The Challenge of Antiplatelet Therapy in Patients with Atrial Fibrillation and Heart Failure

Meta-Analysis of Catheter Ablation versus Medical Therapy for Heart Failure Complicated with Atrial Fibrillation

Objective

To compare the efficacy of catheter ablation and medical therapy in patients with heart failure and atrial fibrillation.

Methods

We searched randomized controlled trials comparing catheter ablation versus medical therapy for heart failure and atrial fibrillation through PubMed, MEDLINE, Embase, Cochrane Clinical Trials Database, Web of Science, and China National Knowledge Infrastructure. Articles were investigated for their methodological quality using the Cochrane Collaboration risk of the bias assessment tool. Forest plots, funnel plots, and sensitivity analysis were also performed on the included articles. Results were expressed as risk ratio (RR) and mean difference (MD) with 95% confidence intervals.

Results

Nine (9) studies were included in this study with 1131 patients. Meta-analysis showed a reduction in all-cause mortality from catheter ablation compared with medical therapy (RR = 0.53, 95% CI = 0.37 to 0.76; P=0.0007) and improved left ventricular ejection fraction (LVEF) (MD = 6.45, 95% CI = 3.49 to 9.41; P < 0.0001), 6-minute walking time (6MWT) (MD = 28.32, 95% CI = 17.77 to 38.87; P < 0.0001), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (MD = 8.19, 95% CI = 0.30 to 16.08; P=0.04).

Conclusion

Catheter ablation had a better improvement than medical treatment in left ventricular ejection fraction, cardiac function, and exercise ability for atrial fibrillation and heart failure patients.

Advances in induced pluripotent stem cells, genomics, biomarkers, and antiplatelet therapy highlights of the year in JCTR 2013

The Journal provides the clinician and scientist with the latest advances in discovery research, emerging technologies, preclinical research design and testing, and clinical trials. We highlight advances in areas of induced pluripotent stem cells, genomics, biomarkers, multimodality imaging, and antiplatelet biology and therapy. The top publications are critically discussed and presented along with anatomical reviews and FDA insight to provide context.

Prevalence, incidence, and lifetime risk of atrial fibrillation in China: new insights into the global burden of atrial fibrillation

BACKGROUND

Much of the epidemiology of atrial fibrillation (AF) is based on data from Western populations. Despite the huge population of Asia, data on the clinical epidemiology of AF in Asian countries are limited. The current study aimed to investigate the prevalence and incidence of newly diagnosed (ie, incident) AF, as well as lifetime risk, in China and to determine the clinical risk factors contributing to its development.

METHODS

Using a medical insurance database involving > 10 million individuals for the years 2001 to 2012 in the southwest of China, trends in incident AF were calculated using Kaplan-Meier analysis and Cox regression. The usefulness of the CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled], vascular disease, age 65-74, and sex category [female]) scores was tested in predicting the occurrence of incident AF.

RESULTS

A total of 471,446 individuals (aged ≥ 20 years) were studied, with 1,924,975 person-years of experience. We identified 921 patients with incident AF (62% male; mean age, 62 years). The prevalence of incident AF in subjects aged ≥ 20 years was 0.2 per 100 people, with an incidence of AF of 0.05 per 100 person-years overall. Over an 11-year period, the prevalence of AF increased 20-fold, whereas AF-related stroke increased 13-fold. The lifetime risk of AF was approximately one in five among Chinese adults, and it increased with advancing age. The CHA2DS2-VASc score was superior to the CHADS2 score in predicting the risk of incident AF in our Chinese population (DeLong test, Z = 6.621, P < .001).

CONCLUSIONS

The AF burden, as well as the risk of AF-related stroke, has increased significantly over the past 11 years in the southwest of China. The public health burden of AF and its complications are greatest in the very elderly, with major implications for health-care systems given the global burden of this common arrhythmia.

Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation

BACKGROUND

Scores for cardio-embolic and bleeding risk in patients with atrial fibrillation are described in the literature. However, it is not clear how they co-classify elderly patients with multimorbidity, nor whether and how they affect the physician's decision on thromboprophylaxis.

METHODS

Four scores for cardio-embolic and bleeding risks were retrospectively calculated for ≥ 65 year old patients with atrial fibrillation enrolled in the REPOSI registry. The co-classification of patients according to risk categories based on different score combinations was described and the relationship between risk categories tested. The association between the antithrombotic therapy received and the scores was investigated by logistic regressions and CART analyses.

RESULTS

At admission, among 543 patients the median scores (range) were: CHADS2 2 (0-6), CHA2DS2-VASc 4 (1-9), HEMORR2HAGES 3 (0-7), HAS-BLED 2 (1-6). Most of the patients were at high cardio-embolic/high-intermediate bleeding risk (70.5% combining CHADS2 and HEMORR2HAGES, 98.3% combining CHA2DS2-VASc and HAS-BLED). 50-60% of patients were classified in a cardio-embolic risk category higher than the bleeding risk category. In univariate and multivariable analyses, a higher bleeding score was negatively associated with warfarin prescription, and positively associated with aspirin prescription. The cardio-embolic scores were associated with the therapeutic choice only after adjusting for bleeding score or age.

CONCLUSION

REPOSI patients represented a population at high cardio-embolic and bleeding risks, but most of them were classified by the scores as having a higher cardio-embolic than bleeding risk. Yet, prescription and type of antithrombotic therapy appeared to be primarily dictated by the bleeding risk.