Risk of stroke in chronic heart failure patients with preserved ejection fraction, but without atrial fibrillation: analysis of the CHARM-Preserved and I-Preserve trials

Comparison of Characteristics and Outcomes Between Acute Ischemic Stroke Patients with Different Types of Heart Failure

Acute ischemic stroke (AIS) can be complicated by heart failure involving preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF), and whether or not the prognosis differs between the 2 types of patients remains unclear. We compared the clinical characteristics and outcomes of the 2 types of patients at 3 months after the stroke.We retrospectively analyzed patients who, between 1 January 2018 and 1 January 2021, experienced AIS that was complicated by HFrEF or HFpEF. All patients had been prospectively registered in the Chengdu Stroke Registry. Poor outcome was defined as a modified Rankin Scale (mRS) score of 2-6 at 3 months. Univariate and binary logistic regression was used to assess whether HFpEF was associated with a significantly worse prognosis than HFrEF.Among the final sample of 108 patients (60.2% men; mean age, 73.08 ± 10.82 years), 75 (69.4%) had HFpEF. Compared to HFrEF patients, those with HFpEF were older (P = 0.002), were more likely to have chronic kidney disease (P = 0.033), and were more likely to experience a poor outcome (P = 0.022). After adjustments, HFpEF was associated with significantly greater risk of poor outcome than HFrEF (OR 4.13, 95%CI 1.20-15.79, P = 0.029). However, rates of hemorrhagic transformation or mortality at 3 months after AIS did not differ significantly between the 2 types of heart failure (all P > 0.05).Patients with AIS involving HFpEF experience worse outcomes than those with HFrEF and therefore may require special monitoring and management. Our findings need to be verified in large prospective studies.

Cost-effectiveness of adding empagliflozin to the standard therapy for Heart Failure with Preserved Ejection Fraction from the perspective of healthcare systems in China

Background

The Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction (EMPEROR-Preserved) is the first randomized controlled trial to provide promising evidence on the efficacy of adding empagliflozin to the standard therapy in patients with Heart Failure with Preserved Ejection Fraction (HFpEF), but the cost-effectiveness of add-on empagliflozin treatment remains unclear.

Method

A Markov model using data from the EMPEROR-Preserved trial and national database was constructed to assess lifetime costs and utility from a China healthcare system perspective. The time horizon was 10 years and a 5% discount rate was applied. Incremental cost-effectiveness ratio (ICER) against willingness to pay (WTP) threshold was performed to evaluate the cost-effectiveness. A series of sensitivity analyses was applied to ensure the robustness of the results.

Results

Compared to standard therapy, the increased cost of adding empagliflozin from $4,645.23 to $5,916.50 was associated with a quality-adjusted life years (QALYs) gain from 4.70 to 4.81, projecting an ICER of $11,292.06, which was lower than a WTP threshold of $12,652.5. Univariate sensitivity analysis revealed that the parameters with the largest impact on ICER were cardiovascular mortality in both groups, followed by the cost of empagliflozin and the cost of hospitalization for heart failure. Probabilistic sensitivity analysis indicated that when the WTP threshold was $12,652.5 and $37,957.5, the probability of being cost-effective for adding empagliflozin was 52.7% and 67.6%, respectively. Scenario analysis demonstrated that the cost of empagliflozin, the cost of hospitalization for heart failure, NYHA functional classes, and time horizon had a greater impact on the ICER.

Conclusion

At a WTP threshold of $12,652.5, the add-on empagliflozin treatment for HFpEF was cost-effective in healthcare systems in China, which promoted the rational use of empagliflozin for HFpEF.

Left Atrial Dilatation and Reduced Left Ventricular Ejection Fraction Are Associated With Cardioembolic Stroke

Objective: Left atrial (LA) dilatation and heart failure are independent risk factors for ischemic stroke. The goal of this study is to evaluate the association between LA dilatation and reduced left ventricular ejection fraction (EF) with cardioembolic stroke. Methods: Four hundred fifty-three patients with ischemic stroke admitted to the University of California, Irvine between 2016 and 2017 were included based on the following criteria: age >18 and availability of echocardiogram. Stroke was categorized into cardioembolic and non-cardioembolic. EF was categorized into normal: 52-72% (male), 54-74% (female), mildly abnormal: 41-51% (male), 41-53% (female), moderately abnormal: 30-40%, and severely abnormal: <30%. LA volume was categorized into normal (≤34 ml/m²) vs. enlarged (≥35 ml/m²). Other variables included gender, hypertension [systolic blood pressure (SBP) ≥ 140 or diastolic blood pressure (DBP) ≥ 90], and known history of atrial fibrillation (Afib). Results: Two hundred eighteen patients had cardioembolic, and 235 had non-cardioembolic stroke. Among patients with cardioembolic stroke, 49 (22.4%) and 142 (65%) had reduced EF and enlarged LA, respectively, as compared with 19 (8.1%) and 65 (27.7%) patients with non-cardioembolic stroke (p < 0.0001). The odds of cardioembolic stroke were 2.0 (95% CI: 0.1-6.0) and 8.8 times (95% CI: 1.9-42.3) higher in patients with moderately and severely reduced EF, respectively, than in patients with normal EF. The odds of cardioembolic stroke was 2.4 times (95% CI: 1.5-3.9) higher in patients with enlarged LA than in patients with normal LA size. Compared with patients with normal LA and EF, patients with combined enlarged LA and reduced EF had significantly higher rates of Afib (43.4 vs. 9.0%, p < 0.0001) and cardioembolic stroke (78.3 vs. 43.4%, p < 0.0001). Conclusions: LA dilatation along with reduced EF is a reliable predictor of Afib and cardioembolic stroke. Further studies are warranted to determine the benefit of anticoagulation for secondary stroke prevention in such patient population.

New-onset atrial fibrillation in patients with worsening heart failure and coronary artery disease: an analysis from the COMMANDER-HF trial

BACKGROUND

Atrial fibrillation (AF) in the presence of heart failure (HF) is associated with poor outcomes including a high-risk of stroke and other thromboembolic events. Identifying patients without AF who are at high-risk of developing this arrhythmia has important clinical implications.

AIMS

To develop a risk score to identify HF patients at high risk of developing AF.

METHODS

The COMMANDER-HF trial enrolled 5022 patients with HF and a LVEF ≤ 40%, history of coronary artery disease, and absence of AF at baseline (confirmed with an electrocardiogram). Patients were randomized to either rivaroxaban (2.5 mg bid) or placebo. New-onset AF was confirmed by the investigator at study visits.

RESULTS

241 (4.8%) patients developed AF during the follow-up (median 21 months). Older age (≥ 65 years), LVEF < 35%, history of PCI or CABG, White race, SBP < 110 mmHg, and higher BMI (≥ 25 kg/m²) were independently associated with risk of new-onset AF, whereas the use of DAPT was associated with a lower risk of new-onset AF. We then built a risk score from these variables (with good accuracy C-index = 0.71) and calibration across observed and predicted tertiles of risk. New-onset AF events rates increased steeply by increasing tertiles of the risk-score. Compared to tertile 1, the risk of new-onset AF was 2.5-fold higher in tertile 2, and 6.3-fold higher in tertile 3. Rivaroxaban had no effect in reducing new-onset AF. In time-updated models, new-onset AF was associated with a higher risk of subsequent all-cause death: HR (95%CI) 1.38 (1.11-1.73).

CONCLUSIONS

A well-calibrated risk-score identified patients at risk of new-onset AF in the COMMANDER-HF trial. Patients who developed AF had a higher risk of subsequent death. Risk of new-onset atrial fibrillation in patients with HFrEF and coronary artery disease.

Oral Anticoagulation and Adverse Outcomes after Ischemic Stroke in Heart Failure Patients without Atrial Fibrillation

BACKGROUND

The safety and effectiveness of oral anticoagulation (OAC) after an ischemic stroke in older patients with heart failure (HF) without atrial fibrillation remains uncertain.

METHODS

Utilizing Get With The Guidelines Stroke national clinical registry data linked to Medicare claims from 2009-2014, we assessed the outcomes of eligible patients with a history of HF who were initiated on OAC during a hospitalization for an acute ischemic stroke. The cumulative incidences of adverse events were calculated using Kaplan-Meier curves and adjusted Cox proportional hazard ratios were compared between patients discharged on or off OAC.

RESULTS

A total of 8,261 patients from 1,370 sites were discharged alive after an acute ischemic stroke and met eligibility criteria. Of those, 747 (9.0%) were initiated on OAC.  Patients on OAC were younger (77.2±8.0 vs. 80.5±8.9 years, p<0.01). After adjustment for clinical covariates, the likelihood of 1 year mortality was higher in those on OAC (aHR: 1.22, 95% CI 1.05-1.41, p<0.01), while no significant differences were noted for ICH (aHR: 1.34, 95% CI 0.69-2.59, p=0.38) and recurrent ischemic stroke (aHR: 0.78, 95% CI 0.54-1.15, p = 0.21).  The likelihood of all-cause bleeding (aHR: 1.59, 95% CI 1.29-1.96, p<0.01) and all-cause re-hospitalization (aHR: 1.14, 95% CI 1.02-1.27, p = 0.02) was higher for those on OAC.

CONCLUSION

Initiation of OAC after an ischemic stroke in older patients with HF in the absence of atrial fibrillation is associated with death, bleeding and re-hospitalization without an associated reduction in recurrent ischemic stroke. If validated, these findings raise caution for prescribing OAC to such patients.

C2HEST score predicts clinical outcomes in heart failure with preserved ejection fraction: a secondary analysis of the TOPCAT trial

BACKGROUND

The C₂HEST score has been validated for predicting AF in the general population or post-stroke patients. We aimed to assess whether this risk score could predict incident AF and other clinical outcomes in heart failure with preserved ejection fraction (HFpEF) patients.

METHODS

A total of 2202 HFpEF patients without baseline AF in the TOPCAT trial were stratified by baseline C₂HEST score. Cox proportional hazard model and competing risk regression model was used to explore the relationship between C₂HEST score and outcomes, including incident AF, stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization. The discriminative ability of the C₂HEST score for various outcomes was assessed by calculating the area under the curve (AUC).

RESULTS

The incidence rates of incident AF, stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization were 1.79, 0.70, 3.81, 2.42, 15.50, and 3.32 per 100 person-years, respectively. When the C₂HEST score was analyzed as a continuous variable, increased C₂HEST score was associated with increased risk of incident AF (HR 1.50, 95% CI 1.29-1.75), as well as increased risks of all-cause death, cardiovascular death, any hospitalization, and HF hospitalization. The AUC for the C₂HEST score in predicting incident AF (0.694, 95% CI 0.640-0.748) was higher than all-cause death, cardiovascular death, any hospitalization, or HF hospitalization.

CONCLUSIONS

The C₂HEST score could predict the risk of incident AF as well as death and hospitalization with moderately good predictive abilities in patients with HFpEF. Its simplicity may allow the possibility of quick risk assessments in busy clinical settings.

Long-Term Risk of Stroke and Poststroke Outcomes in Patients with Heart Failure: Two Nationwide Studies

Objective

To evaluate the long-term risk of stroke and poststroke adverse outcomes in patients with heart failure (HF).

Methods

We used research data from Taiwan’s National Health Insurance Program from 2000 to 2005 and identified 20,072 adults aged ≥30 years who were newly diagnosed with HF. Frequency matching based on age and sex was used to select a comparison cohort consisting of 80,288 adults without HF. Events of incident stroke were identified from medical claims during the 2000–2013 follow-up period. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of the association of stroke with HF were calculated with a multiple Cox proportional hazard model. Another nested stroke cohort study of 480,604 hospitalized stroke patients determined the adjusted odds ratios (ORs) and 95% CIs for adverse events after stroke in patients with and without HF between 2000 and 2009.

Results

Compared with the non-HF cohort, HF patients had an increased risk of stroke (HR 2.32, 95% CI 2.21–2.43), including ischemic stroke and hemorrhagic stroke. The association between HF and stroke was significant in both sexes and in patients in all age groups and with various medical conditions. Previous HF was associated with poststroke mortality (OR 1.40, 95% CI 1.31–1.50), pneumonia (OR 1.33, 95% CI 1.28–1.38), and septicemia (OR 1.30, 95% CI 1.23–1.37).

Conclusion

HF was associated with a higher risk of stroke, and patients with HF had more complications and greater mortality after stroke.

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation: A Report From the GARFIELD-AF Registry

Importance

Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes.

Objective

To assess the treatment strategies and 1-year clinical outcomes of antithrombotic and CHF therapies for patients with newly diagnosed AF with concomitant CHF stratified by etiology (ischemic cardiomyopathy [ICM] vs nonischemic cardiomyopathy [NICM]).

Design, Setting, and Participants

The GARFIELD-AF registry is a prospective, noninterventional registry. A total of 52 014 patients with AF were enrolled between March 2010 and August 2016. A total of 11 738 patients 18 years and older with newly diagnosed AF (≤6 weeks' duration) and at least 1 investigator-determined stroke risk factor were included. Data were analyzed from December 2017 to September 2018.

Exposures

One-year follow-up rates of death, stroke/systemic embolism, and major bleeding were assessed.

Main Outcomes and Measures

Event rates per 100 person-years were estimated from the Poisson model and Cox hazard ratios (HRs) and 95% confidence intervals.

Results

The median age of the population was 71.0 years, 22 987 of 52 013 were women (44.2%) and 31 958 of 52 014 were white (61.4%). Of 11 738 patients with CHF, 4717 (40.2%) had ICM and 7021 (59.8%) had NICM. Prescription of oral anticoagulant and antiplatelet drugs was not balanced between groups. Oral anticoagulants with or without antiplatelet drugs were used in 2753 patients with ICM (60.1%) and 5082 patients with NICM (73.7%). Antiplatelets were prescribed alone in 1576 patients with ICM (34.4%) and 1071 patients with NICM (15.5%). Compared with patients with NICM, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (72.6% [3439] vs 60.3% [4236]) and of β blockers (63.3% [2988] vs 53.2% [3737]) was higher in patients with ICM. Rates of all-cause and cardiovascular death per 100 patient-years were significantly higher in the ICM group (all-cause death: ICM, 10.2; 95% CI, 9.2-11.1; NICM, 7.0; 95% CI, 6.4-7.6; cardiovascular death: ICM, 5.1; 95% CI, 4.5-5.9; NICM, 2.9; 95% CI, 2.5-3.4). Stroke/systemic embolism rates tended to be higher in ICM groups compared with NICM groups (ICM, 2.0; 95% CI, 1.6-2.5; NICM, 1.5; 95% CI, 1.3-1.9). Major bleeding rates were significantly higher in the ICM group (1.1; 95% CI, 0.8-1.4) compared with the NICM group (0.7; 95% CI, 0.5-0.9).

Conclusions and Relevance

Patients with ICM received oral anticoagulants with or without antiplatelet drugs less frequently and antiplatelets alone more frequently than patients with NICM, but they received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers more often than patients with NICM. All-cause and cardiovascular death rates were higher in patients with ICM than patients with NICM.

Trial Registration

ClinicalTrials.gov Identifier: NCT01090362.

Protective mechanism of SIRT1 on Hcy-induced atrial fibrosis mediated by TRPC3

High plasma levels of homocysteine (Hcy) are regarded as a risk factor for atrial fibrillation (AF), which is closely associated with the pathological consequence of atrial fibrosis and can lead to heart failure with a high mortality rate; here, we show that atrial fibrosis is mediated by the relationship between canonical transient receptor potential 3 (TRPC3) channels and sirtuin type 1 (SIRT1) under the stimulation of Hcy. The left atrial appendage was obtained from patients with either sinus rhythm (SR) or AF and used to evaluate the relationship between the concentration of Hcy and a potential mechanism of cardiac fibrosis mediated by TRPC3 and SIRT1. We next performed transverse aortic constriction (TAC) in mouse to investigate the relationship. The mechanisms underlying atrial fibrosis involving TRPC3 and SIRT1 proteins were explored by co‐IP, BLI and lentivirus transfection experiments. qPCR and WB were performed to analyse gene and protein expression, respectively. The higher level of atrial fibrosis was observed in the HH mouse group with a high Hcy diet. Such results suggest that AF patients may be more susceptible to atrial fibrosis and possess a high probability of progressing to hyperhomocysteinemia. Moreover, our findings are consistent with the hypothesis that TRPC3 channel up‐regulation leads to abnormal accumulation of collagen, with the down‐regulation of SIRT1 as an aetiological factor of high Hcy, which in turn predisposes to atrial fibrosis and strongly enhances the possibility of AF.

Ischemic stroke risk during post-discharge phases of heart failure: association of left ventricular concentric geometry

Despite a higher risk of ischemic stroke in hospitalized patients with acute heart failure (HF), little is known about the risk of ischemic stroke during the post-discharge phases of HF. Here we investigated (1) the ischemic stroke incidence rate during the post-discharge phases among HF patients receiving standard treatments; (2) the association between ischemic stroke incidence and clinical background, including cardiac structure and function. Among 950 patients who required hospitalization for HF (median duration: 19 days) at our institution, where they received standard treatments, we investigated stroke occurrences during the 2-year period following their discharge and retrospectively evaluated their clinical data. Relative wall thickness (RWT) and left ventricular (LV) mass were determined based on echocardiographic measurements and then used to determine LV geometric patterns. During the follow-up period, ischemic stroke occurred in 25 patients (2.6%) after hospital discharge (1.4 per 100 patient-years). The incidence rate of IS tended to be higher in patients with AF than those without AF (1.8 vs. 1.0 per 100 patient-years, respectively). Notably, multivariate analysis revealed a significant association between RWT and ischemic stroke risk (p < 0.05). RWT was associated with ischemic stroke risk in patients with AF or left atrial enlargement, but not in patients without them. These findings suggest that even with standard HF treatments, the risk of ischemic stroke is high in patients with HF. Moreover, LV concentric geometry is a significant risk factor for ischemic stroke in patients with HF, especially in those with left atrial remodeling and/or AF.

Arterial Stiffness and Indices of Left Ventricular Diastolic Dysfunction in Patients with Embolic Stroke of Undetermined Etiology

Purpose

The study is aimed at identifying echocardiographic and circulating biomarkers as well as hemodynamic indices of embolic stroke of undetermined etiology (ESUS) in patients aged <65.

Methods

We prospectively investigated 520 patients with confirmed ischemic stroke and selected those 65 patients who were diagnosed with ESUS (age 54 (47-58) years, 42% male). An additional 36 without stroke but with a similar risk profile were included as a control group (age 53 (47-58) years, 61% male). All patients underwent echocardiography, noninvasive assessment of hemodynamic parameters using a SphygmoCor tonometer (AtCor Med., Australia), and measurements of selected biomarkers.

Results

ESUS patients and controls were well matched for baseline characteristics including blood pressure and left ventricular ejection fraction (LVEF). Compared to controls, patients with ESUS had lower mean early diastolic (E') and systolic (S') mitral annular velocities and a higher ratio of the peak velocity of early diastolic transmitral flow to the peak velocity of early diastolic mitral annular motion (all p < 0.01). The peak velocity flow in the late diastole (A wave) value and LV mass indexed to the body surface area (LVMI) (g/m²) were higher in the ESUS group than in the control group (both p < 0.01). The isovolumetric relaxation time (IVRT) was longer and the mean left atrial volume index (LAVI) was higher in ESUS patients compared to the control group. Parameters of arterial stiffness such as augmentation pressure, augmentation index, and augmentation index adjusted to a heart rate of 75 bpm (AIx75) were higher in ESUS patients compared to controls (p < 0.05). Patients in the ESUS group had higher levels of asymmetric dimethylarginine, interleukin 6, and N-terminal probrain natriuretic peptide (NT-proBNP, all p < 0.05) than those in the control group. In multivariate analysis, the following factors were significantly associated with the presence of ESUS: AIx75 (odds ratio (OR) 1.095, 95% confidence interval (CI) 1.004-1.194; p = 0.04), IVRT (OR 1.045, 95% CI: 1.009-1.082; p = 0.014), LAVI (OR 1.3, 95% CI: 1.099-1.537; p = 0.002), and NT-proBNP (OR 1.003, 95% CI: 1.001-1.005; p = 0.005).

Conclusions

Increased arterial stiffness and indices of diastolic dysfunction as well as a higher NT-proBNP level are significantly associated with ESUS. These parameters require further scrutiny over time to understand their impact on the development of symptomatic heart failure. The ClinicalTrials.gov identifier is NCT03377465.

Heart Failure as a Risk Factor for Stroke

Heart failure (HF) is one of the major causes of death worldwide. Despite the high incidence of stroke in patients with HF, there has been a controversy as to whether HF itself is a risk factor for stroke. Recently, there is a great deal of evidence that HF itself increases the risk of stroke. In previous studies, the benefit of warfarin for stroke prevention in patients with HF was offset by the risk of bleeding. In the era of non-vitamin K antagonist oral anticoagulants with low bleeding profiles, we can expect a more effective stroke prevention in patients with HF by selective anticoagulation. The purpose of this review is to describe the relationship between stroke and HF, which could be an unconventional risk factor and a potential intervention target for stroke prevention.

A Software Tool for Heart AVJ Motion Tracking Using Cine Cardiovascular Magnetic Resonance Images

One important index to assess left ventricular diastolic function is the quantitative measurement of atrioventricular junction (AVJ) motion in one cardiac cycle including systole and diastole. The best way to perform the measurement is to use a software tool that can conduct AVJ motion tracking from cine cardiovascular magnetic resonance (CMR) images. In this paper, a software tool for this purpose is presented by using the insight segmentation and registration toolkit (ITK), the visualization toolkit (VTK), and Qt. We propose a surface area-based tracking approach in the software tool. In the tracking approach to obtain the surface area swept by six points being tracked, we manually select six points from four-, three- and two-chamber views of CMR images. After that, we reconstruct the 3-D coordinates of the six points from image acquisition parameters extracted from DICOM files. We perform interpolation by using parametric cubic curve fitting techniques. From the curve fitting results, we finally obtain the surface areas for all time points in one cardiac cycle. The software tool has been successfully implemented. The functionality include single point-based tracking, surface area-based tracking by using 6 tracked points, generation of displacement, sweep surface area and velocity, and generation of tracking movies. From the software engineering practice, it is concluded that ITK, VTK, and Qt are very handy software systems to implement automatic image analysis functions for CMR images, such as quantitative measure of motion by visual tracking. The software tool provides a convenient and efficient way to measure AVJ motion and extends the scope of methods for ventricular function assessment.

Prediction of Thromboembolic Events in Heart Failure Patients in Sinus Rhythm: The Hong Kong Heart Failure Registry

AIM

Heart failure (HF) increases the risk of thromboembolic events (TE). Study in a Caucasian population has shown that the CHA2DS2-VASc score predicts TE among HF patients without atrial fibrillation. We sought to assess the usefulness of the CHA2DS2-VASc score in predicting TE in an Asian population and refine the scoring system to improve its predictability of TE among HF patients in sinus rhythm.

METHODS

A total of 1,202 consecutive patients who were admitted to our institution for new-onset HF from 2005 to 2012 and without atrial fibrillation or anticoagulation were retrospectively reviewed.

RESULTS

The mean age was 77.6 ± 12.2 years and 51.7% were female. After 36.2 ± 30.1 months, 113 (9.4%) developed TE. The annual incidence was 0.54%, 1.54%, 2.98% and 5.04% per year in those who had a CHA2DS2-VASc score of 1, 2-3, 4-5 and ≥6, respectively. In multivariate analysis, age ≥75 years [Hazard ratio (HR) 2.59, 95% confidence interval (CI) 1.23-5.46, p = 0.012), chronic ischemic heart disease (HR 1.54, 95% CI 1.02-2.31, p = 0.040) and chronic kidney disease (HR 1.66, 95% CI 1.09-2.53, p = 0.018) independently predicted TE. Incorporation of chronic ischemic heart disease and chronic kidney disease into the CHA2DS2-VASc score significantly increased the area under the Receiver Operating Curve from 0.57 (95% CI 0.54-0.59) to 0.61 (95% CI 0.55-0.66; p = 0.022).

CONCLUSION

The CHA2DS2-VASc score is useful for stratification of the risk of TE among HF patients in sinus rhythm. Incorporation of chronic ischemic heart disease and chronic kidney disease into the score modestly improves its predictive value.