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Zheng X, Ran H, Ren J, Ling Z, Hou L, Ao M, Zhu Y, Zhang M, Han Y, Li S, Zhou X, Yu Q, Luo P, Su L. Two-dimensional speckle tracking imaging analyses of the correlations between left atrial appendage function and stroke risk in nonvalvular atrial fibrillation patients. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:613-623. [PMID: 38108983 DOI: 10.1007/s10554-023-03031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 12/03/2023] [Indexed: 12/19/2023]
Abstract
Stroke incidence is the most severe complication associated with atrial fibrillation (AF), and the most common site of thrombus formation in AF patients is the left atrial appendage (LAA). This study was developed to use two-dimensional speckle tracking imaging (2D-STI) to explore associations between LAA strain/strain rate and stroke incidence and to evaluate the value of utilizing LAA strain and strain rate values to support the stratification of nonvalvular AF (NVAF) patients based on stroke risk. A total of 486 AF patients who had undergone transesophageal echocardiography to exclude potential intracardiac thrombosis between March 2021 and November 2022 were consecutively enrolled. Patients meeting the inclusion criteria were separated into two groups according to their history of stroke/transient ischemic attack (TIA). LAA strain and strain rate values in these patients were measured via 2D-STI. Multivariable logistic regression analysis was employed to determine independent risk factors for the construction of a combined predictive model. Of the 333 analyzed patients (134 females, aged 65 (56,72) years), 39 (11.71%, 39/333) had a history of stroke at the time of evaluation. Multivariate logistic regression analysis demonstrated that nonparoxysmal AF, CHA2DS2VASc score, LAA thrombus/spontaneous echo contrast (SEC), LAA strain, and strain rate were all predictors of stroke incidence among NVAF patients. The combined predictive model demonstrated excellent discriminative ability, with an AUC of 0.91 (95%CI 0.87-0.95, P < 0.001), and a sensitivity and specificity of 79.49% and 89.46%, respectively. The Hosmer-Lemeshow test confirmed good calibration, yielding a value of 0.98. Comparative decision curve analysis showed that the model provided superior net benefits compared to the CHA2DS2VASc score. Furthermore, the model exhibited improved predictive performance and reclassification for stroke when compared to the CHA2DS2VASc score (AUC 0.91 vs. 0.88, Z = 2.32, P = 0.02), accompanied by a significant increase in the net reclassification index (+ 5.44%, P < 0.001) and integrated discrimination improvement (8.21%, P < 0.001). These data demonstrate that LAA strain and strain rate, as measured via 2D-STI, can offer value when assessing LAA function in AF patients, potentially providing further predictive value to extant clinical risk scoring strategies.
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Affiliation(s)
- Xiwangmin Zheng
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Haitao Ran
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Jianli Ren
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Zhiyu Ling
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lingli Hou
- Department of Ultrasound, The Affiliated Qujing hospital of Kunming Medical University, Yunnan, China
| | - Meng Ao
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Yefeng Zhu
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Maohui Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Ying Han
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Shiyu Li
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Xia Zhou
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Qiujin Yu
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Peng Luo
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China
| | - Lei Su
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Road, Yuzhong District, Chongqing, 40010, China.
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Pang H, Zhu X, Cheang I, Zhang H, Zhou Y, Liao S, Li X. CHA 2DS 2-VASc score for in-hospital recurrence risk stratification in patients with myocardial infarction. Front Cardiovasc Med 2022; 9:925932. [PMID: 36531705 PMCID: PMC9751022 DOI: 10.3389/fcvm.2022.925932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/07/2022] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Using the CHA2DS2-VASc score to recognize the risk of stroke in patients with atrial fibrillation has been well-established. However, few studies have assessed whether the CHA2DS2-VASc score has a similar predictive value in recurrence after myocardial infarction (MI). METHODS We conducted a retrospective observational cohort study of adult inpatients with MI. The CHA2DS2-VASc and modified CHA2DS2-VASc (MCHA2DS2-VASc) scores of all patients were calculated. The associations of both scores with recurrent MI were analyzed. RESULTS A total of 6,700 patients with MI (60.0 ± 11.1 years, 77.2% men) were enrolled, and 759 (11.3%) presented a definite recurrence during hospitalization. After multivariable adjustment by logistic regression in patients with MI, the CHA2DS2-VASc and MCHA2DS2-VASc scores were independently associated with recurrence. The MCHA2DS2-VASc score showed a better predictive value for risk of recurrence than that of CHA2DS2-VASc in overall [area under the receiver operating characteristic curve (AUC) 0.757 vs. 0.676] or male patients (AUC 0.759 vs. 0.708). MCHA2DS2-VASc was superior to CHA2DS2-VASc for identifying "truly high-risk" patients with MI, regardless of overall patients or sex-specific subgroups. The two scores had a similar focus on the identification of "low-risk" patients in overall or women, but not in men. CONCLUSION The CHA2DS2-VASc and MCHA2DS2-VASc scores for predicting recurrence are validated in patients with MI. However, MCHA2DS2-VASc could be more helpful to secondary prevention than CHA2DS2-VASc after MI, especially in men. The superiority of MCHA2DS2-VASc compared with CHA2DS2-VASc in women is just more discriminatory for "truly high-risk" patients.
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Affiliation(s)
- Hui Pang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xu Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Iokfai Cheang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Haifeng Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
| | - Yanli Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shengen Liao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xinli Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Construction of a Clinical Predictive Model of Left Atrial and Left Atrial Appendage Thrombi in Patients with Nonvalvular Atrial Fibrillation. J Interv Cardiol 2022; 2022:7806027. [DOI: 10.1155/2022/7806027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Background. The purpose of this study was to investigate the risk factors of left atrial (LA) or left atrial appendage (LAA) thrombi in patients with nonvalvular atrial fibrillation (NVAF) and to establish and validate relevant predictive models. It might improve thromboembolic risk stratification in patients with NVAF. Methods. This study retrospectively included 1210 consecutive patients with NVAF undergoing transesophageal echocardiography (TEE), of whom 139 patients had thrombi in LA or in LAA. Through literature review and the ten events per variable (10EPV) principle, 13 variables were finally identified for inclusion in multivariate analysis. Models were constructed by multivariate logistic stepwise regression and least absolute shrinkage and selection operator (lasso) regression. Results. After logistic regression, five variables (AF type, age, B-type natriuretic peptide, E/e’ ratio, and left atrial diameter) were finally screened out as model 1. After Lasso regression, AF type, age, gender, B-type natriuretic peptide, E/e’ ratio, left atrial diameter, and left ventricular ejection fraction were finally screened as model 2. After comparing the two models, the simpler model 1 was finally selected. The area under the ROC curve (AUC) of the model 1 was 0.865 (95% CI: 0.838–0.892), the Hosmer–Lemeshow test = 0.898, and the AUC = 0.861 after internal validation. The clinical decision curve showed that the new clinical prediction model could achieve a net clinical benefit when the expected threshold was between 0 and 0.6. Conclusion. This study constructed a new clinical prediction model of LA or LAA thrombi, with a higher discriminative degree than the CHADS2 and CHA2DS2-VASc scoring systems (AUC: 0.865 vs. 0.643; AUC: 0.865 vs 0.652).
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Ito T, Akamatsu K, Hasegawa H, Sakatani Y, Miyamura M, Hoshiga M. Relationship of warfarin versus DOACs with thrombogenic milieu in the left atrium among patients with nonvalvular atrial fibrillation. Echocardiography 2022; 39:483-489. [PMID: 35137446 DOI: 10.1111/echo.15319] [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: 10/20/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Thrombogenic milieu (TM) within the left atrium plays a pivotal role in the pathogenesis of thromboembolic events, for which anticoagulation treatment is indicated typically on the mandatory basis. Little is known, however, about which regimen of anticoagulation, warfarin or direct oral anticoagulants (DOACs), is more likely associated with TM. We evaluated relative relationship of the two treatment options with concurrently-observed TM in patients with nonvalvular atrial fibrillation (AF) who underwent transesophageal echocardiography. METHODS TM was defined as the presence of either left atrial spontaneous echo contrast (SEC) or thrombus, or both. To determine which regimen was more likely related to TM, we firstly compared the prevalence of TM in 208 patients taking warfarin (Warfarin group) versus 486 patients taking DOACs (DOAC group); and secondly, did the same analysis after propensity score matching. RESULTS Warfarin group was more likely associated with TM compared with DOAC group (46% vs 29%, p < 0.001). Similar findings were observed for dense SEC (18% vs 7%, p < 0.001) and thrombus (4% vs 1%, p = 0.057). The propensity score matching (198 patients for each group), where several baseline parameters were matched including age, gender, chronicity of AF, estimated glomerular filtration rate and B-type natriuretic peptide as well as the left ventricular ejection fraction, resulted in similar findings to the original groups (TM, 47% vs 32%, p = 0.002; dense SEC, 18% vs 7%, p = 0.001; thrombus, 4% vs 1%, p = 0.047). CONCLUSIONS This study may strengthen the data on randomized trials that DOACs are superior to warfarin in preventing thromboembolic events in nonvalvular AF patients. Further studies are required to elucidate the details behind this difference.
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Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Hitomi Hasegawa
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuka Sakatani
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masatoshi Miyamura
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
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Chen L, Peng L, Wang C, Li SC, Zhang M. New score for prediction of morbidity in patients undergoing open pancreaticoduodenectomy. J Int Med Res 2021; 49:3000605211001984. [PMID: 33752508 PMCID: PMC7995460 DOI: 10.1177/03000605211001984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is commonly used to predict the risk of postoperative complications in general surgery. However, use of the POSSUM is not absolutely suitable for open pancreaticoduodenectomy (OPD), which has unique complications such as pancreatic fistula formation. This study was performed to establish a new risk score for assessing the incidence of postoperative complications of OPD. Methods This retrospective case-control study involved 159 patients who underwent standard OPD from 2 January 2017 to 1 February 2019. The risk factors for post-OPD complications were statistically investigated, and a risk score model was established by multivariate logistic regression. Results Among all 159 patients, 72 (42.28%) developed complications. A scoring system was developed based on the following five independent variables: sodium concentration of <141.20 mmol/L, white blood cell count of >6.35 × 109/L, pancreatic texture grade, body mass index of >25.06 kg/m2, and basic respiratory diseases. Our risk score model demonstrated better discriminating power, prediction power, and prediction probability than the POSSUM model in the receiver operating characteristic curve analysis. Conclusion This novel risk score may help to predict postoperative complications after OPD with higher accuracy than the POSSUM system.
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Affiliation(s)
- Lian Chen
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Li Peng
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Chao Wang
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Sheng-Chao Li
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Meng Zhang
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, P.R. China
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The relationship between incomplete surgical obliteration of the left atrial appendage and thromboembolic events after mitral valve surgery (from the ISOLATE Registry). J Thromb Thrombolysis 2020; 51:1078-1089. [PMID: 32997332 DOI: 10.1007/s11239-020-02291-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 12/24/2022]
Abstract
Left atrial appendage (LAA) is a common site of thrombus formation especially in patients with atrial fibrillation (AF). Complete surgical LAA closure (cSLC) is the surgical aim, however incomplete surgical LAA closure (iSLC) is not rare. In this study, we aimed to evaluate the risk of thromboembolic complications (TEC) in AF patients with iSLC after mitral valve surgery. A total of 101 AF patients (mean age: 61.8 ± 11.8 years; male:32), who underwent surgical suture ligation during mitral valve surgery were enrolled in this retrospective study. All patients underwent transthoracic and transesophageal echocardiography (TEE) at least 3 months after surgery. The primary outcome was the occurrence of TEC including any ischemic stroke, transient ischemic attack, coronary or peripheral embolism. TEE examination revealed cSLC in 66 (65.3%) and iSLC in 35 patients (34.6%). A total of 12 TECs (11.9%) occurred during a mean follow-up time of 41.1 ± 15.6 months. TECs were found to be significantly higher in the iSLC group (25.7% vs 4.5%, p = 0.002). The prevalence of iSLC was significantly higher in patients with TEC (75 vs. 29.2%, p = 0.002). High CHA2DS2-VASc Score and iSLC were found to be independent predictors of TEC. Long term TEC free survival was found to be significantly decreased in patients with iSLC. The presence of iSLC was associated with a significantly increased risk of TEC in AF patients after mitral valve surgery. Routine intraoperative and postoperative screening for iSLC by TEE and long-term strict anticoagulation therapy are recommended in these patients.
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