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Ardashev A, Passman R, Zotova I, Efimov I, Rytkin E, Trachiotis G, Knight BP. Comprehensive Analysis of Anticoagulant Therapy in Patients with Isolated Atrial Flutter. Am J Cardiol 2024; 230:72-81. [PMID: 39089525 DOI: 10.1016/j.amjcard.2024.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/10/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024]
Abstract
Limited comparative data exist regarding the risk of cardiogenic emboli in patients with isolated atrial flutter (AFL). Some studies suggest a lower complication risk in AFL compared to atrial fibrillation (AFib), but methodological limitations and conflicting reports necessitate a comprehensive investigation. Our analysis proposes that isolated AFL carries a lower risk of ischemic events and left atrial thrombus formation than AFib. Importantly, we caution against applying stroke risk assessment approaches designed for AFib to AFL patients, as it may lead to harmful overestimations and unnecessary anticoagulant prescriptions. Furthermore, we highlight the current lack of sufficient data to determine the overall clinical benefit of prolonged anticoagulant therapy in patients with isolated AFL, especially when CHA2DS2-VASc index values are below 4. This review challenges existing perceptions, offering insights into the nuanced risk profiles of the transitional nature of isolated AFL due to the high incidence of AFib development within a year of AFL diagnosis. In conclusion, tailored risk assessments and further research are essential for precise clinical decision-making in this dynamic landscape.
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Affiliation(s)
- Andrey Ardashev
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago IL, USA.
| | - Rod Passman
- Division of Cardiology, Northwestern University, Chicago IL, USA
| | - Irina Zotova
- Healthcare Department, State Budget Healthcare Institution "City Hospital #17" of Moscow, Moscow, Russia
| | - Igor Efimov
- Department of Biomedical Engineering, Northwestern University, Chicago IL, USA
| | - Eric Rytkin
- Department of Biomedical Engineering, Northwestern University, Chicago IL, USA
| | - Gregory Trachiotis
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC, USA; Department of Surgery, The George Washington University Hospital, Washington, DC, USA; Department of Biomedical Engineering, The George Washington University, Washington, DC, USA
| | - Bradley P Knight
- Division of Cardiology, Northwestern University, Chicago IL, USA
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Mansouri A, Nassiri F, Scales D, Pirouzmand F. Anticoagulation Therapy Timing in patients with Atrial Fibrillation after Acute and Chronic Subdural Haematoma (ATTAACH): a pilot randomised controlled trial. BMJ Open 2024; 14:e090224. [PMID: 39438108 PMCID: PMC11499767 DOI: 10.1136/bmjopen-2024-090224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 09/09/2024] [Indexed: 10/25/2024] Open
Abstract
INTRODUCTION Subdural haematomas (SDHs), acute or chronic, are common neurosurgical diagnoses. These problems can occur among patients requiring direct oral anticoagulation (DOAC) for atrial fibrillation. There are currently no guidelines regarding the optimal timing to resume anticoagulation for these patients after SDH. The objective of this study is to evaluate the feasibility of conducting a future large randomised controlled trial (RCT) evaluating the safety and efficacy of resuming DOACs early (ie, at 30 days) vs late (ie, at 3 months) for patients with atrial fibrillation following diagnosis of SDH. METHODS AND ANALYSIS This is a pilot, open-label, multicentre RCT that will enrol adults with newly diagnosed acute or chronic SDH with or without other intracranial bleeding who were receiving therapeutic anticoagulation with a DOAC as stroke prophylaxis for atrial fibrillation. Patients will be randomly allocated to resume a DOAC at standard dosing starting either days 30+7 or days 90±14. The primary outcomes for the pilot RCT are recruitment rate, protocol adherence and patient compliance with the randomly allocated interventions. Secondary outcomes are patient functional outcomes and safety and effectiveness outcomes, which will comprise key endpoints for the future planned RCT. This pilot RCT will provide important data to inform the feasibility of conducting a future, large RCT of early versus late resumption of DOACs for atrial fibrillation stroke prophylaxis in patients newly diagnosed with SDH. The future RCT will help inform management of a commonly encountered clinical dilemma with high associated morbidity and mortality. ETHICS AND DISSEMINATION This study has been approved by the research ethics board of record. It will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. Informed consent will be obtained from eligible patients or substitute decision-makers. Data from this study will inform the design of future, larger RCTs. TRIAL REGISTRATION NUMBER NCT05472766.
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Affiliation(s)
- Alireza Mansouri
- Neurosurgery, Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Farshad Nassiri
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Damon Scales
- Department of Medicine,Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Farhad Pirouzmand
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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Stiell IG, Taljaard M, Beanlands R, Johnson C, Golian M, Green M, Kwok E, Brown E, Nemnom MJ, Eagles D. RAFF-5 Study to Improve the Quality and Safety of Care for Patients Seen in the Emergency Department With Acute Atrial Fibrillation and Flutter. Can J Cardiol 2024; 40:1554-1562. [PMID: 38331027 DOI: 10.1016/j.cjca.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND We sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist. METHODS This cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED. RESULTS We included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent. CONCLUSIONS We successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients. CLINICALTRIALS GOV IDENTIFIER NCT05468281.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Rob Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher Johnson
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mehrdad Golian
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin Green
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Edmund Kwok
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Erica Brown
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Xu Y, Carrier M, Kimpton M. Arterial Thrombosis in Patients with Cancer. Cancers (Basel) 2024; 16:2238. [PMID: 38927943 PMCID: PMC11201749 DOI: 10.3390/cancers16122238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Patients with cancer are at increased risk of arterial thromboembolic disease due to the presence of risk factors common to both the development of cancer and arterial thrombosis, the cancer itself, and the treatments provided to treat cancer. We review here the epidemiology and pathophysiology of arterial thromboembolic disease in cancer, along with its prevention and treatment strategies. We also propose a generalized approach for the management of arterial thromboembolic disease in this patient population.
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Affiliation(s)
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute at University of Ottawa, Ottawa, ON K1H 8L6, Canada; (Y.X.); (M.K.)
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Kukendrarajah K, Ahmad M, Carrington M, Ioannou A, Taylor J, Razvi Y, Papageorgiou N, Mead GE, Nevis IF, D'Ascenzo F, Wilton SB, Lambiase PD, Morillo CA, Kwong JS, Providencia R. External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis. Cochrane Database Syst Rev 2024; 6:CD013255. [PMID: 38828867 PMCID: PMC11145740 DOI: 10.1002/14651858.cd013255.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion). OBJECTIVES To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption. MAIN RESULTS We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled. AUTHORS' CONCLUSIONS Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.
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Affiliation(s)
| | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | | | - Adam Ioannou
- Royal Free London NHS Foundation Trust, London, UK
| | - Julie Taylor
- Institute of Health Informatics Research, University College London, London, UK
| | - Yousuf Razvi
- Department of Cardiology, Royal Free Hospital, London, UK
| | | | - Gillian E Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Immaculate F Nevis
- Health Economics and Outcomes Research, ICON plc, Blue Bell, Philadelphia, USA
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Pier D Lambiase
- Centre for Cardiology in the Young, The Heart Hospital, University College London Hospitals, London, UK
| | - Carlos A Morillo
- Department of Cardiac Sciences, Cumming School of Medicine, Foothills Medical Centre, Calgary, Canada
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Okaj I, Vadakken ME, Belley-Côté EP, Lengyel AP, Rai AS, Suri RS, Healey JS, McIntyre WF. Peri-mortem arrhythmias in the non-cardiac intensive care unit. Nurs Crit Care 2024. [PMID: 38828923 DOI: 10.1111/nicc.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/27/2024] [Accepted: 05/16/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Cardiovascular failure is recognized as a common final pathway at the end of life but there is a paucity of data describing terminal arrhythmias. AIM We aimed to describe arrhythmias recorded peri-mortem in critically ill patients. STUDY DESIGN We enrolled intensive care unit patients admitted to two tertiary Canadian medico-surgical centres. Participants wore a continuous electrocardiogram (ECG) monitor for 14 days, until discharge, removal or death. We recorded all significant occurrences of arrhythmias in the final hour of life. RESULTS Among 39 patients wearing an ECG monitor at the time of death, 22 (56%) developed at least 1 terminal arrhythmia as adjudicated by an arrhythmia physician: 23% (n = 9) had ventricular fibrillation/polymorphic ventricular tachycardia, 18% (n = 7) had sinoatrial pauses, 15% (n = 6) had atrial fibrillation and 13% (n = 5) had high-degree atrioventricular block. Five participants (13%) developed multiple arrythmias. CONCLUSIONS Arrhythmias are common in dying critically ill patients. There is a roughly even distribution between ventricular arrhythmias, atrial fibrillation, sinus node dysfunction and atrioventricular block. RELEVANCE TO CLINICAL PRACTICE The results of this study may be most useful for critically ill patients who are organ donation candidates. The appearance of arrhythmias may serve as a marker of change in clinical status for organ donation teams to plan mobilization efforts. In participants who are sedated or intubated, arrhythmias could be a surrogate marker for respiratory or neurologic changes.
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Affiliation(s)
- Iva Okaj
- McMaster University, Hamilton, Ontario, Canada
| | | | - Emilie P Belley-Côté
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Anand S Rai
- Nova University, Fort Lauderdale, Florida, USA
| | - Rubani S Suri
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - William F McIntyre
- McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
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Holbrook A, Troyan S, Telford V, Koubaesh Y, Vidug K, Yoo L, Deng J, Lohit S, Giilck S, Ahmed A, Talman M, Leonard B, Refaei M, Tarride JE, Schulman S, Douketis J, Thabane L, Hyland S, Ho JMW, Siegal D. Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial. BMJ Open 2024; 14:e079353. [PMID: 38692712 PMCID: PMC11086462 DOI: 10.1136/bmjopen-2023-079353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 04/05/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVES To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home. DESIGN Randomised, parallel design. SETTING Medical wards at six hospital sites in southern Ontario, Canada. PARTICIPANTS Adults 18 years of age or older being discharged to home on an oral anticoagulant (OAC) to be taken for at least 4 weeks. INTERVENTIONS Clinical pharmacologist-led intervention, including a detailed discharge medication management plan, a circle of care handover and early postdischarge virtual check-up visits to 1 month with 3-month follow-up. The control group received the usual care. OUTCOMES MEASURES Primary outcomes were study feasibility outcomes (recruitment, retention and cost per patient). Secondary outcomes included adverse anticoagulant safety events composite, quality of transitional care, quality of life, anticoagulant knowledge, satisfaction with care, problems with medications and health resource utilisation. RESULTS Extensive periods of restriction of recruitment plus difficulties accessing patients at the time of discharge negatively impacted feasibility, especially cost per patient recruited. Of 845 patients screened, 167 were eligible and 56 were randomised. The mean age (±SD) was 71.2±12.5 years, 42.9% females, with two lost to follow-up. Intervention patients were more likely to rate their ability to manage their OAC as improved (17/27 (63.0%) vs 7/22 (31.8%), OR 3.6 (95% CI 1.1 to 12.0)) and their continuity of care as improved (21/27 (77.8%) vs 2/22 (9.1%), OR 35.0 (95% CI 6.3 to 194.2)). Fewer intervention patients were taking one or more inappropriate medications (7 (22.5%) vs 15 (60%), OR 0.19 (95% CI 0.06 to 0.62)). CONCLUSION This pilot randomised controlled trial suggests that a transitional care intervention at hospital discharge for older adults taking OACs was well received and potentially effective for some surrogate outcomes, but overly costly to proceed to a definitive large trial. TRIAL REGISTRATION NUMBER NCT02777047.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Sue Troyan
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Victoria Telford
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Yousery Koubaesh
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | - Kristina Vidug
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Lindsay Yoo
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Simran Lohit
- Clinical Pharmacology Research, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Stephen Giilck
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Grand River Hospital, Kitchener, Ontario, Canada
| | - Amna Ahmed
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Marianne Talman
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Blair Leonard
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Niagara Health System, St. Catharines, Ontario, Canada
| | - Mohammad Refaei
- Department of Medicine, Niagara Health System, St. Catharines, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Center for Health Economic and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Biotatistics Unit, Research Institute of St. Joes Hamilton, Hamilton, Ontario, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, Ontario, Canada
| | - Joanne Man-Wai Ho
- Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deborah Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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8
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Liu S, Stiell I, Eagles D, Borgundvaag B, Grewal K. Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department. CAN J EMERG MED 2024; 26:103-110. [PMID: 38001329 DOI: 10.1007/s43678-023-00621-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events. METHODS This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events. RESULTS There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88). CONCLUSION Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.
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Affiliation(s)
- Sharon Liu
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada.
- Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Healey JS, Lopes RD, Granger CB, Alings M, Rivard L, McIntyre WF, Atar D, Birnie DH, Boriani G, Camm AJ, Conen D, Erath JW, Gold MR, Hohnloser SH, Ip J, Kautzner J, Kutyifa V, Linde C, Mabo P, Mairesse G, Benezet Mazuecos J, Cosedis Nielsen J, Philippon F, Proietti M, Sticherling C, Wong JA, Wright DJ, Zarraga IG, Coutts SB, Kaplan A, Pombo M, Ayala-Paredes F, Xu L, Simek K, Nevills S, Mian R, Connolly SJ. Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation. N Engl J Med 2024; 390:107-117. [PMID: 37952132 DOI: 10.1056/nejmoa2310234] [Citation(s) in RCA: 113] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Subclinical atrial fibrillation is short-lasting and asymptomatic and can usually be detected only by long-term continuous monitoring with pacemakers or defibrillators. Subclinical atrial fibrillation is associated with an increased risk of stroke by a factor of 2.5; however, treatment with oral anticoagulation is of uncertain benefit. METHODS We conducted a trial involving patients with subclinical atrial fibrillation lasting 6 minutes to 24 hours. Patients were randomly assigned in a double-blind, double-dummy design to receive apixaban at a dose of 5 mg twice daily (2.5 mg twice daily when indicated) or aspirin at a dose of 81 mg daily. The trial medication was discontinued and anticoagulation started if subclinical atrial fibrillation lasting more than 24 hours or clinical atrial fibrillation developed. The primary efficacy outcome, stroke or systemic embolism, was assessed in the intention-to-treat population (all the patients who had undergone randomization); the primary safety outcome, major bleeding, was assessed in the on-treatment population (all the patients who had undergone randomization and received at least one dose of the assigned trial drug, with follow-up censored 5 days after permanent discontinuation of trial medication for any reason). RESULTS We included 4012 patients with a mean (±SD) age of 76.8±7.6 years and a mean CHA2DS2-VASc score of 3.9±1.1 (scores range from 0 to 9, with higher scores indicating a higher risk of stroke); 36.1% of the patients were women. After a mean follow-up of 3.5±1.8 years, stroke or systemic embolism occurred in 55 patients in the apixaban group (0.78% per patient-year) and in 86 patients in the aspirin group (1.24% per patient-year) (hazard ratio, 0.63; 95% confidence interval [CI], 0.45 to 0.88; P = 0.007). In the on-treatment population, the rate of major bleeding was 1.71% per patient-year in the apixaban group and 0.94% per patient-year in the aspirin group (hazard ratio, 1.80; 95% CI, 1.26 to 2.57; P = 0.001). Fatal bleeding occurred in 5 patients in the apixaban group and 8 patients in the aspirin group. CONCLUSIONS Among patients with subclinical atrial fibrillation, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; ARTESIA ClinicalTrials.gov number, NCT01938248.).
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Affiliation(s)
- Jeff S Healey
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Renato D Lopes
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Christopher B Granger
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Marco Alings
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Lena Rivard
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - William F McIntyre
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Dan Atar
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - David H Birnie
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Giuseppe Boriani
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - A John Camm
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - David Conen
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Julia W Erath
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Michael R Gold
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Stefan H Hohnloser
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - John Ip
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Josef Kautzner
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Valentina Kutyifa
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Cecilia Linde
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Philippe Mabo
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Georges Mairesse
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Juan Benezet Mazuecos
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Jens Cosedis Nielsen
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Francois Philippon
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Marco Proietti
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Christian Sticherling
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Jorge A Wong
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - David J Wright
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Ignatius G Zarraga
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Shelagh B Coutts
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Andrew Kaplan
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Marta Pombo
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Felix Ayala-Paredes
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Lizhen Xu
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Kim Simek
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Sandra Nevills
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Rajibul Mian
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Stuart J Connolly
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
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10
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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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11
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Perreault S, Boivin Proulx LA, Lenglet A, Massy ZA, Dorais M. Effectiveness and safety of apixaban and rivaroxaban vs warfarin in patients with atrial fibrillation and chronic kidney disease. World J Nephrol 2023; 12:132-146. [PMID: 38230301 PMCID: PMC10789087 DOI: 10.5527/wjn.v12.i5.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/26/2023] [Accepted: 09/26/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs) included a low proportion of atrial fibrillation (AF) patients with chronic kidney disease (CKD), and suggested that DOACs are safe and effective in patients with mild-to-moderate CKD. In a metanalysis of RCTs and observational studies, DOACs were associated with better efficacy (vs warfarin) in early CKD and had similar efficacy and safety profiles in patients with stages IV-V CKD. But few studies have provided data on the safety and effectiveness of each DOAC vs warfarin in patients with stage III CKD. The effectiveness and safety of DOACs in those patients are still subject to debate. AIM To assess and compare the effectiveness and safety of apixaban and rivaroxaban vs warfarin in this patient population. METHODS A cohort of patients with an inpatient or outpatient code for AF and stage III CKD who were newly prescribed apixaban and rivaroxaban was created using the administrative databases from the Quebec province of Canada between 2013 and 2017. The primary effectiveness outcome was a composite of ischemic stroke, systemic embolism, and death, whereas the primary safety outcome was a composite of major bleeding within a year of DOAC vs warfarin initiation. Treatment groups were compared in an under-treatment analysis using inverse probability of treatment weighting and Cox proportional hazards. RESULTS A total of 8899 included patients filled out a new oral anticoagulation therapy claim; 3335 for warfarin and 5564 for DOACs. Compared with warfarin, 15 mg and 20 mg rivaroxaban presented a similar effectiveness and safety composite risk. Apixaban 5.0 mg was associated with a lower effectiveness composite risk [Hazard ratio (HR) 0.76; 95% confidence interval (CI): 0.65-0.88] and a similar safety risk (HR 0.94; 95%CI: 0.66-1.35). Apixaban 2.5 mg was associated with a similar effectiveness composite (HR 1.00; 95%CI: 0.79-1.26) and a lower safety risk (HR 0.65; 95%CI: 0.43-0.99. Although, apixaban 5.0 mg was associated with a better effectiveness (HR 0.76; 95%CI: 0.65-0.88), but a similar safety risk profile (HR 0.94; 95%CI: 0.66-1.35). The observed improvement in the effectiveness composite for apixaban 5.0 mg was driven by a reduction in mortality (HR 0.61; 95%CI: 0.43-0.88). CONCLUSION In comparison with warfarin, rivaroxaban and apixaban appear to be effective and safe in AF patients with stage III CKD.
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Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, University of Montreal, Quebec, Montreal H3C3J7, Canada
| | - Laurie-Anne Boivin Proulx
- Department of Cardiology, Faculty of Medicine, University of Ottawa Heart Institute, Ontario, Ottawa K1Y4W7, Canada
| | - Aurélie Lenglet
- Department of Pharmacy, Amiens-Picardie Hospital University Center, Amiens 80000, France
- Faculty of Pharmacy, MP3CV Laboratory, UR7545, University of Picardie Jules Verne, Amiens 80000, France
| | - Ziad A Massy
- Division of Nephrology, University of Paris Ouest -Versailles-Saint-Quentin-en-Yvelines (UVSQ), Villejuif, France., AP-HP Ambroise-Paré Hospital, Boulogne Billancourt/Paris 92104, France
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l’Île-Perrot, Quebec, Montreal J7W 3K8, Canada
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12
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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13
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Nakajima E, ShweikiAlrefaee B, Austin PC, Ko DT, Abdel-Qadir H. Validation of the Use of Discharge Diagnostic Codes for the Verification of Secondary Atrial Fibrillation in Administrative Databases. CJC Open 2023; 5:597-602. [PMID: 37720182 PMCID: PMC10502436 DOI: 10.1016/j.cjco.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/14/2023] [Indexed: 09/19/2023] Open
Abstract
Background "Secondary" atrial fibrillation (AF) denotes AF that is precipitated by short-term triggers and that may be reversible. Using administrative data to study secondary AF is of interest, but the ability of these data to verify secondary AF has not been studied. Methods We conducted a cross-sectional analysis of 1000 randomly selected hospitalizations of patients discharged alive between January 1, 2016 and March 31, 2020, with AF coded as the most responsible diagnosis (type 1), post-admit comorbidity (type 2), or secondary diagnosis (type 3). We compared diagnosis types to AF category (secondary or not) as determined by a physician blinded to the discharge diagnosis type. We calculated the positive predictive value (PPV) of the designation of secondary AF in comparison to physician determination. Results A total of 421 hospitalizations had AF documented as a type 2 diagnosis; this had a PPV of 94.8% for physician determination of secondary AF. After excluding hospitalizations with preexisting AF, and those for which AF type could not be determined by the physician, the PPV of a type 2 diagnosis (n = 391) for secondary AF was 99.7%. Type 3 diagnoses of AF (n = 222) mostly captured hospitalizations with preexisting AF (87.8% of type 3 diagnoses). Conclusions A type 2 diagnosis can be used to verify secondary AF in people who were first diagnosed with AF while hospitalized for other causes. This verification facilitates cohort studies and clinical trial recruitment of people with this AF subtype, although it should not be used to determine the prevalence or incidence of secondary AF.
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Affiliation(s)
- Erika Nakajima
- Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter C. Austin
- Department of Medicine, ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
| | - Dennis T. Ko
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
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14
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Chalazan B, Freeth E, Mohajeri A, Ramanathan K, Bennett M, Walia J, Halperin L, Roston T, Lazarte J, Hegele RA, Lehman A, Laksman Z. Genetic testing in monogenic early-onset atrial fibrillation. Eur J Hum Genet 2023; 31:769-775. [PMID: 37217627 PMCID: PMC10325969 DOI: 10.1038/s41431-023-01383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 04/22/2023] [Accepted: 04/27/2023] [Indexed: 05/24/2023] Open
Abstract
A substantial proportion of atrial fibrillation (AF) cases cannot be explained by acquired AF risk factors. Limited guidelines exist that support routine genetic testing. We aim to determine the prevalence of likely pathogenic and pathogenic variants from AF genes with robust evidence in a well phenotyped early-onset AF population. We performed whole exome sequencing on 200 early-onset AF patients. Variants from exome sequencing in affected individuals were filtered in a multi-step process, prior to undergoing clinical classification using current ACMG/AMP guidelines. 200 AF individuals were recruited from St. Paul's Hospital and London Health Sciences Centre who were ≤ 60 years of age and without any acquired AF risk factors at the time of AF diagnosis. 94 of these AF individuals had very early-onset AF ( ≤ 45). Mean age of AF onset was 43.6 ± 9.4 years, 167 (83.5%) were male and 58 (29.0%) had a confirmed family history. There was a 3.0% diagnostic yield for identifying a likely pathogenic or pathogenic variant across AF genes with robust gene-to-disease association evidence. This study demonstrates the current diagnostic yield for identifying a monogenic cause for AF in a well-phenotyped early-onset AF cohort. Our findings suggest a potential clinical utility for offering different screening and treatment regimens in AF patients with an underlying monogenic defect. However, further work is needed to dissect the additional monogenic and polygenic determinants for patients without a genetic explanation for their AF despite the presence of specific genetic indicators such as young age of onset and/or positive family history.
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Affiliation(s)
- Brandon Chalazan
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada
| | - Emma Freeth
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Arezoo Mohajeri
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada
| | | | - Matthew Bennett
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jagdeep Walia
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Laura Halperin
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Thomas Roston
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Julieta Lazarte
- Department of Medicine and Biochemistry, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Robert A Hegele
- Department of Medicine and Biochemistry, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Anna Lehman
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada
| | - Zachary Laksman
- Department of Medicine and The School of Biomedical Engineering, University of British Columbia and the Centre for Heart Lung Innovation, Vancouver, Canada.
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15
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Salah QM, Bhandari S, Chand A, Khan S, Tirmzi SHA, Sheikh M, Khreis K, Palleti SK. The Effectiveness and Safety of Direct Oral Anticoagulants in Obese Patients With Atrial Fibrillation: A Network Meta-Analysis. Cureus 2023; 15:e41619. [PMID: 37565103 PMCID: PMC10410482 DOI: 10.7759/cureus.41619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 08/12/2023] Open
Abstract
Atrial fibrillation (AF) is a cardiac condition characterized by an irregular heart rhythm, which is increasingly prevalent in the modern era. All international guidelines strongly advise the administration of anticoagulants to individuals with AF who are at high risk of stroke. These guidelines recommend the use of direct oral anticoagulants (DOACs) over warfarin because warfarin is significantly associated with increased rates of major bleeding, numerous interactions with food and drugs, and the necessity for frequent monitoring. The aim of this study is to compare the effectiveness and safety of direct oral anticoagulants (DOACs) in obese patients with atrial fibrillation. Two authors independently conducted a comprehensive literature search using electronic databases including PubMed, CINAHL, and EMBASE from inception to June 1, 2023. The efficacy outcome assessed in this meta-analysis included the composite of stroke and systemic embolism. For safety analysis, major bleeding events were compared among the study groups. Eleven studies fulfilled all the inclusion criteria and were included in the present meta-analysis enrolling 144,502 patients. In this study, DOACs demonstrate superior efficacy in preventing stroke/systemic embolism compared to warfarin. Among the DOACs, apixaban emerged as the most effective, followed by rivaroxaban, warfarin, and dabigatran. In terms of safety, apixaban was also found to be the most favorable treatment option, followed by rivaroxaban, dabigatran, and warfarin. In summary, our study concludes that apixaban exhibited greater effectiveness and safety when compared to other DOACs and warfarin in obese patients with AF.
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Affiliation(s)
- Qais M Salah
- Internal Medicine, Al-Quds University Faculty of Medicine, Jerusalem, PSE
| | | | - Ali Chand
- Medicine, Shaikh Khalifa Bin Zayed Medical and Dental College, Lahore, PAK
| | - Saif Khan
- Medicine, North Manchester Hospital, Manchester, GBR
| | | | - Majed Sheikh
- Cardiology, Royal Free London NHS Foundation Trust, London, GBR
| | | | - Sujith K Palleti
- Nephrology, Edward Hines Jr. Veterans Administration Hospital, Hines, USA
- Nephrology, Loyola University Medical Center, Maywood, USA
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16
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Chen Q, Toorop MMA, Tops LF, Lijfering WM, Cannegieter SC. Time Trends in Patient Characteristics, Anticoagulation Treatment, and Prognosis of Incident Nonvalvular Atrial Fibrillation in the Netherlands. JAMA Netw Open 2023; 6:e239973. [PMID: 37097630 PMCID: PMC10130953 DOI: 10.1001/jamanetworkopen.2023.9973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Importance The temporal trend in adverse events regarding stroke prevention for nonvalvular atrial fibrillation (NVAF) in the direct oral anticoagulant (DOAC) era was rarely investigated comprehensively, especially taking into account potential changes in patient characteristics and anticoagulation treatment. Objective To investigate time trends in patient characteristics, anticoagulation treatment, and prognosis of patients with incident NVAF in the Netherlands. Design, Setting, and Participants This retrospective cohort study assessed patients with incident NVAF initially recognized within a hospitalization between 2014 and 2018, using data from Statistics Netherlands. Participants were followed-up for 1 year from the hospital admission at which the incident NVAF diagnosis was made or until death, whichever occurred first. Data were analyzed from January 15, 2021, to March 8, 2023. Exposure Calendar year of the incident NVAF diagnosis, according to which the participants were categorized into 5 cohorts. Main Outcomes and Measures Outcomes of interest were baseline patient characteristics, anticoagulation treatment, and occurrence of ischemic stroke or major bleeding within the 1-year follow-up after incident NVAF. Results Between 2014 and 2018, 301 301 patients (mean [SD] age, 74.2 [11.9] years; 169 748 [56.3%] male patients) experienced incident NVAF in the Netherlands, each of whom was categorized into 1 of 5 cohorts by calendar year. Baseline patient characteristics were broadly the same between cohorts with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74 years, and sex category [female]) score of 2.9 (1.7). The median (IQR) proportion of days covered by OACs (ie, vitamin K antagonists or DOACs) within the 1-year follow-up increased from 56.99% (0%-86.30%) to 75.62% (0%-94.52%), and DOACs increased from 5102 patients (13.5%) to 32 314 patients (72.0%) among those who received OACs, gradually replacing VKAs as the first choice of OACs. Over the course of the study, there were statistically significant decreases in the 1-year cumulative incidence of ischemic stroke (from 1.63% [95% CI, 1.52%-1.73%] to 1.39% [95% CI, 1.30%-1.48%) and major bleeding (from 2.50% [95% CI, 2.37%-2.63%] to 2.07% [95% CI, 1.96%-2.19%]), and the association was consistent after adjusting for baseline patient characteristics and excluding those with preexisting chronic anticoagulation. Conclusions and Relevance This cohort study of patients with incident NVAF diagnosed between 2014 and 2018 in the Netherlands found similar baseline characteristics, increased OAC use with DOACs being favored over time, and improved 1-year prognosis. Comorbidity burden, potential underuse of anticoagulation medications, and specific subgroups of patients with NVAF remain directions for future investigations and further improvement.
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Affiliation(s)
- Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Myrthe M A Toorop
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- The Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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17
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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18
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Escudero-Martínez I, Morales-Caba L, Segura T. Atrial fibrillation and stroke: A review and new insights. Trends Cardiovasc Med 2023; 33:23-29. [PMID: 34890796 DOI: 10.1016/j.tcm.2021.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 02/01/2023]
Abstract
The link between heart and brain continues to be a matter of great interest for the scientific community. One of the most established associations between the two is that the heart is a significant source of emboli and is responsible for 20-25% of all ischemic strokes. The most frequent underlying cause of cardioembolic stroke is atrial fibrillation (AF), a disease that affects almost 3 million people in the USA and 4.5 million in Europe. AF increases the risk of ischemic stroke by a factor of 3 to 5 times. It is estimated that AF is responsible for 15% of all strokes worldwide. A more comprehensive understanding of this association and development of intensive stroke prevention measures are needed, as we know that AF incidence and prevalence will increase over the coming years, becoming one of the largest epidemics and public health challenges we face.
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Affiliation(s)
- Irene Escudero-Martínez
- Stroke Unit, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe - Universidad de Valencia, Valencia, Spain.
| | - Lluis Morales-Caba
- Stroke Unit, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe - Universidad de Valencia, Valencia, Spain
| | - Tomás Segura
- Department of Medical Sciences, Faculty of Medicine of Albacete, University of Castilla-La Mancha, Albacete, Spain; Stroke Unit, Department of Neurology, Hospital General Universitario de Albacete, Spain
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19
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McIntyre WF. Post-operative atrial fibrillation after cardiac surgery: Challenges throughout the patient journey. Front Cardiovasc Med 2023; 10:1156626. [PMID: 36960472 PMCID: PMC10027741 DOI: 10.3389/fcvm.2023.1156626] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 03/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common complication of cardiac surgery, occurring in up to half of patients. Post-operative AF (POAF) refers to new-onset AF in a patient without a history of AF that occurs within the first 4 weeks after cardiac surgery. POAF is associated with short-term mortality and morbidity, but its long-term significance is unclear. This article reviews existing evidence and research challenges for the management of POAF in patients who have had cardiac surgery. Specific challenges are discussed in four phases of care. Pre-operatively, clinicians need to be able to identify high-risk patients, and initiate prophylaxis to prevent POAF. In hospital, when POAF is detected, clinicians need to manage symptoms, stabilize hemodynamics and prevent increases in length of stay. In the month after discharge, the focus is on minimizing symptoms and preventing readmission. Some patients require short term oral anticoagulation for stroke prevention. Over the long term (2-3 months after surgery and beyond), clinicians need to identify which patients with POAF have paroxysmal or persistent AF and can benefit from evidence-based therapies for AF, including long-term oral anticoagulation.
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20
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Al Aseri Z, AlGahtani FH, Bakheet MF, Al-Jedai AH, Almubrik S. Evidence-based Management of Major Bleeding in Patients Receiving Direct Oral Anticoagulants: An Updated Narrative Review on the Role of Specific Reversal Agents. J Cardiovasc Pharmacol Ther 2023; 28:10742484231202655. [PMID: 37872658 DOI: 10.1177/10742484231202655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
The indications of direct oral anticoagulants (DOACs) have expanded over the past 15 years. DOACs are effective and safe oral anticoagulants associated with lower bleeding risks and mortality than vitamin K antagonists. However, DOAC users are prone to a considerable bleeding risk, which can occur at critical sites or lead to severe life-threatening conditions. Recent statistics indicated that major bleeding occurs in up to 6.62 DOAC users per 100 treatment years. With the increased use of DOACs in clinical practice, DOAC-associated major bleeding is expected to be encountered more frequently in the emergency department. The current international guidelines recommend specific reversal agents for the management of DOAC users with severe bleeding to reverse the anticoagulant effect and restore normal hemostasis. An individualized assessment was incorporated in specific clinical situations to guide the decision pathway of major bleeding management. However, specific reversal agents are unavailable or have limited availability in many countries, which is expected to negatively impact the clinical outcomes of DOAC-associated major bleeding. Limited real-world evidence is available from these countries regarding the clinical outcomes of patients with DOAC-associated major bleeding. This narrative review provided an updated assessment of the evidence-based approaches for the management of major bleeding in DOAC users. We also explored the clinical outcomes of patients with major bleeding from clinical settings where specific reversal agents are unavailable.
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Affiliation(s)
- Zohair Al Aseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Adult Critical Care, Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
- Riyadh Hospital & Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Farjah H AlGahtani
- Division of Hematology/Oncology, Oncology Center, Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | - Majid F Bakheet
- Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
- Colleges of Medicine and Pharmacy, Al-Faisal University, Riyadh, Saudi Arabia
| | - Ahmed H Al-Jedai
- Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
- Colleges of Medicine and Pharmacy, Al-Faisal University, Riyadh, Saudi Arabia
| | - Sarah Almubrik
- Emergency Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
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21
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Boivin-Proulx LA, Potter BJ, Dorais M, Perreault S. Evolution of and Evidence-Practice Gaps in Antithrombotic Management of Atrial Fibrillation Patients After Percutaneous Coronary Intervention. CJC Open 2022; 5:15-23. [PMID: 36700177 PMCID: PMC9869359 DOI: 10.1016/j.cjco.2022.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background The management of atrial fibrillation and flutter (AF) patients undergoing percutaneous coronary intervention (PCI) has evolved rapidly in the past decade. We determine whether the publication of the 2016 Canadian Cardiovascular Society AF guidelines were associated with a shift in practice patterns. Methods Using Quebec provincial administrative database information for the period from 2010-2017, a retrospective cohort of patients with inpatient or outpatient coding for AF, who subsequently underwent PCI with placement of a coronary stent, was created and analyzed for the antithrombotic regimen received in the following year. Prescribing behavior was compared among 3 time periods (2010-2011, 2012-2015, 2016-2017), and use of antithrombotics was compared to guideline-predicted therapy using the χ2 test. Predictors of oral anticoagulation (OAC) prescription were identified using adjusted logistic regression. Results A total of 3740 AF patients undergoing PCI were included. The proportion of OAC prescription increased over time (2010-2011 = 51.4%; 2012-2015 = 54.3%; 2016-2017 = 56.6%; P = 0.13), with a significant increase in direct OAC prescription (P < 0.01). A substantial treatment gap in OAC prescription persisted after publication of the 2016 guidelines (56.6% observed vs 89.7% predicted; P < 0.01). Previous stroke, CHADS2 score, Charlson Comorbidity Index ≥ 4, and prior use of direct OAC or warfarin were predictors of being exposed to OAC claims; previous major bleeding, and low-dose acetylsalicylic acid or P2Y12 inhibitor use were predictors of not being exposed to OACs. Conclusion Expert guidance contributed to an increase in OAC prescription following PCI, but up to 2017, substantial further changes in practice patterns would have been required to achieve the recommended rates of OAC prescription.
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Affiliation(s)
- Laurie-Anne Boivin-Proulx
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada,Centre Cardiovasculaire du Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Brian J. Potter
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada,Centre Cardiovasculaire du Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada,Chaire Sanofi sur l'utilisation des médicaments, Université de Montréal, Montreal, Quebec, Canada,Centre de recherche en santé publique (CReSP), partenaire CIUSSS du Centre-Sud-de-l’Île-de-Montréal et l’Université de Montréal, Montreal, Quebec, Canada,Corresponding author: Dr Sylvie Perreault, Chaire Sanofi sur l'utilisation des médicaments, Faculté de Pharmacie, Université de Montréal, Case Postale 6128, Succursale Centre-Ville, Montréal, Québec H3C 3J7, Canada. Tel.: +1-514-343-6111 x3149; fax: +1-514-343-6120.
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22
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Narrow Complex Tachycardias. Emerg Med Clin North Am 2022; 40:717-732. [DOI: 10.1016/j.emc.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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23
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Facin M, Samesima N. Rhythm Control Interventions in Patients with Atrial Fibrillation - Insights on Preprocedural Anticoagulation and Utility of Left Atrial Imaging. Arq Bras Cardiol 2022; 119:520-521. [PMID: 36287407 PMCID: PMC9563887 DOI: 10.36660/abc.20220663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mirella Facin
- Instituto do Coração (InCor) - Hospital das Clínicas HCFMUSP - Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Nelson Samesima
- Instituto do Coração (InCor) - Hospital das Clínicas HCFMUSP - Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
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24
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Yang N, Zhao Y, Bai Z, Chen H, Ning H, Zou M, Cheng G. The association of non-vitamin K antagonist oral anticoagulants vs. warfarin and the risk of fractures for patients with atrial fibrillation: a systematic review and meta-analysis. Acta Cardiol 2022; 78:298-310. [PMID: 36063197 DOI: 10.1080/00015385.2022.2030555] [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: 11/01/2022]
Abstract
BACKGROUND The fracture risks of non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin in patients with atrial fibrillation (AF) remain controversial. METHODS PubMed, Cochrane Library, EMBASE, Clinical Trials.gov databases for RCTs, and cohort studies were systematically searched from inception to 10 June 2021. RESULTS Twelve-two studies met the inclusion criteria and 477,821 patients were included. Warfarin increased the risk of fracture in AF patients compared with NOACs in overall any fracture (RR = 0.79; 95% CI = 0.70-10.88; p = 0.00), osteoporotic fracture (RR = 0.746; 95% CI = 0.630-0.883; p = 0.001). No significant difference was observed in the hip or pelvic fracture, vertebral fracture, extremity fracture, wrist fracture, femoral neck fracture, and ankle fracture. In subgroup analyses based on several aspects, NOACs were associated with a significant reduction in any fracture (standard dosage NOACs, cohort studies, elderly patients, rivaroxaban in RCTs, dabigatran, rivaroxaban, and apixaban in cohort studies), in the hip/pelvic fracture (follow-up time ≤1 year, cohort studies), and osteoporotic fracture (cohort studies). CONCLUSION NOACs were associated with a significantly lower risk of any fracture and osteoporotic fracture compared to warfarin. This benefit was also observed in specific NOACs types of dabigatran, rivaroxaban, and apixaban. However, whether NOACs had a less fracture risk than warfarin on the other risk of fractures was still uncertain.
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Affiliation(s)
- Nana Yang
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Ying Zhao
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Zhaohui Bai
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Haokun Chen
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Haoyu Ning
- School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Meijuan Zou
- Pharmaceutical College, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Gang Cheng
- Pharmaceutical College, Shenyang Pharmaceutical University, Shenyang, Liaoning, China.,NMPA Key Laboratory for Research and Evaluation of Drug Regulatory Technology, Shenyang, Liaoning, China
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25
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Development of a Care Pathway for Atrial Fibrillation Patients in the Emergency Department. Crit Pathw Cardiol 2022; 21:105-113. [PMID: 35994718 DOI: 10.1097/hpc.0000000000000289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and its prevalence is continuously increasing in the United States, leading to a progressive rise in the number of disease-related emergency department (ED) visits and hospitalizations. Although optimal long-term outpatient management for AF is well defined, the guidelines for optimal ED management of acute AF episodes is less clear. Studies have demonstrated that discharging patients with AF from the ED after acute stabilization is both safe and cost effective; however, the majority of these patients in the United States and in our institution are admitted to the hospital. To improve care of these patients, we established a multidisciplinary collaboration to develop an evidence-based systematic approach for the treatment and management of AF in the ED, that led to the creation of the University of California-Cardioversion, Anticoagulation, Rate Control, Expedited Follow-up/Education Atrial Fibrillation Pathway. Our pathway focuses on the acute stabilization of AF, adherence to best practices for anticoagulation, and reduction in unnecessary admissions through discharge from the ED with expedited outpatient follow-up whenever safe. A novel aspect of our pathway is that it is primarily driven by the ED physicians, while other published protocols primarily involve consulting cardiologists to guide management in the ED. Our protocol is very pertinent considering the current trend toward increased AF prevalence in the United States, coupled with a need for widespread implementation of strategies aimed at improving management of these patients while safely reducing hospital admissions and the economic burden of AF.
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26
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Holbrook AM, Vidug K, Yoo L, Troyan S, Schulman S, Douketis J, Thabane L, Giilck S, Koubaesh Y, Hyland S, Keshavjee K, Ho J, Tarride JE, Ahmed A, Talman M, Leonard B, Ahmed K, Refaei M, Siegal DM. Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial. Pilot Feasibility Stud 2022; 8:166. [PMID: 35918731 PMCID: PMC9344454 DOI: 10.1186/s40814-022-01130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Oral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care. Our objective is to test whether a focused, expert medication management intervention using a mix of in-person consultation and virtual care follow-up, is feasible and effective in preventing anticoagulation-related adverse events, for patients transitioning from hospital to home. Methods and analysis A randomized, parallel, multicenter design enrolling consenting adult patients or the caregivers of cognitively impaired patients about to be discharged from medical wards with a discharge prescription for an OAC. The interdisciplinary multimodal intervention is led by a clinical pharmacologist and includes a detailed discharge medication reconciliation and management plan focused on oral anticoagulants at hospital discharge; a circle of care handover and coordination with patient, hospital team and community providers; and early post-discharge follow-up virtual medication check-up visits at 24 h, 1 week, and 1 month. The control group will receive usual care plus encouragement to use the Thrombosis Canada website. The primary feasibility outcomes include recruitment rate, participant retention rates, trial resources management, and the secondary clinical outcomes include adverse anticoagulant safety events composite (AASE), coordination and continuity of care, medication-related problems, quality of life, and healthcare resource utilization. Follow-up is 3 months. Discussion This pilot RCT tests whether there is sufficient feasibility and merit in coordinating oral anticoagulant care early post-hospital discharge to warrant a full sized RCT. Trial registration NCT02777047. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01130-z.
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Affiliation(s)
- Anne M Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada. .,Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. .,Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Kristina Vidug
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Lindsay Yoo
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Sue Troyan
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Sam Schulman
- Divsion of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - James Douketis
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Divsion of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Stephen Giilck
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Grand River Hospital, Kitchener, ON, Canada
| | - Yousery Koubaesh
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Brantford General Hospital, Brantford, ON, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, North York, ON, Canada
| | - Karim Keshavjee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Joanne Ho
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Research Institute for Aging, Schlegel-University of Waterloo, Waterloo, ON, Canada.,Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Center for Health Economic and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada.,Programs for Assessment of Technology in Health (PATH), Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada
| | - Amna Ahmed
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Marianne Talman
- Division of General Internal Medicine, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Blair Leonard
- Department of Medicine, Niagara Health System, Regional Municipality of Niagara, Canada
| | - Khursheed Ahmed
- Clinical Pharmacology Research, Research Institute of St Joes Hamilton, Hamilton, ON, Canada
| | - Mohammad Refaei
- Department of Medicine, Niagara Health System, Regional Municipality of Niagara, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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28
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Chew DS, Au F, Xu Y, Manns BJ, Tonelli M, Wilton SB, Hemmelgarn B, Kong S, Exner DV, Quinn AE. Geographic and temporal variation in the treatment and outcomes of atrial fibrillation: a population-based analysis of national quality indicators. CMAJ Open 2022; 10:E702-E713. [PMID: 35918151 PMCID: PMC9352379 DOI: 10.9778/cmajo.20210246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Assessment of potential geographic variation in quality indicators of atrial fibrillation care may identify opportunities for improvement in the quality of atrial fibrillation care. The objective of this study was to assess for potential geographic variation in the quality of atrial fibrillation care in Alberta, Canada. METHODS In a population-based cohort of adults (age ≥ 18 yr) with incident nonvalvular atrial fibrillation (NVAF) diagnosed between Apr. 1, 2008, and Mar. 31, 2016, in Alberta, we investigated the variation in national quality indicators of atrial fibrillation care developed by the Canadian Cardiovascular Society. Specifically, we assessed the geographic and temporal variation in the proportion of patients with initiation of oral anticoagulant therapy, persistence with therapy, ischemic stroke and major bleeding outcomes 1 year after atrial fibrillation diagnosis using linked administrative data sets. We defined stroke risk using the CHADS2 score. We assessed geographic variation using small-area variation statistics and geospatial data analysis. RESULTS Of the 64 093 patients in the study cohort (35 019 men [54.6%] and 29 074 women [45.4%] with a mean age of 69 [standard deviation 15.9] yr), 36 199 were at high risk for stroke and 14 411 were at moderate risk. Within 1 year of NVAF diagnosis, 20 180 patients (55.7%) in the high-risk group and 6448 patients (44.7%) in the moderate-risk group were prescribed anticoagulation. A total of 2187 patients (3.4%) had an ischemic stroke, and 2996 patients (4.7%) experienced a major bleed. There was substantial regional variation observed in initiation of oral anticoagulant therapy but not in the proportion of patients with ischemic stroke or major bleeding. Among the 64 Health Status Areas in Alberta, therapy initiation rates ranged from 22.6% to 71.2% among patients at high stroke risk and from 22.7% to 55.8% among those at moderate stroke risk, with clustering of lower therapy initiation rates in rural northern regions. INTERPRETATION The rate of initiation of oral anticoagulant therapy among adults with incident atrial fibrillation was less than 60% in patients in whom oral anticoagulant therapy would be considered guideline-appropriate care. The large geographic variation in oral anticoagulant prescribing warrants additional study into patient, provider and health care system factors that contribute to variation and drive disparities in high-quality, equitable atrial fibrillation care.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta.
| | - Flora Au
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Yuan Xu
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Braden J Manns
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Marcello Tonelli
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Stephen B Wilton
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Brenda Hemmelgarn
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Shiying Kong
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Derek V Exner
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Amity E Quinn
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
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29
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Nair GM, Birnie DH, Wells GA, Nery PB, Redpath CJ, Sarrazin JF, Roux JF, Parkash R, Bernier M, Sterns LD, Novak P, Veenhuyzen G, Morillo CA, Singh SM, Sturmer M, Chauhan VS, Angaran P, Essebag V. Augmented wide area circumferential catheter ablation for reduction of atrial fibrillation recurrence (AWARE) trial: Design and rationale. Am Heart J 2022; 248:1-12. [PMID: 35219715 DOI: 10.1016/j.ahj.2022.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/03/2022] [Accepted: 02/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recurrence of atrial fibrillation (AF) after a pulmonary vein isolation procedure is often due to electrical reconnection of the pulmonary veins. Repeat ablation procedures may improve freedom from AF but are associated with increased risks and health care costs. A novel ablation strategy in which patients receive "augmented" ablation lesions has the potential to reduce the risk of AF recurrence. OBJECTIVE The Augmented Wide Area Circumferential Catheter Ablation for Reduction of Atrial Fibrillation Recurrence (AWARE) Trial was designed to evaluate whether an augmented wide-area circumferential antral (WACA) ablation strategy will result in fewer atrial arrhythmia recurrences in patients with symptomatic paroxysmal AF, compared with a conventional WACA strategy. METHODS/DESIGN The AWARE trial was a multicenter, prospective, randomized, open, blinded endpoint trial that has completed recruitment (ClinicalTrials.gov NCT02150902). Patients were randomly assigned (1:1) to either the control arm (single WACAlesion set) or the interventional arm (augmented- double WACA lesion set performed after the initial WACA). The primary outcome was atrial tachyarrhythmia (AA; atrial tachycardia [AT], atrial flutter [AFl] or AF) recurrence between days 91 and 365 post catheter ablation. Patient follow-up included 14-day continuous ambulatory ECG monitoring at 3, 6, and 12 months after catheter ablation. Three questionnaires were administered during the trial- the EuroQuol-5D (EQ-5D) quality of life scale, the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale, and a patient satisfaction scale. DISCUSSION The AWARE trial was designed to evaluate whether a novel approach to catheter ablation reduced the risk of AA recurrence in patients with symptomatic paroxysmal AF.
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Affiliation(s)
- Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Canada
| | | | | | - Pablo B Nery
- University of Ottawa Heart Institute, Ottawa, Canada
| | | | | | | | - Ratika Parkash
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Martin Bernier
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Laurence D Sterns
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - Paul Novak
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - George Veenhuyzen
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlos A Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Marcio Sturmer
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vijay S Chauhan
- University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Centre, Montreal, Quebec, Canada; Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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30
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Guo Y, Imberti JF, Kotalczyk A, Wang Y, Lip GYH. 4S-AF scheme and ABC pathway guided management improves outcomes in atrial fibrillation patients. Eur J Clin Invest 2022; 52:e13751. [PMID: 35080269 PMCID: PMC9286858 DOI: 10.1111/eci.13751] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/11/2022] [Accepted: 01/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 4S-AF scheme and the ABC pathway for integrated care have been proposed to better characterize and treat patients with atrial fibrillation (AF). We aimed to evaluate the assessment of the 4S-AF scheme and ABC pathway in Chinese AF patients. METHODS The ChiOTEAF is a prospective, observational, multicentre registry. Consecutive AF patients from 44 centres across 20 Chinese provinces with available 1-year follow-up data were included. RESULTS A total of 6419 patients were included, median age 76 years (interquartile range 67-83; 39.1% female). Of these, 3503 (59.8%) patients were not characterized using the 4S-AF scheme and not management according to the ABC pathway (group 1); 1795 (28.0%) were characterized according to the 4S-AF scheme but ABC pathway non-adherent or vice versa (group 2); and 1121 (17.4%) characterized according to the 4S-AF scheme and were ABC pathway adherent (group 3). As compared with group 1, group 2 and group 3 were independently associated with lower odds of the composite endpoint of all-cause death/any thromboembolic event, with the greatest benefit observed in group 3 (OR: 0.19; 95% CI 0.12-0.31) [for group 2: OR: 0.28; 95% CI 0.20-0.37]. Similar results were observed for all-cause death (group 2: OR: 0.18; 95% CI 0.12-0.27; group 3: OR: 0.14; 95% CI 0.07-0.25). CONCLUSIONS In a contemporary real-word cohort of Chinese AF patients, it is feasible to characterize and manage AF patients using the novel 4S-AF scheme and ABC pathway for integrated care. The use of both these tools is associated with improved clinical outcomes.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Jacopo F Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Yutang Wang
- Department of Cardiology, Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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31
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Dickow J, Kirchhof P, Van Houten HK, Sangaralingham LR, Dinshaw LHW, Friedman PA, Packer DL, Noseworthy PA, Yao X. Generalizability of the EAST-AFNET 4 Trial: Assessing Outcomes of Early Rhythm-Control Therapy in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e024214. [PMID: 35621202 PMCID: PMC9238730 DOI: 10.1161/jaha.121.024214] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background EAST‐AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) demonstrated clinical benefit of early rhythm‐control therapy (ERC) in patients with new‐onset atrial fibrillation (AF) and concomitant cardiovascular conditions compared with current guideline‐based practice. This study aimed to evaluate the generalizability of EAST‐AFNET 4 in routine practice. Methods and Results Using a US administrative database, we identified 109 739 patients with newly diagnosed AF during the enrollment period of EAST‐AFNET 4. Patients were classified as either receiving ERC, using AF ablation or antiarrhythmic drug therapy, within the first year after AF diagnosis (n=27 106) or not receiving ERC (control group, n=82 633). After propensity score overlap weighting, Cox proportional hazards regression was used to compare groups for the primary composite outcome of all‐cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction. Most patients (79 948 of 109 739; 72.9%) met the inclusion criteria for EAST‐AFNET 4. ERC was associated with a reduced risk for the primary composite outcome (hazard ratio [HR], 0.85; 95% CI, 0.75–0.97 [P=0.02]) with largely consistent results between eligible (HR, 0.89; 95% CI, 0.76–1.04 [P=0.14]) or ineligible (HR, 0.77; 95% CI, 0.60–0.98 [P=0.04]) patients for EAST‐AFNET 4 trial inclusion. ERC was associated with lower risk of stroke in the overall cohort and in trial‐eligible patients. Conclusions This analysis replicates the clinical benefit of ERC seen in EAST‐AFNET 4. The results support adoption of ERC as part of the management of recently diagnosed AF in the United States.
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Affiliation(s)
- Jannis Dickow
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany.,DZHK (German Center for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Berlin Germany
| | - Paulus Kirchhof
- Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany.,DZHK (German Center for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Berlin Germany.,Institute of Cardiovascular SciencesUniversity of Birmingham Birmingham United Kingdom
| | - Holly K Van Houten
- OptumLabs Eden Prairie MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Lindsey R Sangaralingham
- OptumLabs Eden Prairie MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Leon H W Dinshaw
- Department of Cardiology University Heart and Vascular Center HamburgUniversity Hospital Hamburg Eppendorf Hamburg Germany
| | - Paul A Friedman
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Peter A Noseworthy
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
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Jourdi G, Marquis-Gravel G, Martin AC, Lordkipanidzé M, Godier A, Gaussem P. Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines. Front Pharmacol 2022; 13:878416. [PMID: 35571090 PMCID: PMC9092185 DOI: 10.3389/fphar.2022.878416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/29/2022] [Indexed: 12/24/2022] Open
Abstract
Antiplatelet therapy, mainly consisting of aspirin and P2Y12 receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Anne-Céline Martin
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service de Cardiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Anne Godier
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Anesthésie Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
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Lin CH, Timofeeva M, O'Brien T, Lyons OD. Obstructive sleep apnea and nocturnal attacks of paroxysmal atrial fibrillation. J Clin Sleep Med 2022; 18:1279-1286. [PMID: 34931608 PMCID: PMC9059602 DOI: 10.5664/jcsm.9840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/28/2021] [Accepted: 12/03/2021] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is commonly seen in patients with atrial fibrillation (AF), but it is unclear to what extent this relationship is one of causation or association. We examined a cohort of patients with paroxysmal AF to determine whether the presence of OSA (apnea-hypopnea index ≥ 15 events/h) affects the time of onset of symptomatic AF episodes. METHODS Patients with a recent emergency department visit for a symptomatic episode of paroxysmal AF were recruited from an AF clinic. The time of onset of the AF attack was classified as occurring in "sleeping hours" or "waking hours" based on direct history from the patient and emergency department visit documentation. RESULTS Of 152 patients with paroxysmal AF, 67 underwent polysomnography; 1 (1.5%) had central sleep apnea, 46 (68.7%) had mild or no OSA, and 20 (29.8%) had OSA. In the OSA group, 14/20 (70.0%) had their symptomatic AF attack during sleeping hours compared to 12/46 (26.1%) in the mild or no OSA group (P = .001). Compared with those who had a paroxysmal AF attack during waking hours, and adjusting for confounders, those who had a paroxysmal AF attack during sleeping hours had almost 6 times the odds of having OSA (odds ratio, 5.53; P = .007). CONCLUSIONS Compared to patients with paroxysmal AF with mild or no OSA, those with OSA were far more likely to have a symptomatic AF attack during sleeping hours, supporting a causal role for OSA in the pathogenesis of AF in this population. These findings strongly suggest that patients who have nocturnal AF attacks should be evaluated for OSA. CITATION Lin C-H, Timofeeva M, O'Brien T, Lyons OD. Obstructive sleep apnea and nocturnal attacks of paroxysmal atrial fibrillation. J Clin Sleep Med. 2022;18(5):1279-1286.
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Affiliation(s)
- Chou-Han Lin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
- Division of Respiratory Medicine, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Maria Timofeeva
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Tara O'Brien
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Owen D Lyons
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
- Women's College Research Institute, Toronto, Ontario, Canada
- The Sleep Research Laboratory of UHN-TRI KITE, Toronto, Ontario, Canada
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Daniel RC, Atzema CL, Cho DD, Davis PJ, Costello LL. Which Recommendations Are You Using? A Survey of Emergency Physician Management of Paroxysmal Atrial Fibrillation. CJC Open 2022; 4:466-473. [PMID: 35607488 PMCID: PMC9123374 DOI: 10.1016/j.cjco.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/16/2022] [Indexed: 10/29/2022] Open
Abstract
Background Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown. Methods We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces. Results Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA2DS2-VASc score as their stroke-risk assessment tool. Conclusions Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation.
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Affiliation(s)
- Ryan C. Daniel
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clare L. Atzema
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis D. Cho
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Philip J. Davis
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lorne L. Costello
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Abramson BL, Al-Omran M, Anand SS, Albalawi Z, Coutinho T, de Mestral C, Dubois L, Gill HL, Greco E, Guzman R, Herman C, Hussain MA, Huckell VF, Jetty P, Kaplovitch E, Karlstedt E, Kayssi A, Lindsay T, Mancini GBJ, McClure G, McMurtry MS, Mir H, Nagpal S, Nault P, Nguyen T, Petrasek P, Rannelli L, Roberts DJ, Roussin A, Saw J, Srivaratharajah K, Stone J, Szalay D, Wan D, Cox H, Verma S, Virani S. Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease. Can J Cardiol 2022; 38:560-587. [PMID: 35537813 DOI: 10.1016/j.cjca.2022.02.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.
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Affiliation(s)
- Beth L Abramson
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Mohammed Al-Omran
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | | | - Thais Coutinho
- Canadian Women's Heart Health Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Luc Dubois
- LHSC and Western University, London, Ontario, Canada
| | | | - Elisa Greco
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Randolph Guzman
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Mohamad A Hussain
- Centre for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victor F Huckell
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Prasad Jetty
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Eric Kaplovitch
- University Health Network/Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Erin Karlstedt
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Thomas Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - G B John Mancini
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Hassan Mir
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir Nagpal
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrice Nault
- McGill University, Campus Outaouais, Gatineau, Quebec, Canada, Alberta, Canada
| | - Thang Nguyen
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Petrasek
- Cumming School of Medicine, University of Calgary, Peter Lougheed Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Derek J Roberts
- University of Ottawa, The Ottawa Hospital, and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Jacqueline Saw
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Stone
- University of Calgary, Calgary, Alberta, Canada
| | | | - Darryl Wan
- McMaster University, Hamilton, Ontario, Canada
| | - Heather Cox
- Peterborough Regional Hospital, Peterborough, Ontario, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
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INCIDENCE OF NEW ONSET ATRIAL FIBRILLATION AFTER TRANSCATHETER PFO CLOSURE USING 15 YEARS OF ONTARIO ADMINISTRATIVE HEALTH DATA. Heart Rhythm 2022; 19:1414-1420. [DOI: 10.1016/j.hrthm.2022.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 03/17/2022] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace 2022; 24:1844-1871. [PMID: 35323922 DOI: 10.1093/europace/euac020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 12/26/2022] Open
Abstract
Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Barcelona, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, SMaria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Critical Appraisal of Guidelines for Antithrombotic Therapy in Atrial Fibrillation Post-Percutaneous Coronary Intervention. Glob Heart 2022; 17:14. [PMID: 35342701 PMCID: PMC8877875 DOI: 10.5334/gh.1104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 12/11/2022] Open
Abstract
Objective: In our present study, our objective was to appraise guidelines on antithrombotic therapy in atrial fibrillation post-percutaneous coronary intervention and to explore the differences in treatment practices for better informed decision-making. Methods: We searched for English language guidelines published between January 2000 and December 2020 at MEDLINE, Embase and websites of guideline organizations. Guidelines with recommendations on antithrombotic regimens for patients with AF undergoing PCI were included. Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was applied to assess guidelines. The reporting of conflicts of interest (COI) was evaluated separately by the RIGHT (Reporting Item for Practice Guidelines in Healthcare) checklist as supplementary items. Results: Sixteen guidelines were included, among which 13 (81.25%) were considered as ‘recommended’ and 1 (6.25%) as ‘unrecommended.’ The average scores of guidelines ranged from 55% to 88% (<60% as low quality, 60–70% as sufficient quality, and >70% as good quality). Among the 6 domains of AGREE II, scope and purpose (84%) and editorial independence(87%) were considered to be the fields in which CPGs performed best, evidenced by the highest mean AGREE II scores. The domains in which the reviewed CPGs received the lowest mean scores were stakeholder involvement (63%) and applicability (58%). The intraclass correlation coefficient scores were excellent in each domain. The overall quality of the selected CPGs was optimal, with the highest score in domain ‘scope and purpose’, and the lowest score in the domain ‘applicability.’ The reporting of COI was satisfactory. Conclusions: For the recommendations on antithrombotic strategies, guidelines with high AGREE II scores still exist discrepancy on the timing and selection. Current guidance documents on the treatment vary in methodological rigor and recommendations are not always consistent.
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Unni RR, Prager RT, Odabashian R, Zhang JJ, Fat Hing NN, Nery PB, Pi L, Aldawood W, Sadek MS, Redpath CJ, Birnie DH, Alqarawi W, Zagzoog A, Golian M, Klein A, Ramirez FD, Green MS, Chen L, Visintini S, Wells GA, Nair GM. Rhythm Monitoring Strategy and Arrhythmia Recurrence in Atrial Fibrillation Ablation Trials: A Systematic Review. CJC Open 2022; 4:488-496. [PMID: 35607484 PMCID: PMC9123375 DOI: 10.1016/j.cjco.2022.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background : The rhythm-monitoring strategy after catheter ablation (CA) for atrial fibrillation (AF) impacts the detection of atrial arrhythmia recurrence and is not well characterized. We performed a systematic review and meta-regression analysis to determine whether the duration and mode of rhythm monitoring after CA affects detection of atrial arrhythmia recurrence. Methods Databases were systematically searched for randomized controlled trials of adult patients undergoing first CA for AF from 2007 to 2021. Duration and strategy of rhythm monitoring were extracted. Meta-regression was used to identify any association between duration of monitoring and detection of atrial arrhythmia recurrence. The primary measure of outcome was single-procedure recurrence of atrial arrhythmia. Results The search strategy yielded 57 trial arms from 56 randomized controlled trials comprising 5322 patients: 36 arms of patients with paroxysmal AF (PAF), and 21 arms of patients with persistent AF (PeAF) or both PAF/PeAF. Intermittent monitoring was associated with detection of significantly less atrial arrhythmia recurrence than continuous monitoring in PAF arms (31.2% vs 46.9%, P = 0.001), but not in PeAF/PAF-PeAF combined arms (43.3% vs 63.6%, P = 0.12). No significant relationship was seen between the duration of intermittent rhythm monitoring and atrial arrhythmia recurrence detection in either the PAF (P = 0.93) or PeAF/PAF-PeAF combined arms (P = 0.20). Conclusions Continuous rhythm monitoring detected higher atrial arrhythmia recurrence rates, compared to intermittent rhythm monitoring, in patients with PAF. The duration of intermittent monitoring did not show a statistically significant relationship to the yield of arrhythmia detection, in near identical cohorts of trial subjects undergoing similar interventions, with clinical and research implications.
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40
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Roston TM, Islam S, Hawkins NM, Laksman ZW, Sanatani S, Krahn AD, Sandhu R, Kaul P. A Population-Based Study of Unexplained/Lone Atrial Fibrillation: Temporal Trends, Management, and Outcomes. CJC Open 2022; 4:65-74. [PMID: 35072029 PMCID: PMC8767123 DOI: 10.1016/j.cjco.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/06/2021] [Indexed: 11/28/2022] Open
Abstract
Background Previous studies on lone/unexplained atrial fibrillation and atrial flutter (AF) did not exclude patients with contemporary secondary AF triggers. We characterized unexplained AF using a strict definition, and compared it to secondary AF. Methods In this population-based study, unexplained AF was defined by the lack of any identifiable triggering medical/surgical diagnosis. Comparisons by AF type (unexplained vs secondary), age-of-onset (≤ / > 65 years), and sex were undertaken. Data were acquired by linking 6 population databases maintained by the Alberta Ministry of Health over a 9-year period (April 2006 to March 2015). The primary composite outcome of stroke, transient ischemic attack, thromboembolism, and/or death was assessed. Results There were 33,150 incident AF diagnoses identified, including 1145 patients (3.5%) with unexplained AF, 931 (81.2%) of whom were aged ≤ 65 years (2.8% of diagnoses, and 79% male). Patients with unexplained AF less often received rate/rhythm-control drugs (P < 0.0001), but they more often underwent electrical cardioversion (P < 0.0001) vs secondary AF patients. Men were younger at unexplained AF diagnosis (45 [interquartile range: 34-59] vs 58 [interquartile range: 40-69] years; P < 0.001). After adjusting for age at diagnosis, there were no sex-based differences in the primary outcome. Event-free survival in young unexplained AF (age ≤ 65 years) was 99.4% at 1 year and 98.3% at 3 years. At 3 years, hospitalization(s)/emergency visit(s) for noncardiovascular reasons and for AF occurred in 56.6% and 23.8% of these patients, respectively. Conclusions Using a strict contemporary definition of unexplained AF, this study shows that the condition is rare, predominantly male, and has excellent event-free survival. However, the high rate of acute hospital utilization after diagnosis is concerning.
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Affiliation(s)
- Thomas M. Roston
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Nathaniel M. Hawkins
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary W. Laksman
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Shubhayan Sanatani
- Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew D. Krahn
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Roopinder Sandhu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author: Dr Padma Kaul, 4-120 Katz Group Centre for Pharmacy and Health Research, University of Alberta, Edmonton, Alberta T6G 2E1, Canada. Tel.: +1-780-492-1140 ; fax: +1-780-492-0613.
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Fan K, Chen L, Liu F, Ding X, Yan P, Gao M, Yu W, Liu H, Yu Y. Predicting New-Onset Postoperative Atrial Fibrillation Following Isolated Coronary Artery Bypass Grafting: Development and Validation of a Novel Nomogram. Int J Gen Med 2022; 15:937-948. [PMID: 35115819 PMCID: PMC8801512 DOI: 10.2147/ijgm.s346339] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/07/2022] [Indexed: 01/23/2023] Open
Abstract
Objective To select variables associated with new-onset postoperative atrial fibrillation (POAF) following isolated coronary artery bypass grafting (CABG) and develop a nomogram for risk prediction in a Chinese population. Methods The study retrospectively enrolled 4854 consecutive patients undergoing isolated CABG from February 2018 to September 2019, they were divided into derivation cohort and validation cohort with a 3:1 ratio according to the order of operation date. In the derivation cohort, significant variables were selected by use of the multivariate logistic backward stepwise regression analysis and a nomogram model was built on the strength of the results. The model performance was assessed in terms of discrimination and calibration. Besides, we compared the discriminative ability for POAF of the nomogram with established prediction models (CHA2DS2-VASc and HATCH scores) in the two cohorts. Results POAF occurred in 1025 (28.2%) out of 3641 patients in the derivation cohort, and in 337 (27.8%) out of 1213 patients in the validation cohort. A nomogram, composed of eight prognostic variables, namely age, sex, heart rate, hypertension, left ventricular ejection fraction (LVEF) <50%, left atrial diameter (LAD) > 40mm, estimated glomerular filtration rate (eGFR) level, and on-pump surgery, was constructed from the derivation cohort. The nomogram had substantial discriminative ability in derivation and validation cohorts with the area under the receiver operating characteristic curves (AUCs) of 0.661 (95% confidence interval, 0.642–0.681) and 0.665 (95% confidence interval, 0.631–0.699), respectively, and showed well-fitted calibration curves. Compared with CHA2DS2-VASc, HATCH and POAF scores, respectively, the nomogram had superior discrimination performance. Conclusion We constructed a novel nomogram with improved accuracy for predicting the risk of POAF following isolated CABG, which might help clinicians predict individual probability of POAF and achieve effective prophylaxis.
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Affiliation(s)
- Kangjun Fan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Liang Chen
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Fei Liu
- Department of Biology, Faculty of Science, Hong Kong Baptist College, Kowloon Tong, Hong Kong, People’s Republic of China
| | - Xiaohang Ding
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Pengyun Yan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Mingxin Gao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Wenyuan Yu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Hongli Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Yang Yu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
- Correspondence: Yang Yu, Tel +86-10-64456868, Fax +86-10-84005030, Email
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Satisfaction With Oral Anticoagulants Among Patients With Atrial Fibrillation: A Prospective Observational Study. CJC Open 2021; 3:1347-1356. [PMID: 34901803 PMCID: PMC8640622 DOI: 10.1016/j.cjco.2021.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Satisfaction with treatment has been identified as an important contributing factor to adherence with oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). We aimed to evaluate the satisfaction level of patients with AF regarding OAC use over time, using validated patient-reported outcome instruments, and to identify associated patient characteristics. Methods Participants were recruited from specialized AF clinics in Canada. Eligible AF patients who were prescribed OACs were followed for up to 2 years. Participants were interviewed via telephone every 3-4 months using a structured survey. The Treatment Satisfaction Questionnaire for Medication (TSQM II) and the Anti-Clot Treatment Scale (ACTS) were used to measure satisfaction over time. Results Among the 306 participants, satisfaction scores on the TSQM II and ACTS instruments were high. Unadjusted analyses showed significantly greater satisfaction with the burden of therapy with direct OACs (DOACs) compared to that with warfarin (small-magnitude effect) and greater satisfaction with the convenience of rivaroxaban, compared with that of all other OACs (moderate-magnitude effect). After adjustment for all other variables, vitamin K antagonist therapy was associated with greater global satisfaction than was DOAC treatment. Satisfaction with benefit and burden as measured by the ACTS scale, and global satisfaction on the TSQM II scale, tended to increase over time. Patient factors that were somewhat consistently associated with greater satisfaction were female sex and younger age. Conclusions Patients with AF were highly satisfied with their therapy, with few differences among OAC classes and individual OACs. Individual patients may or may not be more satisfied with DOAC than VKA therapy, and regardless of the OAC prescribed, the may require significant support to maintain therapy adherence.
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Eberhardt TE, Bungard TJ, Graham MM, Picard M, Wang GT, Ackman ML. Effect of New Evidence on Antithrombotic Therapies in Atrial Fibrillation Patients Who Undergo Percutaneous Coronary Intervention in Alberta, Canada. CJC Open 2021; 4:378-382. [PMID: 35495861 PMCID: PMC9039572 DOI: 10.1016/j.cjco.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/20/2021] [Indexed: 10/26/2022] Open
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Valle FH, Goodman SG, Tan M, Ha A, Mansour S, Welsh RC, Yan AT, Bainey KR, Rinfret S, Potter BJ, Khan R, Simkus G, Natarajan MK, Schwalm J, Daneault B, Eisenberg MJ, Abunassar J, Har B, Gregoire J, Tanguay JF, Overgaard CB, Dery JP, De Larochelliere R, Paradis JM, Madan M, Elbarouni B, So DY, Quraishi AUR, Bagai A. Antithrombotic Therapy After Percutaneous Coronary Intervention in Patients With Atrial Fibrillation: Findings From the CONNECT AF+PCI Study. CJC Open 2021; 3:1419-1427. [PMID: 34993453 PMCID: PMC8712598 DOI: 10.1016/j.cjco.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/02/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), selecting an antithrombotic regimen requires balancing risks of ischemic cardiac events, stroke, and bleeding. METHODS We studied 467 patients with AF undergoing PCI in the time period from December 2015 to July 2018 identified via a chart audit by 47 Canadian cardiologists in the CONNECT AF+PCI (the Coordinated National Network to Engage Interventional Cardiologists in the Antithrombotic Treatment of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) study, to determine patterns of initial antithrombotic therapy selection. RESULTS The median (25th, 75th percentile) CHADS2 score was 2 (1, 3), and PCI was performed in the setting of acute coronary syndrome in 62.1%. Triple antithrombotic therapy (TAT) was the initial treatment in 62.7%, dual-pathway therapy in 25.7%, and dual antiplatelet therapy in 11.6%, with a temporal increase in use of dual-pathway therapy during the course of the study; median intended TAT duration was 1 (1, 3) month. Compared with patients selected for TAT, patients selected for dual-pathway therapy were less likely to have prior myocardial infarction (35.8% vs 25.8%, P = 0.045) and prior PCI (33.8% vs 23.3%, P = 0.03), and they received shorter total length of stents (38 [23, 56] vs 30 [20, 46] mm, P = 0.03). Patients selected for dual-pathway therapy had a higher prevalence of prior stroke/transient ischemic attack (13.0% vs 23.3%, P = 0.01). There was no difference in prevalence of anemia (21.5% vs 25.8%, P = 0.30). Use of dual-pathway therapy was similar among patients with acute coronary syndrome and those with stable disease (24.1% vs 28.2%, P = 0.32). CONCLUSIONS Approximately one-quarter of AF patients undergoing PCI are treated with dual-pathway therapy in Canadian practice, with its use increasing during the studied period. Patients selected for dual-pathway therapy have less-complex coronary disease history and intervention.
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Affiliation(s)
- Felipe H. Valle
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G. Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Mary Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Andrew Ha
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T. Yan
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Stephane Rinfret
- Centre universitaire de santé McGill, McGill University, Montreal, Quebec, Canada
| | - Brian J. Potter
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Razi Khan
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Gerald Simkus
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Madhu K. Natarajan
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - J.D. Schwalm
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Benoit Daneault
- Centre hospitalier universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark J. Eisenberg
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Joseph Abunassar
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Bryan Har
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Jean Gregoire
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Francois Tanguay
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Robert De Larochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Basem Elbarouni
- St.Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek Y.F. So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ata-Ur-Rehman Quraishi
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - CONNECT AF+PCI Study Investigators
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Heart Research Centre, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Centre universitaire de santé McGill, McGill University, Montreal, Quebec, Canada
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Centre hospitalier universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- St.Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Shaikh F, Wynne R, Castelino RL, Inglis SC, Ferguson C. Effectiveness of Direct Oral Anticoagulants in Obese Adults With Atrial Fibrillation: A Systematic Review of Systematic Reviews and Meta-Analysis. Front Cardiovasc Med 2021; 8:732828. [PMID: 34692784 PMCID: PMC8531486 DOI: 10.3389/fcvm.2021.732828] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia. Obesity is an independent risk factor for AF. Anticoagulants have been strongly recommended by all international guidelines to prevent stroke. However, altered pathophysiology in obese adults may influence anticoagulant pharmacology. Direct oral anticoagulants (DOACs) in the context of obesity and AF have been examined in recent systematic reviews. Despite the similarities in included studies, their results and conclusions do not agree. Methods and Results: The protocol for this review was registered with PROSPERO (CRD42020181510). Seven key electronic databases were searched using search terms such as “atrial fibrillation,” “obese,*” “overweight,” “novel oral anticoagulant,” “direct oral anticoagulant,” “DOAC,” “NOAC,” “apixaban,” dabigatran,” “rivaroxaban,” and “edoxaban” to locate published and unpublished studies. Only systematic reviews with meta-analyses that examined the effect of DOACs in overweight or obese adults with AF, published in the English language, were included. A total of 9,547 articles were initially retrieved. After removing the duplicates, title and abstract review and full-text review, five articles were included in the systematic review. From these only RCTs were included in the meta-analyses. There was disagreement within the published systematic reviews on DOACs in obesity. The results from our meta-analysis did not show any significant difference between all body mass index (BMI) groups for all outcomes at both 12 months and for the entire trial duration. Non-significant differences were seen among the different types of DOACs. Conclusion: There was no difference between the BMI classes in any of the outcomes assessed. This may be due to the limited number of people in the trial that were in the obese class, especially obese class III. There is a need for large prospective trials to confirm which DOACs are safe and efficacious in the obese class III adults and at which dose.
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Affiliation(s)
- Fahad Shaikh
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Rochelle Wynne
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown, NSW, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Ronald L Castelino
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Sally C Inglis
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, NSW, Australia
| | - Caleb Ferguson
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown, NSW, Australia
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Bawazeer GA, Alkofide HA, Alsharafi AA, Babakr NO, Altorkistani AM, Kashour TS, Miligkos M, AlFaleh KM, Al-Ansary LA. Interrupted versus uninterrupted anticoagulation therapy for catheter ablation in adults with arrhythmias. Cochrane Database Syst Rev 2021; 10:CD013504. [PMID: 34674223 PMCID: PMC8530018 DOI: 10.1002/14651858.cd013504.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The management of anticoagulation therapy around the time of catheter ablation (CA) procedure for adults with arrhythmia is critical and yet is variable in clinical practice. The ideal approach for safe and effective perioperative management should balance the risk of bleeding during uninterrupted anticoagulation while minimising the risk of thromboembolic events with interrupted therapy. OBJECTIVES To compare the efficacy and harms of interrupted versus uninterrupted anticoagulation therapy for catheter ablation (CA) in adults with arrhythmias. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and SCI-Expanded on the Web of Science for randomised controlled trials on 5 January 2021. We also searched three registers on 29 May 2021 to identify ongoing or unpublished trials. We performed backward and forward searches on reference lists of included trials and other systematic reviews and contacted experts in the field. We applied no restrictions on language or publication status. SELECTION CRITERIA We included randomised controlled trials comparing uninterrupted anticoagulation with any modality of interruption with or without heparin bridging for CA in adults aged 18 years or older with arrhythmia. DATA COLLECTION AND ANALYSIS Two review authors conducted independent screening, data extraction, and assessment of risk of bias. A third review author resolved disagreements. We extracted data on study population, interruption strategy, ablation procedure, thromboembolic events (stroke or systemic embolism), major and minor bleeding, asymptomatic thromboembolic events, cardiovascular and all-cause mortality, quality of life (QoL), length of hospital stay, cost, and source of funding. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We identified 12 studies (4714 participants) that compared uninterrupted periprocedural anticoagulation with interrupted anticoagulation. Studies performed an interruption strategy by either a complete interruption (one study) or by a minimal interruption (11 studies), of which a single-dose skipped strategy was used (nine studies) or two-dose skipped strategy (two studies), with or without heparin bridging. Studies included participants with a mean age of 65 years or greater, with only two studies conducted in relatively younger individuals (mean age less than 60 years). Paroxysmal atrial fibrillation (AF) was the primary type of AF in all studies, and seven studies included other types of AF (persistent and long-standing persistent). Most participants had CHADS2 or CHADS2-VASc demonstrating a low-moderate risk of stroke, with almost all participants having normal or mildly reduced renal function. Ablation source using radiofrequency energy was the most common (seven studies). Ten studies (2835 participants) were conducted in East Asian countries (Japan, China, and South Korea), while the remaining two studies were conducted in the USA. Eight studies were conducted in a single centre. Postablation follow-up was variable among studies at less than 30 days (three studies), 30 days (six studies), and more than 30 days postablation (three studies). Overall, the meta-analysis showed high uncertainty of the effect between the interrupted strategy compared to uninterrupted strategy on the primary outcomes of thromboembolic events (risk ratio (RR) 1.76, 95% confidence interval (CI) 0.33 to 9.46; I2 = 59%; 6 studies, 3468 participants; very low-certainty evidence). However, subgroup analysis showed that uninterrupted vitamin A antagonist (VKA) is associated with a lower risk of thromboembolic events without increasing the risk of bleeding. There is also uncertainty on the outcome of major bleeding events (RR 1.10, 95% CI 0.59 to 2.05; I2 = 6%; 10 studies, 4584 participants; low-certainty evidence). The uncertainty was also evident for the secondary outcomes of minor bleeding (RR 1.01, 95% CI 0.46 to 2.22; I2 = 87%; 9 studies, 3843 participants; very low-certainty evidence), all-cause mortality (RR 0.34, 95% CI 0.01 to 8.21; 442 participants; low-certainty evidence) and asymptomatic thromboembolic events (RR 1.45, 95% CI 0.85 to 2.47; I2 = 56%; 6 studies, 1268 participants; very low-certainty evidence). There was a lower risk of the composite endpoint of thromboembolic events (stroke, systemic embolism, major bleeding, and all-cause mortality) in the interrupted compared to uninterrupted arm (RR 0.23, 95% CI 0.07 to 0.81; 1 study, 442 participants; low-certainty evidence). In general, the low event rates, different comparator anticoagulants, and use of different ablation procedures may be the cause of imprecision and heterogeneity observed. AUTHORS' CONCLUSIONS This meta-analysis showed that the evidence is uncertain to inform the decision to either interrupt or continue anticoagulation therapy around CA procedure in adults with arrhythmia on outcomes of thromboembolic events, major and minor bleeding, all-cause mortality, asymptomatic thromboembolic events, and a composite endpoint of thromboembolic events (stroke, systemic embolism, major bleeding, and all-cause mortality). Most studies in the review adopted a minimal interruption strategy which has the advantage of reducing the risk of bleeding while maintaining a lower level of anticoagulation to prevent periprocedural thromboembolism, hence low event rates on the primary outcomes of thromboembolism and bleeding. The one study that adopted a complete interruption of VKA showed that uninterrupted VKA reduces the risk of thromboembolism without increasing the risk of bleeding. Hence, future trials with larger samples, tailored to a more generalisable population and using homogeneous periprocedural anticoagulant therapy and ablation source are required to address the safety and efficacy of the optimal management of anticoagulant therapy prior to ablation.
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Affiliation(s)
- Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hadeel A Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Aya A Alsharafi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nada O Babakr
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | | | - Tarek S Kashour
- Department of Cardiology, King Saud University, Riyadh, Saudi Arabia
| | - Michael Miligkos
- Department of Biomathematics, Medical School, University of Thessaly, Larissa, Greece
| | - Khalid M AlFaleh
- Department of Pediatrics (Division of Neonatology), King Saud University, Riyadh, Saudi Arabia
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
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Long Y, Tong Y, Miao R, Fan R, Cao X, Wang J, Sun J, Day JD, Liu C, Li G. Early Coagulation Disorder Is Associated With an Increased Risk of Atrial Fibrillation in Septic Patients. Front Cardiovasc Med 2021; 8:724942. [PMID: 34660726 PMCID: PMC8514978 DOI: 10.3389/fcvm.2021.724942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/01/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Atrial fibrillation (AF) and coagulation disorder, two common complications of sepsis, are associated with the mortality. However, the relationship between early coagulation disorder and AF in sepsis remains elusive. This study aimed to evaluate the interaction between AF and early coagulation disorder on mortality. Methods: In this retrospective study, all data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Septic patients with coagulation tests during the first 24 h after admission to intensive care units (ICUs) meeting study criteria were included in the analysis. Early coagulation disorder is defined by abnormalities in platelet count (PLT), international normalized ratio (INR) and activated partial thromboplastin time (APTT) within the first 24 h after admission, whose score was defined with reference to sepsis-induced coagulopathy (SIC) and coagulopathy. Patients meeting study criteria were divided into AF and non-AF groups. Results: In total, 7,528 septic patients were enrolled, including 1,243 (16.51%) with AF and 5,112 (67.91%) with early coagulation disorder. Compared with patients in the non-AF group, patients in the AF group had higher levels of INR and APTT (P < 0.001). Multivariable logistic regression analyses showed that stroke, early coagulation disorder, age, gender, congestive heart failure (CHF), chronic pulmonary disease, renal failure, and chronic liver disease were independent risk factors for AF. In addition, AF was related to in-hospital mortality and 90-day mortality. In the subgroup analysis stratified by the scores of early coagulation disorder, AF was associated with an increased risk of 90-day mortality when the scores of early coagulation disorder were 1 or 2 and 3 or 4. Conclusion: In sepsis, coagulation disorder within the first 24 h after admission to the ICUs is an independent risk factor for AF. The effect of AF on 90-day mortality varies with the severity of early coagulation disorder.
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Affiliation(s)
- Yunxiang Long
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yingmu Tong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Runchen Miao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rong Fan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiangqi Cao
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jie Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingjing Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - John D Day
- Department of Cardiology, St. Mark's Hospital, Salt Lake City, UT, United States
| | - Chang Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Toufic El Hussein M, Green T. Alphabetical Mnemonic to Assist in the Treatment of an Acute Ischemic Stroke. Crit Care Nurs Q 2021; 44:368-378. [PMID: 34437315 DOI: 10.1097/cnq.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Determining the treatment plan and how to successfully manage a patient suffering from an acute ischemic stroke can be challenging for a registered nurse (RN) in the emergency department. Using a mnemonic in the treatment process assists in reducing medical errors and increases the likelihood of making positive clinical outcomes. Mnemonics sum up complex strategies into relevant information that can be comprehensible for users. The authors have created a mnemonic strategy to provide RNs in the emergency department with a structured approach to the pharmacotherapeutic strategies used in treating patients with an acute ischemic stroke. All guidelines used throughout the article are in concurrence.
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Affiliation(s)
- Mohamed Toufic El Hussein
- School of Nursing and Midwifery, Mount Royal University, Calgary, Alberta, Canada (Dr El Hussein and Ms Green); Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada (Dr El Hussein); and NP Cardiology CCU, Alberta Health Services, Rockyview Hospital, Calgary, Alberta, Canada (Dr El Hussein)
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Reddin C, Judge C, Loughlin E, Murphy R, Costello M, Alvarez A, Ferguson J, Smyth A, Canavan M, O’Donnell MJ. Association of Oral Anticoagulation With Stroke in Atrial Fibrillation or Heart Failure: A Comparative Meta-Analysis. Stroke 2021; 52:3151-3162. [PMID: 34281383 PMCID: PMC8478106 DOI: 10.1161/strokeaha.120.033910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/04/2021] [Accepted: 03/31/2021] [Indexed: 01/11/2023]
Abstract
Background and Purpose Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit. Methods PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I2 among all trials and testing the between-trial-population P-interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage. Results Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I2=12.4%; P interaction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations. Conclusions The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.
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Affiliation(s)
- Catriona Reddin
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Conor Judge
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Translational Medical Device Laboratory (C.J.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
- Wellcome Trust – HRB, Irish Clinical Academic Training (C.J.)
| | - Elaine Loughlin
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Robert Murphy
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Maria Costello
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Alberto Alvarez
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
| | - John Ferguson
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
| | - Andrew Smyth
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Michelle Canavan
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
| | - Martin J. O’Donnell
- HRB-Clinical Research Facility (C.R., C.J., E.L., R.M., M. Costello, A.A., J.F., A.S., M. Canavan, M.J.O.), National University of Ireland Galway
- Department of Geriatric and Stroke Medicine, Galway University Hospital, Newcastle Road, Ireland (C.R., C.J., E.L., R.M., M. Costello, A.S., M. Canavan, M.J.O.)
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Beaulieu MC, Boivin-Proulx LA, Matteau A, Mansour S, Gobeil JF, Potter BJ. Evolution of Antithrombotic Management of Atrial Fibrillation After Percutaneous Coronary Intervention Over 10 Years and Guidelines Uptake. CJC Open 2021; 3:1025-1032. [PMID: 34505042 PMCID: PMC8413257 DOI: 10.1016/j.cjco.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background The management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks. Methods A tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010–2011; cohort 2014–2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ2 test. Results A total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P = 0.23). Conclusions A combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI.
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Affiliation(s)
| | | | | | | | | | - Brian J. Potter
- Corresponding author: Dr Brian J. Potter, Health Innovation and Evaluation Hub, Research Centre of CHUM, Cardiology & Interventional Cardiology, CHUM, Pavillon S, S03-334, 850, Rue St-Denis, Montréal, Quebec H2 × 0A9, Canada. Tel.: +1-514-890-8000 ext.15473; fax: +1-514-412-7212.
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