAA thrombus resolution rate at 6 weeks of end of treatment confirmed by TEE. The secondary objectives are to describe categories of thrombus outcome in patients (resolved, reduced, unchanged, larger, or new) confirmed on TEE at the end of treatment (after 6 weeks of treatment), incidence of the composite of stroke and noncentral nervous system systemic embolism at the end of treatment and during follow-up, and incidence of all bleeding at the end of treatment and during follow-up. The objective of the CLOT-AF registry is to provide retrospective thrombus-related patient outcome data after standard-of-care anticoagulant treatment in patients with nonvalvular AF or atrial flutter, who have TEE-documented LA/LAA thrombi. The data will be used as a reference for the prospective X-TRA study. In conclusion, X-TRA and CLOT-AF will provide some answers to the many unresolved issues concerning patient outcomes and prognostic factors in patients with AF and LAA thrombi. Results from this study program would provide the first prospective interventional study (X-TRA) and a large international retrospective observational registry (CLOT-AF) on the prevalence and natural history of LA/LAA thrombi. Unique data on clot resolution with rivaroxaban in a prospective cohort would be obtained in X-TRA.
Collapse
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | | | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Center, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Bodo Kirsch
- Global Research and Development Statistics, Bayer HealthCare, Berlin, Germany
| | - Eolo Morandi
- Therapeutic Cardiovascular and Coagulation, Global Development, Bayer HealthCare, São Paulo, Brazil
| | | | - Ariel Cohen
- Cardiology Department, Assistance Publique-Hôpitaux de Paris and Université Pierre-et-Marie-Curie, Saint-Antoine University and Medical School, Paris, France
| |
Collapse
|
221
|
Burkholder TP, Cunningham BE, Clayton JR, Lander PA, Brown ML, Doti RA, Durst GL, Montrose-Rafizadeh C, King C, Osborne HE, Amos RM, Zink RW, Stramm LE, Burris TP, Cardona G, Konkol DL, Reidy C, Christe ME, Genin MJ. Design and synthesis of a novel series of [1-(4-hydroxy-benzyl)-1H-indol-5-yloxy]-acetic acid compounds as potent, selective, thyroid hormone receptor β agonists. Bioorg Med Chem Lett 2015; 25:1377-80. [DOI: 10.1016/j.bmcl.2015.02.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 02/18/2015] [Accepted: 02/24/2015] [Indexed: 11/25/2022]
|
222
|
Zhang Y, Lu P, Zhang L, Xiao X. Association between lipids profile and thyroid parameters in euthyroid diabetic subjects: a cross-sectional study. BMC Endocr Disord 2015; 15:12. [PMID: 25887732 PMCID: PMC4379692 DOI: 10.1186/s12902-015-0008-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 03/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The concept is now emerging that higher thyroid-stimulating hormone (TSH) and lower thyroid hormone levels within the euthyroid range may adversely affect atherosclerosis. The aim of this study was to investigate the potential association between thyroid parameters and lipids profile in a cohort of euthyroid diabetic subjects. METHODS Four hundred and sixty-two euthyroid type 2 diabetes subjects (302 males and 160 females) were consecutively recruited. Clinical and anthropometric data was collected from all participants. Whole blood samples were drawn in the morning after an overnight fasting for the measurement of serum TSH, free thyroxine (FT4), free triiothyronine (FT3), anti-thyroid peroxidase antibody (TPO-Ab) levels, as well as lipid concentrations and glucose. RESULTS TSH was higher in females than males. Stratified by TSH, high-density lipoprotein cholesterol (HDL-c) level increased in subjects with TSH ≥2.5uIU/mL (P = 0.004). And TSH was associated with HDL-c in a Pearson correlation test, however, the association failed to attain significance in partial correlation analyses, adjusted for age, sex, duration of diabetes, fasting glucose and BMI. In females, total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-c) level was significant lower in subjects with TSH <2.5uIU/mL. TSH was significantly associated with TC and LDL-c, even in a partial correlation analysis (P = 0.006 and 0.011, respectively). In a multiple linear regression analysis (stepwise), TSH was positive associated with TC (β = 0.202, P = 0.005) and LDL-c (β = 0.144, P = 0.010). In one hundred and six patients having TPO antibody assays, 6 (5.66%) were positive. The blood pressure and lipid levels were lower in TPO-Ab positive patients, however, the differences were not significantly. CONCLUSIONS In conclusion, we identified TSH was positively associated with serum TC and LDL-c in euthyroid diabetic women. Our analysis in the subgroup having TPO antibody assays demonstrating non-significantly lower TC levels among seropositive subjects was consistent with the above stated consideration for women as a whole. Further investigations are needed to understand the intimate mechanisms of lipid metabolism in type 2 diabetes with respect to thyroid function.
Collapse
Affiliation(s)
- Yun Zhang
- Department of Endocrinology, Henan Province People's Hospital & Zhengzhou University People' Hospital, Zhengzhou City, Henan Province, P R China.
| | - Ping Lu
- Department of Endocrinology, Henan Province People's Hospital & Zhengzhou University People' Hospital, Zhengzhou City, Henan Province, P R China.
| | - Ling Zhang
- Department of Endocrinology, Henan Province People's Hospital & Zhengzhou University People' Hospital, Zhengzhou City, Henan Province, P R China.
| | - Xinhua Xiao
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 100730, Beijing, P R China.
| |
Collapse
|
223
|
Jabbar A, Ingoe L, Pearce S, Zaman A, Razvi S. Thyroxine in acute myocardial infarction (ThyrAMI) - levothyroxine in subclinical hypothyroidism post-acute myocardial infarction: study protocol for a randomised controlled trial. Trials 2015; 16:115. [PMID: 25872532 PMCID: PMC4379597 DOI: 10.1186/s13063-015-0621-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/26/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Cardiac disease is the most common cause of morbidity and mortality in the United Kingdom. Even minor changes in thyroid hormone concentration may impact adversely on the cardiovascular system. Subclinical hypothyroidism (SCH) after admission for an acute cardiac problem has been associated with an increase in cardiac mortality and overall death. We have designed protocols for a prospective observational study to assess the association of thyroid function at the time of acute myocardial infarction (AMI) with cardiovascular outcomes, and a double-blinded randomised placebo-controlled trial of levothyroxine to evaluate its effect on LV function and vascular health. METHODS/DESIGN ThyrAMI 1: This will be a prospective longitudinal observational study of patients with AMI that will be followed for 24 months to study the association between thyroid status at the time of AMI (within 24 hours of diagnosis) with vascular outcomes. ThyrAMI 2: This will be a prospective double-blinded randomised placebo-controlled trial of levothyroxine of 12 months duration in patients with AMI and SCH. SETTING Patients will be recruited from five hospitals in the North East of England. PARTICIPANTS One hundred patients with thyroid function tests within the subclinical hypothyroid range upon admission with an AMI and no previous history of thyroid disease. INTERVENTION Levothyroxine will be administered at a starting dose of 25 mcg once daily, which will be increased at intervals if needed to maintain a TSH level between 0.4 to 2.5 mU/L, versus a placebo. RANDOMISATION Participants will be randomized with a computerised randomisation algorithm, stratified by type of MI (NSTEMI versus STEMI), in a 1:1 ratio to levothyroxine therapy or placebo (as container or bottle numbers), starting within 21 (+/- 7) days of AMI. BLINDING Assignment to either the LT4 or placebo arm will be double-blinded. OUTCOMES The outcome will be the effect of levothyroxine on ventricular function, endothelial function and blood coagulability and rheology. DISCUSSION There is evidence to suggest that treatment of SCH can improve cardiovascular parameters. Therefore, ThyrAMI 1 and ThyrAMI 2 will be the first trials investigating SCH in AMI to give a better insight into whether thyroid hormone levels are a key target for improving cardiovascular outcomes. TRIAL REGISTRATION ISRCTN number: ISRCTN52505169 . Date of registration: 09/01/2015.
Collapse
Affiliation(s)
- Avais Jabbar
- Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK.
| | - Lorna Ingoe
- Department of Endocrinology, Gateshead Health NHS Foundation trust, Sheriff Hill, Gateshead, NE9 6SX, UK.
| | - Simon Pearce
- Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK. .,Endocrine Unit, Newcastle upon Tyne Hospitals NHS foundation trust, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
| | - Azfar Zaman
- Department of Cardiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Road, NE7 7DN, Newcastle upon Tyne, UK. .,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
| | - Salman Razvi
- Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK. .,Department of Endocrinology, Gateshead Health NHS Foundation trust, Sheriff Hill, Gateshead, NE9 6SX, UK. .,Newcastle University, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, NE9 6SX, UK.
| |
Collapse
|
224
|
Andò G, Trio O, Carerj S. New oral anticoagulants versus vitamin K antagonists before cardioversion of atrial fibrillation: a meta-analysis of data from 4 randomized trials. Expert Rev Cardiovasc Ther 2015; 13:577-83. [DOI: 10.1586/14779072.2015.1024107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
225
|
Breitenstein A, Glanzmann M, Falk V, Maisano F, Stämpfli SF, Holy EW, Finlay M, Ling LH, Schilling RJ, Lüscher TF, Steffel J, Camici GG. Increased prothrombotic profile in the left atrial appendage of atrial fibrillation patients. Int J Cardiol 2015; 185:250-5. [PMID: 25814212 DOI: 10.1016/j.ijcard.2015.03.092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with an increased risk for thromboembolic events. While observational data demonstrated that the majority of clots are formed within the left atrial appendage, the mechanisms behind this finding remain unclear also due to the fact that vitro studies so far have been hampered by the inability to isolate and culture cells from the atrial appendages. METHODS Patients suffering from AF undergoing cardiac surgery were recruited for this study and endocardial cells from their left (LAA) and right atrial appendage (RAA) were isolated and cultured according to a novel established protocol. Once in culture, cells were stimulated with TNF-α (10 ng/mL) and the expression of prothrombotic as well as proinflammatory markers was analyzed. RESULTS FACS analysis confirmed a high purity (98%) of isolated LAA endocardial cells. TNF-α significantly increased tissue factor (TF) and PAI-1 expression (n=5; P<0.005), while TFPI remained unchanged. Similarly, expression of VCAM-1 was significantly higher in the LAA as compared to the RAA (n=5; P<0.0001). CONCLUSION According to our newly established cell isolation protocol, this study reveals that in patients with AF, the endocardium of the LAA displays an increased prothrombotic and proinflammatory profile as compared to the RAA. This novel observation may constitute an important mechanism to explain the increased propensity of the LAA for clot formation, as well as the predominance of LAA-related thromboembolic complications in AF patients, and may have important implications for the development of novel treatment strategies.
Collapse
Affiliation(s)
- Alexander Breitenstein
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland; Department of Electrophysiology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Martina Glanzmann
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland; Department of Electrophysiology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Volkmar Falk
- Cardiovascular Surgery, University Heart Center, University Hospital Zurich, Switzerland
| | - Francesco Maisano
- Cardiovascular Surgery, University Heart Center, University Hospital Zurich, Switzerland
| | - Simon F Stämpfli
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland
| | - Erik W Holy
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland
| | - Malcolm Finlay
- Department of Electrophysiology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom; University College London, London, United Kingdom
| | - Liang-Han Ling
- Department of Electrophysiology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Richard J Schilling
- Department of Electrophysiology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Thomas F Lüscher
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland
| | - Jan Steffel
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland
| | - Giovanni G Camici
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland; Center for Integrative Human Physiology (ZHIP), University of Zurich, Switzerland.
| |
Collapse
|
226
|
Rajagopalan B, Curtis AB. Management of atrial fibrillation: What is new in the 2014 ACC/AHA/HRS guideline? Postgrad Med 2015; 127:396-404. [PMID: 25746135 DOI: 10.1080/00325481.2015.1022495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Recently, the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society published an updated guideline on the management of atrial fibrillation (AF). This document is a complete revision of the 2006 guideline. Prominent changes in the 2014 guideline include the use of the CHA2DS2-VASc score for risk stratification of stroke, recommendations on when and how to use newer oral anticoagulants for thromboprophylaxis, downgrading of the use of aspirin for thromboprophylaxis of moderate-risk patients, and the use of catheter ablation in selected patients as first-line therapy for paroxysmal AF. In regard to rate control, the 2014 guideline reverts back to a previous recommendation for stricter targets for mean and maximum heart rate on therapy. The current guideline incorporates many recent trials in updating existing recommendations from the 2006 guideline. The 2014 guideline will be a vital tool in guiding physicians in the management of AF.
Collapse
|
227
|
Dentali F, Botto GL, Gianni M, Ambrosino P, Di Minno MND. Efficacy and safety of direct oral anticoagulants in patients undergoing cardioversion for atrial fibrillation: A systematic review and meta-analysis of the literature. Int J Cardiol 2015; 185:72-7. [PMID: 25791094 DOI: 10.1016/j.ijcard.2015.03.096] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 03/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND DOACs are increasingly used in patients with NVAF. Information on efficacy and safety of these compounds in patients undergoing electrical or pharmacological cardioversion is limited. Thus, we performed a systematic review and a meta-analysis of the literature to address this issue. METHODS Randomized controlled trials comparing the efficacy and safety of DOACs and VKAs in patients with NVAF were systematically searched in Medline, Web of Science, Scopus, Cochrane, and EMBASE databases (up to September 2014). Pooled relative risk (RR) and the corresponding 95% confidence interval (CI) were calculated for each outcome. RESULTS Four randomized controlled trials (3635 patients), for a total of 4517 cardioversions (2869 with DOACs and 1648 with VKAs), were included in the analysis. DOACs and VKAs appeared equally effective in the prevention of stroke/systemic embolism (0.41% vs 0.61%; RR: 0.73, 95% CI: 0.31, 1.72; P=0.48) and of post-cardiovascular death (0.52% vs 0.81%; RR: 0.73, 95% CI: 0.27, 2.03; P=0.55), with a similar risk of major bleeding complications (0.81% vs 0.60%; RR: 1.23, 95% CI: 0.55, 2.71). Heterogeneity among studies was generally absent. Furthermore, the Weighted Mean Incidence (WMI) of complications appeared very low in patients randomized to DOACs (WMI: 0.6% and 0.9% for stroke/systemic embolism and major bleeding, respectively). CONCLUSION Our results suggest that DOACs are at least as effective and safe as VKAs in patients with NVAF undergoing to an electrical or pharmacological cardioversion. Thus, DOACs may be considered a valid and practical alternative to VKAs.
Collapse
Affiliation(s)
- Francesco Dentali
- Department of Clinical Medicine, Insubria University, Varese, Italy.
| | | | - Monica Gianni
- Department of Cardiology, Hospital of Tradate, Tradate, Italy
| | - Pasquale Ambrosino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | |
Collapse
|
228
|
Mitamura H, Nagai T, Watanabe A, Takatsuki S, Okumura K. Left atrial thrombus formation and resolution during dabigatran therapy: A Japanese Heart Rhythm Society report. J Arrhythm 2015; 31:226-31. [PMID: 26336564 DOI: 10.1016/j.joa.2014.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/22/2014] [Accepted: 12/26/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Protocols on the use of novel oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) undergoing electrical cardioversion (ECV) are lacking. AIM The study was aimed at evaluating the efficacy of dabigatran (Dabi) treatment in preventing peri-ECV stroke. METHODS A retrospective survey of the incidence and fate of left atrial (LA) thrombus during Dabi therapy in patients with AF was conducted between December 2012 and January 2013 by the Japanese Heart Rhythm Society. RESULTS A total of 198 patients from 299 institutions underwent transesophageal echocardiography (TEE) to rule out LA thrombus before ECV. Of these, LA thrombus was found in eight patients (4%), who tended to be older (67.3 vs. 61.3 years, p=0.175), had higher CHADS2 scores (1.88 vs. 0.95, p=0.058), and a higher prevalence of prior stroke or transient ischemic attack (22.2% vs. 2.6%, p=0.034) than those without LA thrombus. Of the eight patients with LA thrombus, one had LA thrombus during a Dabi 150 mg b.i.d treatment, whereas the remaining seven were receiving 110 mg b.i.d for 3 weeks or longer. In 6 of the 8 patients with LA thrombus, a second TEE was performed, revealing complete resolution of LA thrombus in five; among these five patients, one received Dabi dosage of 150 mg b.i.d unchanged, two received an increased dosage from 110 mg to 150 mg b.i.d, and two were switched to warfarin. Two patients had a stroke 3 and 15 days after ECV, and one had a major large intestine bleeding episode during Dabi therapy. CONCLUSIONS LA thrombus developed in 4% of patients with AF receiving Dabi. Older patients with a higher CHADS2 score receiving a lower Dabi dosage were more likely to develop LA thrombus, which was resolved with a prolonged or increased dosage. A higher Dabi dosage may be more beneficial before ECV but prospective randomized studies would be needed to confirm these results.
Collapse
Affiliation(s)
- Hideo Mitamura
- Cardiovascular Center, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, 4-2-22 Nishikicho, Tachikawa, Tokyo, Japan
| | - Takayuki Nagai
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | | | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan
| |
Collapse
|
229
|
Stiell IG, Healey JS, Cairns JA. Safety of Urgent Cardioversion for Patients With Recent-Onset Atrial Fibrillation and Flutter. Can J Cardiol 2015; 31:239-41. [DOI: 10.1016/j.cjca.2014.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 11/26/2014] [Accepted: 11/26/2014] [Indexed: 11/28/2022] Open
|
230
|
Maan A, Heist EK, Ruskin JN, Mansour M. Practical issues in the management of novel oral anticoagulants-cardioversion and ablation. J Thorac Dis 2015; 7:115-31. [PMID: 25713727 DOI: 10.3978/j.issn.2072-1439.2014.11.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 10/23/2014] [Indexed: 12/12/2022]
Abstract
Recent research and publication of various landmark trials have led to the approval and subsequent use of novel oral anticoagulants (NOACs) in clinical practice. The use of these newer agents for anticoagulation offers several benefits such as greater specificity, relatively rapid onset and offset of action and a predictable pharmacological profile as compared to warfarin. With the increasing use of these agents, several key issues ranging from appropriate selection to management of complications and considerations for concurrent procedures (cardioversion and catheter ablation) have also emerged. The timing of interruption of anticoagulants prior to catheter ablation and re-initiation after the procedure to minimize the peri-procedural thromboembolism risk without increasing the bleeding risk is of key relevance in electrophysiology practice. The use of NOACs in patients undergoing catheter ablation and cardioversion also requires special considerations based on the pharmacological properties of the individual agent and the presence of comorbidities such as renal and or hepatic impairment. In this review we aim to discuss the practical considerations with the use of NOACs in the setting of cardioversion and catheter ablation based on the currently available data.
Collapse
Affiliation(s)
- Abhishek Maan
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| | - E Kevin Heist
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jeremy N Ruskin
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Moussa Mansour
- Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02114, USA
| |
Collapse
|
231
|
Abstract
Atrial fibrillation is the most common form of cardiac arrhythmia, occurring in 1-2 % of the population and due to an increased life expectancy the prevalence will increase further. Pharmacological treatment of atrial fibrillation is an important component of basic initial therapeutic options for patients with atrial fibrillation. Independent of an individually adjusted prevention of thromboembolism, rate and rhythm management can also be carried out. While rate control mainly applies to all patients, rhythm control is only indicated in patients who remain clinically symptomatic despite sufficient rate control. Profound knowledge about antiarrhythmic drugs including specific interactions is necessary due to the variable individual effects and sometimes severe side effects.
Collapse
|
232
|
Caldeira D, Costa J, Ferreira JJ, Lip GYH, Pinto FJ. Non-vitamin K antagonist oral anticoagulants in the cardioversion of patients with atrial fibrillation: systematic review and meta-analysis. Clin Res Cardiol 2015; 104:582-90. [PMID: 25643952 DOI: 10.1007/s00392-015-0821-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/27/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) are at least non-inferior to Vitamin K Antagonists (VKAs) for stroke prevention on patients with non-valvular atrial fibrillation (AF). We aimed to evaluate the efficacy and safety of NOACs in patients undergoing cardioversion through a systematic review and meta-analysis. METHODS MEDLINE, Cochrane Library, and Web of Science(®) databases (until September 2014) were searched for studies fulfilling inclusion criteria. Two reviewers independently selected randomized controlled trials (RCTs) evaluating NOACs and VKA in patients with AF undergoing cardioversion. The primary outcome was ischemic stroke or systemic embolism (IS/SE). Secondary outcomes were major bleeding, myocardial infarction, and mortality. Risk ratio (RR) and 95 % confidence intervals were derived through random-effects meta-analysis. Heterogeneity was evaluated through I (2) test. RESULTS Four RCTs (3 post-hoc analysis) evaluating apixaban, dabigatran, and rivaroxaban in 3,512 patients with AF were included. The risk of IS/SE with NOACs was similar to VKA (RR 0.60, 95 % CI 0.20-1.80; I (2) = 17 %). There was no significant increase in major bleeding (RR 1.27, 95 % CI 0.58-2.81; I (2) = 0 %), myocardial infarction (RR 0.71, 95 % CI 0.10-5.04; I (2) = 0 %), or mortality (RR 0.87, 95 % CI 0.24-3.08; I (2) = 0 %) with NOACs. CONCLUSIONS This systematic review and meta-analysis suggests that NOACs may be as safe as VKAs in the setting of AF cardioversion.
Collapse
Affiliation(s)
- Daniel Caldeira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal,
| | | | | | | | | |
Collapse
|
233
|
Meier B, Blaauw Y, Khattab AA, Lewalter T, Sievert H, Tondo C, Glikson M. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. EUROINTERVENTION 2015. [DOI: 10.4244/eijy14m09_18] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
234
|
Seo JH, Je JH, Lee HJ, Na YJ, Jeong IW, An JH, Kim SG, Choi DS, Kim NH. Metastatic papillary thyroid cancers with malignant pleural effusion aggravated during thyroid hormone withdrawal for radioiodine therapy. Yeungnam Univ J Med 2015. [DOI: 10.12701/yujm.2015.32.2.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ji Hye Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Hye Je
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyun Jung Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Ju Na
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Il Woo Jeong
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jee Hyun An
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sin Gon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dong Seop Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Nam Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
235
|
|
236
|
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199-267. [PMID: 24682347 PMCID: PMC4676081 DOI: 10.1161/cir.0000000000000041] [Citation(s) in RCA: 919] [Impact Index Per Article: 91.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
237
|
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.03.021] [Citation(s) in RCA: 508] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
238
|
Cohen A, Stellbrink C, Le Heuzey JY, Faber T, Aliot E, Banik N, Kropff S, Omran H. SAfety of Fondaparinux in transoesophageal echocardiography-guided Electric cardioversion of Atrial Fibrillation (SAFE-AF) study: a pilot study. Arch Cardiovasc Dis 2014; 108:122-31. [PMID: 25684570 DOI: 10.1016/j.acvd.2014.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/13/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Current guidelines recommend unfractionated heparin (UFH) or low-molecular-weight heparin plus an oral anticoagulant for the prevention of thromboembolism in patients undergoing electric cardioversion of atrial fibrillation (AF). Selective factor Xa inhibitors, such as fondaparinux, which has a favourable benefit-risk profile in the prevention and treatment of venous thromboembolism and the management of acute coronary syndromes, have not been systematically evaluated in this setting. AIM To evaluate the efficacy and safety of fondaparinux versus standard treatment in patients undergoing echocardiographically-guided cardioversion of AF. METHODS In this multicentre, randomized, open-label, controlled, two-parallel-group, phase II pilot study, patients with AF undergoing electric cardioversion following transoesophageal echocardiography (TEE) were randomized to fondaparinux or standard therapy (UFH plus vitamin K antagonist [VKA]). Patients showing an atrial thrombus in the first TEE (clot-positive) were randomized to treatment with fondaparinux or standard care for 4 weeks before cardioversion. RESULTS The primary endpoint (combined rate of cerebral neurological events, systemic thromboembolism, all-cause death and major bleeding events) occurred in 3 of 174 (1.7%) patients on fondaparinux and 2 of 170 (1.2%) patients on UFH+VKA. The rate of thrombus disappearance among clot-positive patients was higher in the fondaparinux arm (11 of 14; 78.6%) than in the UFH+VKA arm (7 of 14; 50.0%). Incidences of adverse events were similar (45.4% with fondaparinux and 46.5% with UFH+VKA). CONCLUSION In this pilot study in patients with TEE-guided cardioversion, the use of fondaparinux appeared to be well tolerated, with similar efficacy to UFH+VKA. Furthermore, a trend to greater thrombus resolution was observed.
Collapse
Affiliation(s)
- Ariel Cohen
- Saint-Antoine university and medical school, université Pierre et Marie Curie, CHU Saint-Antoine, department of cardiology, 184, rue du Faubourg Saint-Antoine, 75571 Paris cedex 12, France.
| | - Christoph Stellbrink
- Hospital Bielefeld centre, department of cardiology and internal intensive care, Bielefeld, Germany
| | - Jean-Yves Le Heuzey
- René-Descartes university, Georges-Pompidou European hospital, arrhythmia department, Paris, France
| | - Thomas Faber
- Heart centre, Freiburg university, cardiology and angiology I, Freiburg, Germany
| | - Etienne Aliot
- Institute of heart and vessels Louis-Mathieu, department of cardiology, Vandœuvre-les-Nancy, France
| | | | | | - Heyder Omran
- St-Marien hospital Bonn Venusberg, department of internal medicine, Bonn, Germany.
| | | |
Collapse
|
239
|
Abstract
Percutaneous left atrial appendage (LAA) closure is being increasingly used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. Several approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. In this article, the published studies on surgical and percutaneous approaches to LAA closure are reviewed, focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management.
Collapse
Affiliation(s)
- Faisal F Syed
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
240
|
Rose AH, Hoffmann PR. Selenoproteins and cardiovascular stress. Thromb Haemost 2014; 113:494-504. [PMID: 25354851 DOI: 10.1160/th14-07-0603] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/18/2014] [Indexed: 02/07/2023]
Abstract
Dietary selenium (Se) is an essential micronutrient that exerts its biological effects through its incorporation into selenoproteins. This family of proteins contains several antioxidant enzymes such as the glutathione peroxidases, redox-regulating enzymes such as thioredoxin reductases, a methionine sulfoxide reductase, and others. In this review, we summarise the current understanding of the roles these selenoproteins play in protecting the cardiovascular system from different types of stress including ischaemia-reperfusion, homocysteine dysregulation, myocardial hypertrophy, doxirubicin toxicity, Keshan disease, and others.
Collapse
Affiliation(s)
| | - Peter R Hoffmann
- Peter R. Hoffmann, University of Hawaii, John A. Burns School of Medicine, 651 Ilalo Street, Honolulu, HI 96813, USA, Fax: +1 808 692 1968, E-mail:
| |
Collapse
|
241
|
Dzeshka MS, Lip GY. Warfarin versus dabigatran etexilate: an assessment of efficacy and safety in patients with atrial fibrillation. Expert Opin Drug Saf 2014; 14:45-62. [PMID: 25341529 DOI: 10.1517/14740338.2015.973847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Oral anticoagulation is the mainstay for stroke and thromboembolic event prevention in patients with atrial fibrillation (AF). Given limitations of warfarin therapy, non-vitamin K oral anticoagulants have been developed including direct thrombin inhibitors (i.e., dabigatran etexilate). Dabigatran etexilate has been tested thoroughly in terms of efficacy and safety in clinical trials and studies, involving 'real-world' cohorts. In this review, currently available evidence in patients with non-valvular AF is discussed. AREAS COVERED The pharmacology, efficacy and safety, and current aspects of use of dabigatran etexilate in patients with non-valvular AF are reviewed in a comparative manner to warfarin both for chronic anticoagulation and in different clinical settings. EXPERT OPINION Dabigatran etexilate appeared to have several pharmacokinetic and pharmacodynamic advantages over warfarin, as well as a favorable efficacy and safety profile being at least noninferior and often superior to warfarin in patients with non-valvular AF. The latter was shown in the clinical trials, meta-analyses and studies with 'real-world' data. Currently ongoing trials will expand the body of evidence on warfarin and will aid decision making in currently controversial areas. Important limitations of dabigatran etexilate include contraindications for its use in patients with prosthetic heart valves and end-stage chronic kidney disease.
Collapse
Affiliation(s)
- Mikhail S Dzeshka
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital , Birmingham B18 7QH , UK
| | | |
Collapse
|
242
|
Rose-Jones LJ, Bode WD, Gehi AK. Current Approaches to Antiarrhythmic Therapy in Heart Failure. Heart Fail Clin 2014; 10:635-52. [DOI: 10.1016/j.hfc.2014.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
243
|
Frequency and significance of right atrial appendage thrombi in patients with persistent atrial fibrillation or atrial flutter. J Am Soc Echocardiogr 2014; 27:1200-7. [PMID: 25240491 DOI: 10.1016/j.echo.2014.08.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and atrial flutter (AFL) are strong atrial thrombosis (THR) risk factors. In recent-onset tachyarrhythmias, the incidence of left atrial appendage (LAA) THR, detected by transesophageal echocardiography (TEE), has been widely studied, ranging from 6% to 18% (AF) and 4% to 11% (AFL). On the contrary, few studies have assessed right atrial appendage (RAA) THR, and there is no information on the relation between the RAA flow characteristics and the presence of RAA THR. The aims of this study were to evaluate the incidence of RAA THR in a population of patients undergoing TEE-guided cardioversion for recent-onset atrial tachyarrhythmias and to analyze RAA Doppler flow and its relation to thrombus formation. METHODS From 1998 to 2012, patients admitted to the emergency department for persistent, non-self-terminating atrial tachyarrhythmia lasting >2 days who gave informed consent for TEE-guided cardioversion were prospectively enrolled in the study. Among 1,042 patients, complete anatomic and functional studies of the LAA and RAA were feasible in 983 (AF, n = 810 [23%]; AFL, n = 173 [5%]). The presence of RAA and LAA THR, appendage emptying velocities, and the presence of severe spontaneous echocardiographic contrast were studied. RESULTS The overall incidence of atrial THR was 9.7% (96 of 983). The incidence of THR was 9.3% (91 of 983) in the LAA and 0.73% (seven of 983) in the RAA (P < .01). In the AF and AFL groups, the incidence of LAA THR was 10.3% (83 of 805), compared with 0.75% (six of 805) for RAA THR (P < .01). Among patients with AFL, the incidence of LAA THR was 6% (10 of 178), compared with 0.6% (one of 178) for RAA THR (P < .01). The mean LAA peak emptying velocity was 24 cm/sec (range, 10-32 cm/sec) in patients with LAA THR, compared with 38 cm/sec (range, 20-59 cm/sec) in those without THR; the mean RAA peak emptying velocity was 17 ± 7 cm/sec in patients with RAA THR, compared with 34 ± 13 cm/sec in those without THR (P < .001). CONCLUSIONS RAA thrombi are significantly less frequent than LAA thrombi but may reach large dimensions. Multiplane TEE allows RAA morphologic and functional assessment. Before TEE-guided cardioversion, both the LAA and the RAA must be routinely studied.
Collapse
|
244
|
Hansen ML, Jepsen RMH, Olesen JB, Ruwald MH, Karasoy D, Gislason GH, Hansen J, Køber L, Husted S, Torp-Pedersen C. Thromboembolic risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy. ACTA ACUST UNITED AC 2014; 17:18-23. [DOI: 10.1093/europace/euu189] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
245
|
Cappato R, Ezekowitz MD, Klein AL, Camm AJ, Ma CS, Le Heuzey JY, Talajic M, Scanavacca M, Vardas PE, Kirchhof P, Hemmrich M, Lanius V, Meng IL, Wildgoose P, van Eickels M, Hohnloser SH. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J 2014; 35:3346-55. [DOI: 10.1093/eurheartj/ehu367] [Citation(s) in RCA: 292] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
246
|
Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi S, Smith SC, Darbar D, Wee JO, Waddell TK, Amar D, Adler D. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014; 148:e153-93. [PMID: 25129609 PMCID: PMC4454633 DOI: 10.1016/j.jtcvs.2014.06.036] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Gyorgy Frendl
- Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass.
| | - Alissa C Sodickson
- Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Department of Molecular Cardiology, Lerner Research Institute Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University Cleveland Clinic, Cleveland, Ohio
| | - Albert L Waldo
- Division of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Bernard J Gersh
- Division of Cardiovascular Diseases and Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - James E Tisdale
- Department of Pharmacy Practice, College of Pharmacy, Purdue University and Indiana University School of Medicine, Indianapolis, Ind
| | - Hugh Calkins
- Department of Medicine, Cardiac Arrhythmia Service, Johns Hopkins University, Baltimore, Md
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Stephen Cassivi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Sidney C Smith
- Center for Heart and Vascular Care, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Dawood Darbar
- Division of Cardiovascular Medicine, Department of Medicine, Arrhythmia Service, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Jon O Wee
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Thomas K Waddell
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Amar
- Memorial Sloan-Kettering Cancer Center, Department of Anesthesiology and Critical Care Medicine, New York, NY
| | - Dale Adler
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| |
Collapse
|
247
|
2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. Executive summary. J Thorac Cardiovasc Surg 2014; 148:772-91. [DOI: 10.1016/j.jtcvs.2014.06.037] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 11/23/2022]
|
248
|
|
249
|
Meier B, Blaauw Y, Khattab AA, Lewalter T, Sievert H, Tondo C, Glikson M, Lip GYH, Lopez-Minguez J, Roffi M, Israel C, Dudek D, Savelieva I. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. ACTA ACUST UNITED AC 2014; 16:1397-416. [DOI: 10.1093/europace/euu174] [Citation(s) in RCA: 194] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Bernhard Meier
- Cardiology, Bern University Hospital, 3010 Bern, Switzerland
| | - Yuri Blaauw
- Department of Cardiology, Maastricht University Medical Center, 6281 Maastricht, The Netherlands
| | | | | | - Horst Sievert
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
| | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
| | - Michael Glikson
- Davidai Arrhythmia Center, Sheba Medical Center, 52621 Tel Hashomer, Israel
| | | | | | | | | | | | | | | |
Collapse
|
250
|
Mehrzad R, Rajab M, Spodick DH. The three integrated phases of left atrial macrophysiology and their interactions. Int J Mol Sci 2014; 15:15146-60. [PMID: 25167138 PMCID: PMC4200839 DOI: 10.3390/ijms150915146] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/17/2014] [Accepted: 08/21/2014] [Indexed: 11/24/2022] Open
Abstract
Our understanding of the left atrium is growing, although there are many aspects that are still poorly understood. The left atrium size as an imaging biomarker has been consistently shown to be a powerful predictor of outcomes and of different cardiovascular disorders, such as, but not limited to, atrial fibrillation, congestive heart failure, mitral regurgitation and stroke. Left atrial function has been conventionally divided into three integrated phases: reservoir, conduit and booster-pump. The highly dynamic left atrium and its response to the stretch and secretion of atrial neuropeptides leaves the left atrium far from being a simple transport chamber. The aim of this review is to provide an understanding of the left atrial physiology and its relation to disorders within the heart.
Collapse
Affiliation(s)
- Raman Mehrzad
- Department of Medicine, Steward Carney Hospital, Tufts University School of Medicine, 2100 Dorchester Avenue, Boston, MA 02124, USA.
| | - Mohammad Rajab
- Department of Medicine, Division of Cardiology, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA.
| | - David H Spodick
- Department of Medicine, Division of Cardiology, St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA 02124, USA.
| |
Collapse
|