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Noubiap JJ, Nyaga UF, Middeldorp ME, Stokes MB, Sanders P. Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis. J Cardiovasc Med (Hagerstown) 2024; 25:280-293. [PMID: 38407860 DOI: 10.2459/jcm.0000000000001608] [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: 02/27/2024]
Abstract
BACKGROUND New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation. METHODS MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates. RESULTS We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke. CONCLUSION These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.
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Affiliation(s)
- Jean Jacques Noubiap
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | | | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Smidt Heart Institute, Cedar-Sinai Medical Centre, Los Angeles, California, USA
| | - Michael B Stokes
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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2
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Sharma AK, Singh S, Bhat M, Gill K, Zaid M, Kumar S, Shakya A, Tantray J, Jose D, Gupta R, Yangzom T, Sharma RK, Sahu SK, Rathore G, Chandolia P, Singh M, Mishra A, Raj S, Gupta A, Agarwal M, Kifayat S, Gupta A, Gupta P, Vashist A, Vaibhav P, Kathuria N, Yadav V, Singh RP, Garg A. New drug discovery of cardiac anti-arrhythmic drugs: insights in animal models. Sci Rep 2023; 13:16420. [PMID: 37775650 PMCID: PMC10541452 DOI: 10.1038/s41598-023-41942-4] [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: 04/24/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023] Open
Abstract
Cardiac rhythm regulated by micro-macroscopic structures of heart. Pacemaker abnormalities or disruptions in electrical conduction, lead to arrhythmic disorders may be benign, typical, threatening, ultimately fatal, occurs in clinical practice, patients on digitalis, anaesthesia or acute myocardial infarction. Both traditional and genetic animal models are: In-vitro: Isolated ventricular Myocytes, Guinea pig papillary muscles, Patch-Clamp Experiments, Porcine Atrial Myocytes, Guinea pig ventricular myocytes, Guinea pig papillary muscle: action potential and refractory period, Langendorff technique, Arrhythmia by acetylcholine or potassium. Acquired arrhythmia disorders: Transverse Aortic Constriction, Myocardial Ischemia, Complete Heart Block and AV Node Ablation, Chronic Tachypacing, Inflammation, Metabolic and Drug-Induced Arrhythmia. In-Vivo: Chemically induced arrhythmia: Aconitine antagonism, Digoxin-induced arrhythmia, Strophanthin/ouabain-induced arrhythmia, Adrenaline-induced arrhythmia, and Calcium-induced arrhythmia. Electrically induced arrhythmia: Ventricular fibrillation electrical threshold, Arrhythmia through programmed electrical stimulation, sudden coronary death in dogs, Exercise ventricular fibrillation. Genetic Arrhythmia: Channelopathies, Calcium Release Deficiency Syndrome, Long QT Syndrome, Short QT Syndrome, Brugada Syndrome. Genetic with Structural Heart Disease: Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Atrial Fibrillation, Sick Sinus Syndrome, Atrioventricular Block, Preexcitation Syndrome. Arrhythmia in Pluripotent Stem Cell Cardiomyocytes. Conclusion: Both traditional and genetic, experimental models of cardiac arrhythmias' characteristics and significance help in development of new antiarrhythmic drugs.
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Affiliation(s)
- Ashish Kumar Sharma
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India.
| | - Shivam Singh
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Mehvish Bhat
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Kartik Gill
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Mohammad Zaid
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Sachin Kumar
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Anjali Shakya
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Junaid Tantray
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Divyamol Jose
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Rashmi Gupta
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Tsering Yangzom
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Rajesh Kumar Sharma
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | | | - Gulshan Rathore
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Priyanka Chandolia
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Mithilesh Singh
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Anurag Mishra
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Shobhit Raj
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Archita Gupta
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Mohit Agarwal
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Sumaiya Kifayat
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Anamika Gupta
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Prashant Gupta
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Ankit Vashist
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Parth Vaibhav
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Nancy Kathuria
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Vipin Yadav
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Ravindra Pal Singh
- NIMS Institute of Pharmacy, NIMS University Rajasthan, Jaipur, Rajasthan, 303121, India
| | - Arun Garg
- MVN University, Palwal, Haryana, India
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3
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Chung SC, Lai A, Lip GYH, Lambiase PD, Providencia R. Impact of anti-arrhythmic drugs and catheter ablation on the survival of patients with atrial fibrillation: a population study based on 199 433 new-onset atrial fibrillation patients in the UK. Europace 2023; 25:351-359. [PMID: 36106534 PMCID: PMC10103560 DOI: 10.1093/europace/euac155] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Utilizing real-world UK data, we aimed to understand: (i) whether anti-arrhythmic drugs and catheter ablation are effective in improving the survival of atrial fibrillation (AF) patients and (ii) which rhythm control option produces better results for the whole AF population and for specific groups of patients, stratified by age, sex, and history of heart failure. METHODS AND RESULTS We identified 199 433 individuals (mean age at diagnosis 75.7 ± 12.7 years; 50.2% women) with new-onset AF diagnosis in nationwide electronic health records linking primary care consultation with hospital data and death registry data from 1998 to 2016. We investigated the survival and causes of death of new-onset AF patients receiving vs. not-receiving rhythm control therapies. During a median follow-up of 2.7 (0.7-6.0) years, we observed a significantly lower mortality in patients receiving rhythm control [multivariate-adjusted hazard ratio (HR) = 0.86, 95% confidence interval (CI) 0.84-0.88]. Pulmonary vein isolation was associated with a two-third significant mortality reduction compared with no rhythm control (HR = 0.36, 95% CI 0.28-0.48), flecainide with 50% reduction (HR = 0.52, 95% CI 0.48-0.57), and propafenone and sotalol with reduction by a third (HR = 0.63, 95% CI 0.50-0.81, 0.71, 95% CI 0.68-0.74, respectively). Amiodarone showed no survival benefit in individuals <70 years (HR = 0.99, 95% CI 0.97-1.02). Otherwise, the effect of rhythm control on survival did not differ by age, sex, nor history of heart failure. CONCLUSION Among individuals with new-onset AF, favourable survival was observed for patients receiving rhythm control treatment. Among different rhythm control strategies, pulmonary vein isolation showed the most pronounced survival benefit.
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Affiliation(s)
- Sheng-Chia Chung
- UCL Institute of Health Informatics Research, University College London, 222 Euston Rd, London NW1 2DA, UK
| | - Alvina Lai
- UCL Institute of Health Informatics Research, University College London, 222 Euston Rd, London NW1 2DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Pier D Lambiase
- UCL Institute of Cardiovascular Science University College London, London, UK.,St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rui Providencia
- UCL Institute of Health Informatics Research, University College London, 222 Euston Rd, London NW1 2DA, UK.,St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
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4
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Blackwell DJ, Schmeckpeper J, Knollmann BC. Animal Models to Study Cardiac Arrhythmias. Circ Res 2022; 130:1926-1964. [PMID: 35679367 DOI: 10.1161/circresaha.122.320258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac arrhythmias are a significant cause of morbidity and mortality worldwide, accounting for 10% to 15% of all deaths. Although most arrhythmias are due to acquired heart disease, inherited channelopathies and cardiomyopathies disproportionately affect children and young adults. Arrhythmogenesis is complex, involving anatomic structure, ion channels and regulatory proteins, and the interplay between cells in the conduction system, cardiomyocytes, fibroblasts, and the immune system. Animal models of arrhythmia are powerful tools for studying not only molecular and cellular mechanism of arrhythmogenesis but also more complex mechanisms at the whole heart level, and for testing therapeutic interventions. This review summarizes basic and clinical arrhythmia mechanisms followed by an in-depth review of published animal models of genetic and acquired arrhythmia disorders.
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Affiliation(s)
- Daniel J Blackwell
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey Schmeckpeper
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Bjorn C Knollmann
- Vanderbilt Center for Arrhythmia Research and Therapeutics, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN
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5
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Hofer F, Pailer U, Sulzgruber P, Gerges C, Winter MP, Giugliano RP, Gottsauner-Wolf M, Hülsmann M, Kazem N, Koller L, Schönbauer R, Niessner A, Hengstenberg C, Zelniker TA. Relationship of diabetes, heart failure, and N-terminal pro-B-type natriuretic peptide with cardiovascular outcomes in patients with atrial fibrillation. ESC Heart Fail 2022; 9:2367-2377. [PMID: 35593128 PMCID: PMC9288777 DOI: 10.1002/ehf2.13930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 03/20/2022] [Accepted: 04/04/2022] [Indexed: 12/11/2022] Open
Abstract
Aims We aim to explore the relationship of heart failure (HF) and diabetes with cardiovascular (CV) death or hospitalization for HF (HHF) and to study the clinical utility of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in an unselected patient population with atrial fibrillation (AF). Methods and results Patients with AF admitted to a tertiary academic center between January 2005 and July 2019 were identified through a search of electronic health records. We used Cox regression models adjusted for age, sex, estimated glomerular filtration rate, diabetes, HF, body mass index, prior myocardial infarction, coronary artery disease, hypertension, smoking, C‐reactive protein, and low‐density lipoprotein cholesterol. To select the most informative variables, we performed a least absolute shrinkage and selection operator Cox regression with 10‐fold cross‐validation. In total, 7412 patients (median age 70 years, 39.7% female) were included in this analysis and followed over a median of 4.5 years. Both diabetes [adjusted (Adj.) HR 1.87, 95% CI 1.55–2.25] and HF (Adj. HR 2.57, 95% CI 2.22–2.98) were significantly associated with CV death/HHF after multivariable adjustment. Compared with patients with diabetes, HF patients had a higher risk of HHF but a similar risk of CV and all‐cause death. NT‐proBNP showed good discriminatory performance (area under the curve 0.78, 95% CI 0.77–0.80) and the addition of NT‐proBNP to the covariates used for adjustment resulted in a significant area under the curve improvement (Δ = 0.04, P < 0.001). With least absolute shrinkage and selection operator, the strongest associations for CV death/HHF were obtained for NT‐proBNP [HR 1.91 per 1‐SD in log‐transformed biomarker], HF (HR 1.72), and diabetes (HR 1.56). Conclusions Diabetes and HF were independently associated with an increased risk of CV death/HHF in an unselected AF patient population, and NT‐proBNP improved risk assessment. These findings suggest that AF patients with diabetes and/or HF should be managed not only for their risk of stroke and systemic embolic events but also for CV death/HHF.
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Affiliation(s)
- Felix Hofer
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | - Christian Gerges
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Max-Paul Winter
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Martin Hülsmann
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Niema Kazem
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Lorenz Koller
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Robert Schönbauer
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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6
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Jang AY, Kang WC, Park YM, Ha K, Seo J, Oh PC, Lee K, Moon J. The Thromboembolic Predictability of CHA 2DS 2-VASc Scores Using Different Echocardiographic Criteria for Congestive Heart Failure in Korean Patients with Nonvalvular Atrial Fibrillation. J Clin Med 2022; 11:jcm11020300. [PMID: 35053995 PMCID: PMC8781364 DOI: 10.3390/jcm11020300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 01/27/2023] Open
Abstract
The association between congestive heart failure (CHF) of the CHA2DS2-VASc scores and thromboembolic (TE) events in patients with atrial fibrillation (AF) is a topic of debate due to conflicting results. As the importance of diastolic impairment in the occurrence of TE events is increasingly recognized, it is crucial to evaluate the predictive power of CHA2DS2-VASc scores with C criterion integrating diastolic parameters. We analyzed 4200 Korean nonvalvular AF patients (71 years of age, 59% men) to compare multiple echocardiographic definitions of CHF. Various guideline-suggested echocardiographic parameters for systolic or diastolic impairment, including left ventricular ejection fraction (LVEF) ≤ 40%, the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E’) ≥ 11, left atrial volume index > 34 mL/m2, and many others were tested for C criteria. Multivariate-adjusted Cox regression analysis showed that CHA2DS2-VASc score was an independent predictor for composite thromboembolic events only when CHF was defined as E/E’ ≥ 11 (hazard ratio, 1.26; p = 0.044) but not with other criteria including the original definition (hazard ratio, 1.10; p = 0.359). Our findings suggest that C criterion defined as diastolic impairment, such as E/E’ ≥ 11, may improve the predictive value of CHA2DS2-VASc scores.
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Affiliation(s)
| | - Woong Chol Kang
- Correspondence: (W.C.K.); (J.M.); Tel.: +82-32-460-3054 (W.C.K. & J.M.); Fax: +82-32-460-1901 (W.C.K.); +82-32-469-1906 (J.M.)
| | | | | | | | | | | | - Jeonggeun Moon
- Correspondence: (W.C.K.); (J.M.); Tel.: +82-32-460-3054 (W.C.K. & J.M.); Fax: +82-32-460-1901 (W.C.K.); +82-32-469-1906 (J.M.)
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7
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Hiasa KI, Kaku H, Kawahara G, Inoue H, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A, Tsutsui H. Echocardiographic Structure and Function in Elderly Patients With Atrial Fibrillation in Japan - The ANAFIE Echocardiographic Substudy. Circ J 2021; 86:222-232. [PMID: 34937815 DOI: 10.1253/circj.cj-21-0180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Echocardiographic data on the cardiac structure and function in elderly patients with atrial fibrillation (AF) and heart failure (HF) are limited. This subcohort study of the ANAFIE Registry analyzed echocardiographic parameters to identify cardiac structural and functional characteristics.Methods and Results:Of 32,726 subjects in the ANAFIE population, 1,494 (4.6%) were entered as the echocardiography subcohort. Half of the patients, including those with persistent and permanent AF, older age (≥80 years), and CHADS2score ≥2, had left atrial (LA) volume index ≥48 mL/m2, indicating severe LA enlargement. LA enlargement significantly correlated with impaired LA reservoir function, regardless of age and CHADS2score. Types of AF and rhythm were strongly related to LA volume and reservoir function (P<0.0001). Moderate-to-severe mitral and tricuspid regurgitation were significantly more common, and the early diastolic mitral inflow velocity to mitral annulus velocity ratio was significantly higher among patients with than without HF history (all, P<0.0001). CONCLUSIONS In this subcohort, LA enlargement correlated with impaired LA reservoir function. Elderly patients with non-valvular AF and a history of HF had LA enlargement and dysfunction, increased LV mass index, low LV ejection fraction, and high heart rate.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
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8
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Lin Y, Fu S, Yao Y, Li Y, Zhao Y, Luo L. Heart failure with preserved ejection fraction based on aging and comorbidities. J Transl Med 2021; 19:291. [PMID: 34229717 PMCID: PMC8259336 DOI: 10.1186/s12967-021-02935-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a leading cause of hospitalizations and mortality when diagnosed at the age of ≥ 65 years. HFpEF represents multifactorial and multisystemic syndrome and has different pathophysiology and phenotypes. Its diagnosis is difficult to be established based on left ventricular ejection fraction and may benefit from individually tailored approaches, underlying age-related changes and frequent comorbidities. Compared with the rapid development in the treatment of heart failure with reduced ejection fraction, HFpEF presents a great challenge and needs to be addressed considering the failure of HF drugs to improve its outcomes. Further extensive studies on the relationships between HFpEF, aging, and comorbidities in carefully phenotyped HFpEF subgroups may help understand the biology, diagnosis, and treatment of HFpEF. The current review summarized the diagnostic and therapeutic development of HFpEF based on the complex relationships between aging, comorbidities, and HFpEF.
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Affiliation(s)
- Ying Lin
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China
| | - Shihui Fu
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Yao Yao
- Centre for the Study of Ageing and Human Development and Geriatrics Division, Medical School of Duke University, Durham, NC, 27708, USA
- Centre for Healthy Ageing and Development Studies, National School of Development, Peking University, Beijing, 100871, China
| | - Yulong Li
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Yali Zhao
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
| | - Leiming Luo
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
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9
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Arques S, Chelaifa H, Vieillard M, Roux E. Clinical relevance of spectral tissue Doppler-derived E/e' in older patients with preserved ejection fraction. Ann Cardiol Angeiol (Paris) 2021; 70:286-293. [PMID: 34130804 DOI: 10.1016/j.ancard.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/07/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The E/e' index measured in spectral tissue Doppler is included in the recommendations for the diagnosis by transthoracic Doppler echocardiography of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. While E/e' is influenced by age in healthy individuals, no studies have evaluated this index in elderly patients. This study addressed the clinical relevance of E/e' in assessment of left ventricular diastolic function in elderly patients with preserved ejection fraction and its relevance from both a diagnostic and prognostic perspective based on the existing literature. METHODS A total of 76 patients≥70years of age were prospectively included. The analysis of left ventricular diastolic function was adapted from the 2016 ASE/EACVI recommendations without consideration of E/e'. RESULTS The mean age was 85years. In all, 42 patients had moderate-to-severe diastolic dysfunction (elevated left atrial pressure). Mean E/e' was significantly correlated with diastolic function (r=0.58, P<0.001). Mean E/e'>13.3 had a sensitivity of 86% and a specificity of 91% in the diagnosis of moderate-to-severe diastolic dysfunction (AUC: 0.92). E/(e'xs') (AUC: 0.89) and NT pro-BNP (AUC: 0.80) did not perform better than E/e'. The existing literature offers large body of evidence that E/e' provides essential diagnostic and prognostic information in older patients with cardiovascular disease. CONCLUSION E/e' is accurate in the diagnosis of significant diastolic dysfunction, in the diagnosis of heart failure with preserved ejection fraction and in risk stratification in older patients with cardiovascular disease.
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Affiliation(s)
- S Arques
- Structure de cardiologie, centre hospitalier Edmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France.
| | - H Chelaifa
- Structure de cardiologie, centre hospitalier Edmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France
| | - M Vieillard
- Structure de cardiologie, centre hospitalier Edmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France
| | - E Roux
- Structure de cardiologie, centre hospitalier Edmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France
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10
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Tufano A, Galderisi M. Can echocardiography improve the prediction of thromboembolic risk in atrial fibrillation? Evidences and perspectives. Intern Emerg Med 2020; 15:935-943. [PMID: 32124208 DOI: 10.1007/s11739-020-02303-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/20/2020] [Indexed: 01/28/2023]
Abstract
Atrial fibrillation is the most common arrhythmia and its prevalence is expected to further increase. Patients with atrial fibrillation have an increased risk of stroke (fivefold increased risk), heart failure, and death. In patients with non-valvular atrial fibrillation, the most recent guidelines recommend the use of the CHA2DS2-VASc (congestive heart failure, arterial hypertension, age > 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) scoring system to identify those who may benefit from oral anticoagulant treatment. Guidelines recommend initiation of oral anticoagulation with vitamin K antagonists or direct oral anticoagulants in men with a score ≥ 2 and in women with a score ≥ 3, while oral anticoagulation in individuals with a score of 0 is not recommended. Accordingly, men with CHA2DS2VASc score = 1 (and women with CHA2DS2VASc = 2) represent a grey zone where guidelines do not provide a definite oral anticoagulant indication. Implementation of risk stratification with transthoracic echocardiography could be extremely useful. Both prospective and observational studies using transthoracic echocardiography prediction of events and studies utilizing transesophageal echocardiographic parameters as surrogate markers of thromboembolic events make sustainable the hypothesis that echocardiography could improve thromboembolism prediction in non-valvular atrial fibrillation. However, because of some controversial results of different studies, determination of the best echocardiographic parameter predicting thromboembolic events in atrial fibrillation remains uncertain. The combination of left atrial enlargement with left atrial function (in particular assessing left atrial strain) appears to be very valuable, but needs to be confirmed in large-scale multi-center trials.
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Affiliation(s)
- Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Via S. Pansini, 5, 80131, Naples, Italy.
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
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11
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Hofer F, Kazem N, Hammer A, El-Hamid F, Koller L, Niessner A, Sulzgruber P. Long-term prognosis of de novo atrial fibrillation during acute myocardial infarction: the impact of anti-thrombotic treatment strategies. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:189-195. [PMID: 32289167 DOI: 10.1093/ehjcvp/pvaa027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/08/2020] [Accepted: 04/08/2020] [Indexed: 12/12/2022]
Abstract
AIMS While the prognosis of patients presenting with de novo atrial fibrillation (AF) during the acute phase of myocardial infarction has been controversially discussed, it seems intuitive that affected individuals have an increased risk for both thrombo-embolic events and mortality. However, profound data on long-term outcome of this highly vulnerable patient population are not available in current literature. Therefore, we aimed to investigate the impact of de novo AF and associated anti-thrombotic treatment strategies on the patient outcome from a long-term perspective. METHODS AND RESULTS Patients presenting with acute myocardial infarction, treated at the Medical University of Vienna, were enrolled within a clinical registry and screened for the development of de novo AF. After discharge, participants were followed prospectively over a median time of 8.6 years. Primary study endpoint was defined as cardiovascular mortality. Out of 1372 enrolled individuals 149 (10.9%) developed de novo AF during the acute phase of acute myocardial infarction. After a median follow-up time of 8.6 years, a total of 418 (30.5%) died due to cardiovascular causes, including 93 (62.4%) in the de novo AF subgroup. We found that de novo AF was significantly associated with long-term cardiovascular mortality with an adjusted HR of 1.45 (95% CI 1.19-2.57; P < 0.001). While patients with de novo AF were less likely to receive a triple anti-thrombotic therapy as compared to patients with pre-existing AF at time of discharge, this therapeutic approach showed a strong and inverse association with mortality in de novo AF, with an adj. HR of 0.86 (95% CI 0.45-0.92; P = 0.012). CONCLUSION De novo AF was independently associated with a poor prognosis with a 67% increased risk of long-term cardiovascular mortality. Intensified anti-thrombotic treatment in this high-risk patient population might be considered.
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Affiliation(s)
- Felix Hofer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Niema Kazem
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Andreas Hammer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Feras El-Hamid
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lorenz Koller
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Patrick Sulzgruber
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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12
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Galderisi M, Esposito R, Sorrentino R, Mura LL, Santoro C, Tufano A. Atrial Fibrillation, Cancer and Echocardiography. J Cardiovasc Echogr 2020; 30:S33-S37. [PMID: 32566464 PMCID: PMC7293868 DOI: 10.4103/jcecho.jcecho_8_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/23/2019] [Accepted: 10/03/2019] [Indexed: 01/05/2023] Open
Abstract
Nonvalvular atrial fibrillation (AF) is a relatively frequent arrhythmia in cancer patients; it is possibly due to direct effect of cancer or consequence of cancer therapies. AF creates important problems for both therapeutic management and prognosis in cancer patients. The anticoagulation of cancer patients presenting AF is a main issue because of the difficult balance between thromboembolic and bleeding risks, both elevated in this clinical setting. A comprehensive echo Doppler examination is mandatory to identify the eventual sources of emboli in left atrial (LA) cavity, mainly the transesophageal echocardiography (TEE), but also to predict the subsequent development of heart failure. This evaluation is particularly important to graduate anticoagulation and to prevent and manage symptoms/signs of heart failure. The performance of a TEE precardioversion is highly encouraged to detect possible thrombi in LA appendage. A careful assessment of LA size (LA volume index) and function (LA emptying fraction and/or LA strain) should always be planned to predict the possible recurrence of AF paroxysmal episodes. This is in fact a key action, not only from the cardiologic point of view but also for the oncologic perspectives in individual situations. Patients with larger left atrium and more impaired LA function should be addressed toward a less aggressive cancer treatment, with drugs which are not associated or are poorly related with the risk of AF development. A correct and comprehensive echocardiographic assessment could even induce the oncologist to change the cancer management balancing the oncologic and the cardiac risk.
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Affiliation(s)
- Maurizio Galderisi
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
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13
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Zhuang B, Li S, Xu J, Zhou D, Yin G, Zhao S, Lu M. Age‐ and Sex‐Specific Reference Values for Atrial and Ventricular Structures in the Validated Normal Chinese Population: A Comprehensive Measurement by Cardiac
MRI. J Magn Reson Imaging 2020; 52:1031-1043. [DOI: 10.1002/jmri.27160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Baiyan Zhuang
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shuang Li
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Jing Xu
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Di Zhou
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Gang Yin
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, Cardiovascular imaging and intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
- Key Laboratory of Cardiovascular Imaging(Cultivation) Chinese Academy of Medical Sciences Beijing 100037 China
- National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH) Bethesda Maryland USA
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14
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Packer M. Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment. Eur J Heart Fail 2019; 22:214-227. [PMID: 31849132 DOI: 10.1002/ejhf.1646] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/14/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023] Open
Abstract
Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College London, London, UK
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15
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Inciardi RM, Giugliano RP, Claggett B, Gupta DK, Chandra A, Ruff CT, Antman EM, Mercuri MF, Grosso MA, Braunwald E, Solomon SD. Left atrial structure and function and the risk of death or heart failure in atrial fibrillation. Eur J Heart Fail 2019; 21:1571-1579. [PMID: 31777160 DOI: 10.1002/ejhf.1606] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/31/2019] [Accepted: 08/11/2019] [Indexed: 12/29/2022] Open
Abstract
AIMS The present study aimed to assess the association between left atrial (LA) structure and function and the risk for cardiovascular (CV) death or heart failure (HF) hospitalization in a population with atrial fibrillation (AF). METHODS AND RESULTS In a prospective echocardiographic substudy of the Effective Anticoagulation with Factor Xa Next Generation in AF-Thrombolysis in Myocardial Infarction 48 (ENGAGE AF-TIMI 48) study, 971 patients underwent transthoracic echocardiography. The associations between LA structure (LA volume index [LAVi]) and function (LA emptying fraction [LAEF] and LA expansion index [LAEi]) and risk for the composite endpoint of CV death or HF hospitalization, and its components, were assessed. Over a median follow-up of 2.5 years, 142 patients (14.6%) experienced CV death or HF hospitalization. Higher LAVi and lower LAEF and LAEi were each associated with a higher unadjusted risk for the composite outcome and its components. After adjustment for clinical and echocardiographic confounders, only measures of impaired LA function were predictive of the composite outcome (hazard ratio [HR] per 1 standard deviation [SD] decrease in LAEF: 1.35; 95% confidence interval [CI] 1.09-1.67 [P = 0.005]; HR per 1 SD decrease in LAEi: 1.34; 95% CI 1.06-1.69 [P = 0.012]). These findings were similar regardless of left ventricular ejection fraction, history of HF or whether patients were in AF or sinus rhythm at the time of the echocardiographic examination. CONCLUSIONS In patients with AF, LA dysfunction was significantly associated with an increased risk for CV death or HF hospitalization and was more predictive of these outcomes than LA size. These parameters may help to identify AF patients at greatest risk for the development of HF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT00781391.
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Affiliation(s)
- Riccardo M Inciardi
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Cardiology, Department of Medicine, University Hospital of Verona, Verona, Italy
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak K Gupta
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alvin Chandra
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michele F Mercuri
- Cardiovascular, Metabolic and Renal Disease Therapeutic Area, Global Clinical Development, Daiichi Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Michael A Grosso
- Cardiovascular, Metabolic and Renal Disease Therapeutic Area, Global Clinical Development, Daiichi Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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16
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Jung JM, Kim YH, Yu S, O K, Kim CK, Song TJ, Kim YJ, Kim BJ, Heo SH, Park KY, Kim JM, Park JH, Choi JC, Park MS, Kim JT, Choi KH, Hwang YH, Chung JW, Bang OY, Kim GM, Seo WK. Long-Term Outcomes of Real-World Korean Patients with Atrial-Fibrillation-Related Stroke and Severely Decreased Ejection Fraction. J Clin Neurol 2019; 15:545-554. [PMID: 31591844 PMCID: PMC6785482 DOI: 10.3988/jcn.2019.15.4.545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE The clinical implications of echocardiography findings for long-term outcomes in atrial fibrillation (AF)-related stroke patients are unknown. METHODS This was a substudy of the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION), which is a multicenter-based cohort comprising prospective stroke registries from 11 tertiary centers. Stroke survivors who underwent two-dimensional transthoracic echocardiography during hospitalization were enrolled. Echocardiography markers included the left-ventricle (LV) ejection fraction (LVEF), the left atrium diameter, and the ratio of the peak transmitral filling velocity to the mean mitral annular velocity during early diastole (E/e' ratio). LVEF was categorized into normal (≥55%), mildly decreased (>40% and <55%), and severely decreased (≤40%). The E/e' ratio associated with the LV filling pressure was categorized into normal (<8), borderline (≥8 and <15), and elevated (≥15). Kaplan-Meier and Cox regression analyses were performed for recurrent stroke, major adverse cardiac events, and all-cause death. RESULTS This study finally included 1,947 patients. Over a median follow-up of 1.65 years (interquartile range, 0.42-2.87 years), the rates of recurrent stroke, major adverse cardiac events, and all-cause death were 35.1, 10.8, and 69.6 cases per 1,000 person-years, respectively. Multivariable analyses demonstrated that severely decreased LVEF was associated with a higher risks of major adverse cardiac events [hazard ratio (HR), 3.91; 95% confidence interval (CI), 1.58-9.69] and all-cause death (HR, 1.95; 95% CI, 1.23-3.10). The multivariable fractional polynomial plot indicated that recurrent stroke might be associated with a lower LVEF. CONCLUSIONS Severe LV systolic dysfunction could be a determinant of long-term outcomes in AF-related stroke.
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Affiliation(s)
- Jin Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Yong Hyun Kim
- Department of Cardiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Sungwook Yu
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyungmi O
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Tae Jin Song
- Department of Neurology, Mokdong Hospital, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Yong Jae Kim
- Department of Neurology, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jeong Min Kim
- Department of Neurology, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jong Ho Park
- Department of Neurology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Man Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Joon Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kang Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea.,Department of Neurology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yang Ha Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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17
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Froehlich L, Meyre P, Aeschbacher S, Blum S, Djokic D, Kuehne M, Osswald S, Kaufmann BA, Conen D. Left atrial dimension and cardiovascular outcomes in patients with and without atrial fibrillation: a systematic review and meta-analysis. Heart 2019; 105:1884-1891. [DOI: 10.1136/heartjnl-2019-315174] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/15/2019] [Accepted: 07/24/2019] [Indexed: 12/28/2022] Open
Abstract
ObjectiveThe prognostic value of left atrial (LA) dimensions may differ between patients with and without atrial fibrillation (AF).MethodsMEDLINE and EMBASE were searched for studies that investigated the association between LA echocardiographic parameters measured by transthoracic echocardiography and cardiovascular outcomes in patients with or without AF. Data were independently abstracted by two reviewers and pooled using random-effects meta-analysis. The primary outcome was incident stroke or thromboembolic events. Secondary outcomes were heart failure, all-cause mortality and major adverse cardiac events (MACE).ResultsTwenty-three studies of patients with AF (14 939 patients) and 68 studies of patients without AF (50 720 patients) in this systematic review. Increasing LA diameter was significantly associated with stroke and thromboembolic events in patients without AF (risk ratio (RR) 1.38, 95% CI 1.02 to 1.87; p=0.03), but not in patients with AF (RR 1.02, 95% CI 0.98 to 1.07; p=0.27; p for difference=0.05). Increasing LA diameter index was significantly associated with MACE in patients with AF (RR 1.13, 95% CI 1.09 to 1.17; p<0.001) and in patients without AF (RR 2.98, 95% CI 1.90 to 4.66; p<0.001), with stronger effects in non-AF populations (p for difference <0.001). Greater LA volume index was significantly associated with the risk of MACE in patients with AF (RR 1.01, 95% CI 1.00 to 1.02; p=0.03) and in non-AF populations (RR 1.08, 95% CI 1.05 to 1.10; p<0.001), the association being stronger in individuals without AF (p for difference <0.001).ConclusionsLarger LA parameters were associated with various adverse cardiovascular events. Many of these associations were stronger in individuals without AF, highlighting the potential importance of LA myopathy.
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18
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Donal E, Galli E, Lederlin M, Martins R, Schnell F. Multimodality Imaging for Best Dealing With Patients in Atrial Arrhythmias. JACC Cardiovasc Imaging 2019; 12:2245-2261. [PMID: 30878420 DOI: 10.1016/j.jcmg.2018.06.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/21/2018] [Accepted: 06/22/2018] [Indexed: 12/28/2022]
Abstract
The management of atrial fibrillation (AF) is not only a clinical challenge but also an imaging challenge. The role of different imaging modalities to estimate the thromboembolic risk in AF is a key clinical question. The present review summarizes the advances of myocardial imaging in the stratification of thromboembolic risk, diagnosis, and management of left atrial thrombosis in patients with AF. These imaging techniques are also important for understanding arrhythmias and their consequences. It is becoming fundamental for guiding therapy. Still, large studies are required, but be sure that left atrial imaging will become more and more clinically fundamental.
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Affiliation(s)
- Erwan Donal
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France.
| | - Elena Galli
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France
| | - Matthieu Lederlin
- Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France; Service de Radiologie, CHU Pontchaillou, Rennes, France
| | - Raphael Martins
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France
| | - Frederic Schnell
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Service de médecine du sport et laboratoire de physiologie, Université Rennes 1, CHU Pontchaillou, Rennes, France
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19
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Borre ED, Goode A, Raitz G, Shah B, Lowenstern A, Chatterjee R, Sharan L, Allen LaPointe NM, Yapa R, Davis JK, Lallinger K, Schmidt R, Kosinski A, Al-Khatib SM, Sanders GD. Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review. Thromb Haemost 2018; 118:2171-2187. [PMID: 30376678 DOI: 10.1055/s-0038-1675400] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining the optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. AIM This article reviews published literature and summarizes available risk stratification tools for stroke and bleeding prediction in patients with AF. METHODS We searched for English-language studies in PubMed, Embase and the Cochrane Database of Systematic Reviews published between 1 January 2000 and 14 February 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality, and applicability were extracted. RESULTS Sixty-one studies were relevant to predicting thromboembolic risk and 38 to predicting bleeding risk. Data suggest that CHADS2, CHA2DS2-VASc and the age, biomarkers, and clinical history (ABC) risk scores have the best evidence for predicting thromboembolic risk (moderate strength of evidence for limited prediction ability of each score) and that HAS-BLED has the best evidence for predicting bleeding risk (moderate strength of evidence). LIMITATIONS Studies were heterogeneous in methodology and populations of interest, setting, interventions and outcomes analysed. CONCLUSION CHADS2, CHA2DS2-VASc and ABC scores have the best prediction for stroke events, and HAS-BLED provides the best prediction for bleeding risk. Future studies should define the role of imaging tools and biomarkers in enhancing the accuracy of risk prediction tools. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute (PROSPERO #CRD42017069999).
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Affiliation(s)
- Ethan D Borre
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Adam Goode
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, United States
| | - Giselle Raitz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Bimal Shah
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Livongo, Mountain View, California, United States
| | - Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Ranee Chatterjee
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Lauren Sharan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Nancy M Allen LaPointe
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Premier Inc., Charlotte, North Carolina, United States
| | - Roshini Yapa
- Department of Medicine, University of Colorado, Aurora, Colorado, United States
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, United States
| | - Kathryn Lallinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Robyn Schmidt
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Andrzej Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gillian D Sanders
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
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20
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Abstract
BACKGROUND A critical appraisal of all pooled evidence regarding novel oral anticoagulants (NOACs) for stroke prevention regardless of publication status or study design has not been conducted yet. Being the latest addition to NOACs, the data on edoxaban are especially scarce. STUDY QUESTION What are the comparative clinical outcomes of edoxaban versus warfarin and other NOACs apixaban, dabigatran, or rivaroxaban in adults with nonvalvular atrial fibrillation? DATA SOURCES Randomized controlled trials (RCTs), observational studies, and network meta-analyses were identified in PubMed, EMBASE, the Cochrane Library, Pharmapendium, Elsevier Clinical Pharmacology, and the clinicaltrials.gov trial registry in June 2018. STUDY DESIGN Rapid review per a priori developed protocol, direct frequentist random-effects meta-analysis of aggregate data, grading the quality of evidence per the Grading of Recommendations Assessment, Development and Evaluation working group approach. RESULTS Direct 4 RCTs (23,021 patients) suggest that edoxaban is noninferior to warfarin in prevention of stroke and systemic embolism [pooled relative risk (RR): 0.65, 95% confidence interval (CI): 0.23-1.81, 2 RCTs] and reduces the risk of cardiovascular mortality (RR: 0.87, 95% CI: 0.78-0.97, 1 RCT), major cardiovascular morbidity (RR: 0.90, 95% CI: 0.82-0.98, 2 RCTs), and major bleeding events (RR: 0.80, 95% CI: 0.71-0.91, 1 RCT) but increases the risk of gastrointestinal bleeding (RR: 1.21, 95% CI: 1.01-1.46, 1 RCT) and anemia (RR: 1.45, 95% CI: 1.05-1.99, 3 RCTs). Edoxaban is superior to warfarin in patients with increased risk of bleeding with warfarin because of variants in CYP2C9 and VKORC1 genes. Indirect evidence does not allow valid conclusions regarding comparative superiority of NOACs. The quality of evidence was downgraded because of reporting bias, small number of events, and indirectness in comparisons. CONCLUSIONS Edoxaban is a welcome addition to the NOAC's armamentarium. However, the comparative data with other novel NOACs are mostly nonexisting, and urgently needed for better individual patient assessment.
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21
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Jang AY, Yu J, Park YM, Shin MS, Chung WJ, Moon J. Cardiac Structural or Functional Changes Associated with CHA 2DS 2-VASc Scores in Nonvalvular Atrial Fibrillation: A Cross-Sectional Study Using Echocardiography. J Cardiovasc Imaging 2018; 26:135-143. [PMID: 30310880 PMCID: PMC6160813 DOI: 10.4250/jcvi.2018.26.e17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND CHA2DS2-VASc is the most widely accepted scoring system for atrial fibrillation (AF) to assess stroke risk, although little has been revealed regarding the accompanying cardiac functional/structural changes. This echocardiography study was undertaken to understand the changes related to CHA2DS2-VASc scores. METHODS A total of 4,795 nonvalvular AF patients were enrolled for the cohort, from which 591 were excluded as they did not meet the inclusion criteria. Based on the CHA2DS2-VASc scores, the remaining 4,204 patients included in the study were divided into 4 groups: 0 to 1 (n = 991); 2 to 3 (n = 1,642); 4 to 6 (n = 1,407); 7 to 9 (n = 164). RESULTS Increase in the left ventricular mass index and prevalence of left ventricular hypertrophy (LVH) were observed with elevating CHA2DS2-VASc scores (p < 0.05 for all). Diastolic parameters such as left atrial volume index (LAVI) and the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E′) also increased significantly in the higher CHA2DS2-VASc score groups (p < 0.001 for all), although two-way ANOVA analysis showed that such incremental diastolic impairment was independent of hypertension. LVH (hazard ratio [HR], 3.609; confidence interval [CI], 2.426–5.369; p < 0.001) and E/E′ (HR, 1.087; CI, 1.054–1.121; p < 0.001) were independent risk factors for CHA2DS2-VASc scores 2 or higher. CONCLUSIONS Our findings suggest that increasing CHA2DS2-VASc scores are associated with impaired diastolic function that may represent high left atrial pressure favoring thrombogenic propensity.
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Affiliation(s)
- Albert Youngwoo Jang
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jongwook Yu
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ye Min Park
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Mi Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Wook-Jin Chung
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeonggeun Moon
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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22
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Arques S. Clinical Relevance of the Spectral Tissue Doppler E/e' Ratio in the Management of Patients with Atrial Fibrillation: a Comprehensive Review of the Literature. J Atr Fibrillation 2018; 11:2038. [PMID: 30505378 DOI: 10.4022/jafib.2038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/19/2018] [Accepted: 07/24/2018] [Indexed: 01/19/2023]
Abstract
Atrial fibrillation is the most common cardiac rhythm disorder observed in clinical practice. It carries high morbidity and mortality rates, primarily related to heart failure, stroke and death. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is relevant in this clinical setting. The spectral tissue Dopplerderived E/e' ratio is a simple and reproducible index, which has been validated in noninvasive assessment of left ventricular diastolic pressures, regardless of rhythm. Septal E/e' >11 is a good predictor of invasively determined left ventricular diastolic pressure >15 mmHg in patients with atrial fibrillation. Several studies have validated the clinical relevance of abnormal values for E/e' at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. Increased E/e' value is associated with adverse outcome (death, left atrial appendage thrombus, stroke and heart failure) in patients with atrial fibrillation and predicts arrhythmia recurrence after cardioversion and catheter ablation. In conclusion, E/e' by spectral tissue Doppler is clinically relevant in the clinical management of any patients with atrial fibrillation referred for transthoracic Doppler echocardiography.
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Affiliation(s)
- Stephane Arques
- Department of Cardiology, Centre hospitalier Edmond Garcin, Aubagne, France
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23
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Nauta JF, Hummel YM, van der Meer P, Lam CSP, Voors AA, van Melle JP. Correlation with invasive left ventricular filling pressures and prognostic relevance of the echocardiographic diastolic parameters used in the 2016 ESC heart failure guidelines and in the 2016 ASE/EACVI recommendations: a systematic review in patients with heart failure with preserved ejection fraction. Eur J Heart Fail 2018; 20:1303-1311. [PMID: 29877602 DOI: 10.1002/ejhf.1220] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/10/2018] [Accepted: 04/22/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Five echocardiographic parameters-left atrial volume index, left ventricular mass index, tricuspid regurgitation velocity, myocardial tissue velocity, and the ratio of early mitral inflow to tissue velocity of the mitral annulus (E/e')-are recommended in both the current European Society of Cardiology heart failure guidelines and the American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for the evaluation of left ventricular diastolic function. We aimed to perform a systematic review of these echocardiographic parameters at resting conditions for their correlation with left ventricular filling pressures in patients with heart failure with preserved ejection fraction (HFpEF). In addition, the prognostic value of these parameters was assessed. METHODS AND RESULTS Nine studies reported the correlation between echocardiography and invasive haemodynamics, and 18 papers reported on the prognostic value of echocardiography in HFpEF. Among the parameters, most data were reported for E/e'. The pooled correlation coefficient r was 0.56 for the relation between E/e' and invasively measured filling pressures. Combined weighted-mean meta-analysis of prognostic studies resulted in a hazard ratio of 1.05 (95% confidence interval 1.03-1.06) per unit increase in E/e' for the combined outcome of all-cause mortality and cardiovascular hospitalization. The other echocardiographic parameters, when taken individually, had similar or lower association with prognosis. CONCLUSION Only a small number of studies validated the use of echocardiographic parameters at rest in patients with HFpEF. The best established parameter appears to be E/e', but the existing data only show modest correlations of E/e' with invasive filling pressures and outcomes in HFpEF.
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Affiliation(s)
- Jan F Nauta
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Carolyn S P Lam
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Cardiology, National Heart Centre Singapore, Duke-National University of Singapore, Singapore
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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24
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Galderisi M, Donal E, Magne J, Lo Iudice F, Agricola E, Sade LE, Cameli M, Schwammenthal E, Cardim N, Cosyns B, Hagendorff A, Neskovic AN, Zamorano JL, Lancellotti P, Habib G, Edvardsen T, Popescu BA. Rationale and design of the EACVI AFib Echo Europe Registry for assessing relationships of echocardiographic parameters with clinical thrombo-embolic and bleeding risk profile in non-valvular atrial fibrillation. Eur Heart J Cardiovasc Imaging 2018; 19:245-252. [DOI: 10.1093/ehjci/jex322] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, via S. Pansini 5, 80131 Naples, Italy
| | - Erwan Donal
- CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Université Rennes, 2 rue Henri Le Guilloux, Rennes, France
| | - Julien Magne
- Service Cardiologie, CHU Limoges, Hospital Dupuytren, 2, avenue Martin Luther King, 87042 Limoges, France
| | - Francesco Lo Iudice
- Department of Advanced Biomedical Sciences, Federico II University Hospital, via S. Pansini 5, 80131 Naples, Italy
| | - Eustachio Agricola
- Cardiothoracic Department, Echocardiography Laboratory, Clinical Cardiology Unit, San Raffaele Hospital of Milan (IRCCS), via Olgettina 60, 20132 Milano, Italy
| | - Leyla Elif Sade
- Department of Cardiology, Baskent University, Faculty of Medicine, Fevzi okmak Cad. 10. Sok. Bahcelievler, 06490 Ankara, Turkey
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico ‘S. Maria alle Scotte’, viale M. Bracci, 16, 53100 Siena, Italy
| | - Ehud Schwammenthal
- Department of Cardiology, Heart Center, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Emek HaEla St 1, Ramat Gan, Israel
| | - Nuno Cardim
- Cardiac Imaging Department, Hospital Da Luz, Av. Lusíada 100, 1500-650 Lisbon, Portugal
| | - Bernard Cosyns
- CHVZ (Centrum voor Hart en Vaatziekten)-Universitair ziekenhuis and ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, 101 Laarbeeklaan, 1090 Jette, Brussels, Belgium
| | - Andreas Hagendorff
- Department of Cardiology, Echokardiographie-Labore des Universitätsklinikums AöR, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany
| | - Alexandar N Neskovic
- Department of Cardiology, Clinic of Internal Medicine/Interventional Cardiology Clinical Hospital Center Zemun-Belgrade, Faculty of Medicine, University of Belgrade, Vukova 9, 11070 Beograd, Serbia
| | - Josè Luis Zamorano
- Department of Cardiology, University Alcala de Henares, Hospital Ramon y Cajal, CIBERCV, Ctra. De Colmenar Viejo, km. 9100, 28034 Madrid, Spain
| | - Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Domaine Universitaire du Sart Tilman, Bâtiment B 35, B-4000 Liège Belgium
- Gruppo Villa Maria Care and Research, Anthea Hospital, via C. Rosalba, 35/37, 70124 Bari, Italy
| | - Gilbert Habib
- URMITE, Aix Marseille Universite, UM63, CNRS 7278, IRD 198, INSERM 1095 IHU—Méditerranée Infection, 58, bd Charles Livon, 13284 Marseille, France
- Cardiology Department, APHM, La Timone Hospital, 264 Rue Saint-Pierre, 13385 Marseille, France
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, University of Oslo, 4950 Nydalen, 0424 Oslo, Norway
| | - Bogdan A Popescu
- University of Medicine and Pharmacy ‘Carol Davila’-Euroecolab, Institute of Cardiovascular Diseases, Sos. Fundeni 258, Sector 2, 022328 Bucharest, Romania
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25
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Kimachi M, Furukawa TA, Kimachi K, Goto Y, Fukuma S, Fukuhara S. Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease. Cochrane Database Syst Rev 2017; 11:CD011373. [PMID: 29105079 PMCID: PMC6485997 DOI: 10.1002/14651858.cd011373.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an independent risk factor for atrial fibrillation (AF), which is more prevalent among CKD patients than the general population. AF causes stroke or systemic embolism, leading to increased mortality. The conventional antithrombotic prophylaxis agent warfarin is often prescribed for the prevention of stroke, but risk of bleeding necessitates regular therapeutic monitoring. Recently developed direct oral anticoagulants (DOAC) are expected to be useful as alternatives to warfarin. OBJECTIVES To assess the efficacy and safety of DOAC including apixaban, dabigatran, edoxaban, and rivaroxaban versus warfarin among AF patients with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register (up to 1 August 2017) through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) which directly compared the efficacy and safety of direct oral anticoagulants (direct thrombin inhibitors or factor Xa inhibitors) with dose-adjusted warfarin for preventing stroke and systemic embolic events in non-valvular AF patients with CKD, defined as creatinine clearance (CrCl) or eGFR between 15 and 60 mL/min (CKD stage G3 and G4). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed quality, and extracted data. We calculated the risk ratio (RR) and 95% confidence intervals (95% CI) for the association between anticoagulant therapy and all strokes and systemic embolic events as the primary efficacy outcome and major bleeding events as the primary safety outcome. Confidence in the evidence was assessing using GRADE. MAIN RESULTS Our review included 12,545 AF participants with CKD from five studies. All participants were randomised to either DOAC (apixaban, dabigatran, edoxaban, and rivaroxaban) or dose-adjusted warfarin. Four studies used a central, interactive, automated response system for allocation concealment while the other did not specify concealment methods. Four studies were blinded while the other was partially open-label. However, given that all studies involved blinded evaluation of outcome events, we considered the risk of bias to be low. We were unable to create funnel plots due to the small number of studies, thwarting assessment of publication bias. Study duration ranged from 1.8 to 2.8 years. The large majority of participants included in this study were CKD stage G3 (12,155), and a small number were stage G4 (390). Of 12,545 participants from five studies, a total of 321 cases (2.56%) of the primary efficacy outcome occurred per year. Further, of 12,521 participants from five studies, a total of 617 cases (4.93%) of the primary safety outcome occurred per year. DOAC appeared to probably reduce the incidence of stroke and systemic embolism events (5 studies, 12,545 participants: RR 0.81, 95% CI 0.65 to 1.00; moderate certainty evidence) and to slightly reduce the incidence of major bleeding events (5 studies, 12,521 participants: RR 0.79, 95% CI 0.59 to 1.04; low certainty evidence) in comparison with warfarin. AUTHORS' CONCLUSIONS Our findings indicate that DOAC are as likely as warfarin to prevent all strokes and systemic embolic events without increasing risk of major bleeding events among AF patients with kidney impairment. These findings should encourage physicians to prescribe DOAC in AF patients with CKD without fear of bleeding. The major limitation is that the results of this study chiefly reflect CKD stage G3. Application of the results to CKD stage G4 patients requires additional investigation. Furthermore, we could not assess CKD stage G5 patients. Future reviews should assess participants at more advanced CKD stages. Additionally, we could not conduct detailed analyses of subgroups and sensitivity analyses due to lack of data.
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Affiliation(s)
- Miho Kimachi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Kimihiko Kimachi
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
| | - Yoshihito Goto
- Kyoto University School of Public HealthDepartment of Health InformaticsYoshida Konoecho, Sakyo‐kuKyotoJapan606‐8501
| | - Shingo Fukuma
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
| | - Shunichi Fukuhara
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoKyotoJapan606‐8501
- Fukushima Medical UniversityCenter for Innovative Research for Communities and Clinical ExcellenceFukushimaJapan
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26
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Arques S, Roux E. [Usefulness of spectral tissue Doppler (E/e' ratio) in the management of patients with atrial fibrillation]. Ann Cardiol Angeiol (Paris) 2017; 66:303-308. [PMID: 29025686 DOI: 10.1016/j.ancard.2017.09.011] [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: 05/22/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
Atrial fibrillation is the most common cardiac rhythm disorder encountered in daily clinical practice. It carries high morbidity and mortality rates, mainly related to sudden death, heart failure and stroke. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is therefore attractive in this clinical setting. The spectral tissue Doppler-derived E/e' ratio is a simple and user-friendly index which has been validated in the assessment of left ventricular diastolic pressures, regardless of rhythm. A septal E/e' >11 is associated with invasive left ventricular diastolic pressures >15mmHg in patients with atrial fibrillation. Several studies have reported the clinical relevance of abnormal values of E/e' at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. There is now convincing evidence that increased E/e' is associated with adverse outcome in patients with atrial fibrillation and predicts the recurrence of arrhythmia after cardioversion or catheter ablation. In conclusion, we recommend the measurement of E/e' in each patient with atrial fibrillation referred for clinically indicated transthoracic Doppler echocardiography.
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Affiliation(s)
- S Arques
- Service de cardiologie, centre hospitalier Edmond-Garcin, avenue des Soeurs-Gastine, 13400 Aubagne, France.
| | - E Roux
- Service de cardiologie, centre hospitalier Edmond-Garcin, avenue des Soeurs-Gastine, 13400 Aubagne, France
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27
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Topaz G, Flint N, Steinvil A, Finkelstein A, Banai S, Keren G, Shacham Y, Yankelson L. Long term prognosis of atrial fibrillation in ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention. Int J Cardiol 2017; 240:228-233. [DOI: 10.1016/j.ijcard.2017.03.060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
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28
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Hammond-Haley M, Providência R, Lambiase PD. Temporal pattern/episode duration-based classification of atrial fibrillation as paroxysmal vs. persistent: is it time to develop a more integrated prognostic score to optimize management? Europace 2017; 20:f288-f298. [PMID: 29016766 DOI: 10.1093/europace/eux178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 05/01/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
| | - Rui Providência
- Bart’s Heart Centre, Bart’s Health NHS Trust, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - Pier D Lambiase
- Bart’s Heart Centre, Bart’s Health NHS Trust, St. Bartholomew's Hospital, West Smithfield, London, UK
- Institute of Cardiovascular Science, University College & Barts Heart Centre, Paul O’Gorman Building, Huntley St, London, UK
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