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Zamora-Olaya JM, Tejero-Jurado R, Alañón-Martínez PE, Prieto-Torre M, Rodríguez-Medina C, Montero JL, Sánchez-Frías M, Briceño J, Ciria R, Barrera P, Poyato A, De la Mata M, Rodríguez-Perálvarez ML. Donor Atheromatous Disease is a Risk Factor for Hepatic Artery Thrombosis After Liver Transplantation. Clin Transplant 2024; 38:e15405. [PMID: 39033509 DOI: 10.1111/ctr.15405] [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: 02/18/2024] [Revised: 06/13/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024]
Abstract
The increasing age of liver donors and transplant candidates, together with the growing prevalence of metabolic comorbidities, could impact the risk of vascular complications after liver transplantation. We enrolled a consecutive cohort of adult patients undergoing liver transplantation from 2012 to 2021 who had a blinded pathological assessment of atherosclerosis in the donor and recipient hepatic arteries (HA). Patients receiving partial or reduced grafts, retransplantation, or combined organ transplantation were excluded. The relationship between HA atherosclerosis and HA thrombosis after liver transplantation was evaluated using logistic regression in the whole study cohort and in a propensity score-matched subpopulation. Among 443 eligible patients, 272 had a full pathological evaluation of the donor and recipient HA and were included in the study. HA atheroma was present in 51.5% of donors and in 11.4% of recipients. HA thrombosis occurred in 16 patients (5.9%), being more likely in patients who received a donor with HA atherosclerosis than in those without (10.7% vs. 0.8%; p < 0.001). Donor HA atherosclerosis was an independent risk factor of HA thrombosis (OR = 17.79; p = 0.008), and this finding was consistent in the propensity score-matched analysis according to age, sex, complex arterial anastomosis, and alcoholic liver disease (OR = 19.29; p = 0.007). Atheromatous disease in the recipient had no influence on the risk of HA thrombosis (OR = 1.70; p = 0.55). In conclusion, patients receiving donors with HA atherosclerosis are at increased risk for HA thrombosis after liver transplantation. The evaluation of the donor graft vasculature could guide antiplatelet therapy in the postoperative period.
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Affiliation(s)
- Javier M Zamora-Olaya
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Rocío Tejero-Jurado
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Paloma E Alañón-Martínez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - María Prieto-Torre
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Cristina Rodríguez-Medina
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - José L Montero
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Marina Sánchez-Frías
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Department of Pathology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Javier Briceño
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Department of HPB Surgery and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Rubén Ciria
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Department of HPB Surgery and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pilar Barrera
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Antonio Poyato
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Manuel De la Mata
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Manuel L Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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Malavasi VL, Muto F, Ceresoli PA, Menozzi M, Righelli I, Gerra L, Vitolo M, Imberti JF, Mei DA, Bonini N, Gargiulo M, Boriani G. Atrial fibrillation in vascular surgery: a systematic review and meta-analysis on prevalence, incidence and outcome implications. J Cardiovasc Med (Hagerstown) 2023; 24:612-624. [PMID: 37605953 PMCID: PMC10754485 DOI: 10.2459/jcm.0000000000001533] [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: 05/26/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
AIMS To know the prevalence of atrial fibrillation (AF), as well as the incidence of postoperative AF (POAF) in vascular surgery for arterial diseases and its outcome implications. METHODS We performed a systematic review and meta-analysis following the PRISMA statement. RESULTS After the selection process, we analyzed 44 records (30 for the prevalence of AF history and 14 for the incidence of POAF).The prevalence of history of AF was 11.5% [95% confidence interval (CI) 1-13.3] with high heterogeneity (I2 = 100%). Prevalence was higher in the case of endovascular procedures. History of AF was associated with a worse outcome in terms of in-hospital death [odds ratio (OR) 3.29; 95% CI 2.66-4.06; P < 0.0001; I2 94%] or stroke (OR 1.61; 95% CI 1.39-1.86; P < 0.0001; I2 91%).The pooled incidence of POAF was 3.6% (95% CI 2-6.4) with high heterogeneity (I2 = 100%). POAF risk was associated with older age (mean difference 4.67 years, 95% CI 2.38-6.96; P = 0.00007). The risk of POAF was lower in patients treated with endovascular procedures as compared with an open surgical procedure (OR 0.35; 95% CI 0.13-0.91; P = 0.03; I2 = 61%). CONCLUSIONS In the setting of vascular surgery for arterial diseases a history of AF is found overall in 11.5% of patients, more frequently in the case of endovascular procedures, and is associated with worse outcomes in terms of short-term mortality and stroke.The incidence of POAF is overall 3.6%, and is lower in patients treated with an endovascular procedure as compared with open surgery procedures. The need for oral anticoagulants for preventing AF-related stroke should be evaluated with randomized clinical trials.
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Affiliation(s)
- Vincenzo L. Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Federico Muto
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Pietro A.C.M. Ceresoli
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Matteo Menozzi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Ilaria Righelli
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena
| | - Jacopo F. Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena
| | - Davide A. Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena
| | - Mauro Gargiulo
- Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena
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Escobar-Cervantes C, Díez-Villanueva P, Bonanad Lozano C, Reino AP, Almendro-Delia M, Facila L, Valle A, Suárez C. Vascular protection with rivaroxaban in the comprehensive management of atrial fibrillation. Expert Rev Cardiovasc Ther 2023; 21:791-802. [PMID: 37933665 DOI: 10.1080/14779072.2023.2276893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/25/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION In addition to an increased risk of thromboembolic complications, patients with atrial fibrillation (AF) are at risk for vascular events. Consequently, complete vascular protection is warranted in these patients. AREAS COVERED A narrative search was conducted on PubMed (MEDLINE), using the MeSH terms [Rivaroxaban] + [Atrial fibrillation] + [Cardiovascular] + [Vascular] + [Treatment]. Original data from clinical trials, prospective and retrospective studies, useful reviews and experimental studies, were selected. EXPERT OPINION The ROCKET-AF trial showed that rivaroxaban is effective in reducing the risk of stroke, with a lower risk of fatal and intracranial bleeding compared to warfarin. Remarkably, experimental data have provided a number of pathogenic mechanisms through which rivaroxaban could provide beneficial vascular properties beyond its antithrombotic activity. Moreover, in the AF population, additional to its ability to reduce the risk of thromboembolic complications, rivaroxaban is associated with a lower risk of myocardial infarction, major adverse cardiac and limb events, and vascular mortality in patients with diabetes, also attenuating renal impairment during follow-up. These findings suggest that rivaroxaban may provide a comprehensive vascular protection in patients with AF.
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Affiliation(s)
| | | | - Clara Bonanad Lozano
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Instituto de Investigación Sanitaria del Hospital Clínico de Valencia (INCLIVA), Spain
| | - Antonio Pose Reino
- Hypertension and Vascular Risk Unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia Valencia, Spain
| | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Carmen Suárez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Escobar-Cervantes C, Reino AP, Díez-Villanueva P, Facila L, Freixa-Pamias R, Valle A, Almendro-Delia M, Bonanad C, Vivas D, Suarez C. Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach. Expert Rev Cardiovasc Ther 2023; 21:779-790. [PMID: 37874226 DOI: 10.1080/14779072.2023.2272652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention. AREAS COVERED In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed. EXPERT OPINION The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.
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Affiliation(s)
| | - Antonio Pose Reino
- Hypertension and vascular risk unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia, Valencia,Spain
| | | | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Health Research Institute of the Valencia Clinical Hospital (INCLIVA), Valencia, Spain
| | - David Vivas
- Cardiology Department, Instituto Cardiovascular Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Suarez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Batta A, Hatwal J, Batta A, Verma S, Sharma YP. Atrial fibrillation and coronary artery disease: An integrative review focusing on therapeutic implications of this relationship. World J Cardiol 2023; 15:229-243. [PMID: 37274376 PMCID: PMC10237004 DOI: 10.4330/wjc.v15.i5.229] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/05/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023] Open
Abstract
The incidence of both atrial fibrillation (AF) and coronary artery disease (CAD) increases with advancing age. They share common risk factors and very often coexist. Evidence points to an intricate relationship between atrial tissue excitability and neuronal remodeling with ischemia at the microcirculatory level. In this review, we delineated this complex relationship, identified a common theme between the two, and discussed how the knowledge of this relationship translates into a positive and meaningful impact in patient management. Recent research indicates a high prevalence of CAD among AF patients undergoing coronary angiography. Further, the incidence of AF is much higher in those suffering from CAD compared to age-matched adults without CAD underlying this reciprocal relationship. CAD adversely affects AF by promoting progression via re-entry and increasing excitability of atrial tissue as a result of ischemia and electrical inhomogeneity. AF in turn accelerates atherosclerosis via endothelial dysfunctional and inflammation and together with enhanced thrombogenicity and hypercoagulability contribute to micro and macrothrombi throughout cardiovascular system. In a nutshell, the two form a vicious cycle wherein one disease promotes the other. Most AF recommendations focuses on rate/rhythm control and prevention of thromboembolism. Very few studies have discussed the importance of unmasking coexistent CAD and how the treatment of underlying ischemia will impact the burden of AF in these patients. Inflammation and endothelial dysfunction remain central to both disease processes and form a handsome therapeutic target in the management of the two diseases. The relationship between AF and CAD is complex and much more than mere coincidence. The two diseases share common risk factor and pathophysiology. Hence, it is impractical to treat them in isolation. Accordingly, we share the implications of managing underlying ischemia and inflammation to positively impact and improve quality of life among AF patients.
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Affiliation(s)
- Akash Batta
- Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana 141001, Punjab, India
| | - Juniali Hatwal
- Department of Internal Medicine, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Akshey Batta
- Department of Medicine and Surgery, Sohana Multi Super Specialty Hospital, Mohali 160062, Punjab, India
| | - Samman Verma
- Department of Cardiology, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Yash Paul Sharma
- Department of Cardiology, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
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Direct Oral Anticoagulants as the First Choice of Anticoagulation for Patients with Peripheral Artery Disease to Prevent Adverse Vascular Events: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10020065. [PMID: 36826561 PMCID: PMC9964590 DOI: 10.3390/jcdd10020065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
The best method of anticoagulation for patients with peripheral artery disease (PAD) is still a topic of interest for physicians. We conducted a meta-analysis to compare the effects of direct oral anticoagulants (DOACs) with those of vitamin-K-antagonist (VKA) anticoagulants in patients with peripheral artery disease. Five databases (Medline (via PubMed), EMBASE, Scopus, Web of Science, and CENTRAL) were searched systematically for studies comparing the effects of the two types of anticoagulants in patients with PAD, with an emphasis on lower-limb outcomes, cardiovascular events, and mortality. In PAD patients with concomitant non-valvular atrial fibrillation (NVAF), the use of DOACs significantly reduced the risk of major adverse limb events (HR = 0.58, 95% CI, 0.39-0.86, p < 0.01), stroke/systemic embolism (HR 0.76; 95% CI 0.61-0.95; p < 0.01), and all-cause mortality (HR 0.78; 95% CI 0.66-0.92; p < 0.01) compared with warfarin, but showed similar risks of MI (HR = 0.81, 95% CI, 0.59-1.11, p = 0.2) and cardiovascular mortality (HR = 0.77, 95% CI, 0.58-1.02, p = 0.07). Rivaroxaban at higher doses significantly increased the risk of major bleeding (HR = 1.16, 95% CI, 1.07-1.25, p < 0.01). We found no significant difference in terms of revascularization (OR = 1.49, 95% CI, 0.79-2.79, p = 0.14) in PAD patients in whom a poor distal runoff was the reason for the anticoagulation. DOACs have lower rates of major limb events, stroke, and mortality than VKAs in PAD patients with atrial fibrillation. Rivaroxaban at higher doses increased the risk of major bleeding compared with other DOAC drugs. More high-quality studies are needed to determine the most appropriate anticoagulation regimen for patients with lower-limb atherosclerosis.
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Jortveit J, Sandberg EL, Pripp AH, Halvorsen S. Time trends in adherence to guideline recommendations for anticoagulation therapy in patients with atrial fibrillation and myocardial infarction. Open Heart 2022; 9:openhrt-2021-001934. [PMID: 35387862 PMCID: PMC8987752 DOI: 10.1136/openhrt-2021-001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/22/2022] [Indexed: 12/04/2022] Open
Abstract
Background Poor adherence to guideline recommendations for anticoagulation in patients with acute myocardial infarction (MI) and atrial fibrillation (AF) is previously reported. The aim of the present cohort study was to assess time trends in prescription of anticoagulation therapy in a nationwide registry-based cohort of patients with acute MI and AF. Methods All patients, registered in the Norwegian Myocardial Infarction Registry (NORMI) between 2013 and 2019 with ECG-verified AF at hospitalisation, were included in the cohort study. The primary outcome was the prescription rate of anticoagulation therapy at hospital discharge and follow-up through 2019. Results AF was observed in 8565 (10.9% of 78369) patients registered in the NORMI from 2013 through 2019. The congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65–75, and sex (female) score was ≥2 in 7845 (92%) of the hospitalised patients with AF, and in 7174 (96%) of 7440 patients discharged alive. Only 3704 (47.2%) of these patients were treated with anticoagulation prior to the MI. The prescription rate of anticoagulation therapy at discharge was 55% in 2013, increasing to 78% in 2019 (annual per cent change 6.0 (95% CI 0.7 to 11.6)). Patients prescribed anticoagulation therapy had reduced risk of all types of stroke or death at follow-up compared with patients without prescription of anticoagulation therapy (multivariate-adjusted HR 0.8, 95% CI 0.7 to 0.8, p<0.001). Conclusions The prescription rate of anticoagulation therapy in patients with MI and AF increased during the study period, but many patients were still undertreated with respect to stroke prevention.
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Affiliation(s)
- Jarle Jortveit
- Department of Cardiology, Sorlandet Sykehus HF Arendal, Arendal, Norway
| | - Edvard L Sandberg
- Department of Cardiology, Sorlandet Sykehus HF Arendal, Arendal, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevaal and University of Oslo, Oslo, Norway
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9
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Ngcobo SR, Nkambule BB, Nyambuya TM, Mokgalaboni K, Ntsethe A, Mxinwa V, Ziqubu K, Ntamo Y, Nyawo TA, Dludla PV. Activated monocytes as a therapeutic target to attenuate vascular inflammation and lower cardiovascular disease-risk in patients with type 2 diabetes: A systematic review of preclinical and clinical studies. Biomed Pharmacother 2022; 146:112579. [PMID: 35062054 DOI: 10.1016/j.biopha.2021.112579] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 12/20/2022] Open
Abstract
Low grade inflammation is associated with the progression of atherosclerosis. Patients with type 2 diabetes (T2D) have altered cholesterol levels, which are targeted by free radicals to promote lipid peroxidation. Elevated levels of monocyte-associated cytokines such as interleukin (IL)-6, monocyte chemoattractant protein 1 (MCP-1), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), and tumor necrosis factor-alpha (TNF-α), subsequently drive endothelial tissue injury. In fact, the levels of circulating platelet-monocyte aggregates in patients with T2D is a robust marker for atherosclerosis and a cardiovascular disease (CVD)-risk factor. To identify eligible studies, we searched the major online databases using PubMed and Google Scholar. The cumulative evidence synthesized in the current review suggests that, traditional therapies which include thiazolidinediones, statins and some calcium channel blockers can be useful in the primary prevention of atherosclerosis by inhibiting the formation of monocyte-derived microparticles, and pro-inflammatory cytokines such as IL-6, TNF-α, MCP-1, and NF-κB in patients with T2D. Future studies are needed to ascertain whether the combination of dietary interventions and glucose or lipid lowering agents can provide an enhanced cardioprotection in patients with T2D.
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Affiliation(s)
- Siphamandla R Ngcobo
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4000, South Africa
| | - Bongani B Nkambule
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4000, South Africa
| | - Tawanda M Nyambuya
- Department of Health Sciences, Namibia University of Science and Technology, Windhoek 9000, Namibia
| | - Kabelo Mokgalaboni
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4000, South Africa
| | - Aviwe Ntsethe
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4000, South Africa
| | - Vuyolwethu Mxinwa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4000, South Africa
| | - Khanyisani Ziqubu
- Department of Biochemistry, North-West University, Mmabatho 2745, South Africa
| | - Yonela Ntamo
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
| | - Thembeka A Nyawo
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa; Centre for Cardiometabolic Research in Africa (CARMA), Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
| | - Phiwayinkosi V Dludla
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa.
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10
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Abolbashari M. Atherosclerosis and Atrial Fibrillation: Double Trouble. Curr Cardiol Rep 2022; 24:67-73. [PMID: 34993746 DOI: 10.1007/s11886-021-01625-w] [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] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis. RECENT FINDINGS MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.
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Affiliation(s)
- Mehran Abolbashari
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
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11
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Xie X, Li T. Anticoagulation for atrial fibrillation patients with the CHA2DS2-VASc score =1 (beyond sex). Acta Cardiol 2021; 76:258-264. [PMID: 32056508 DOI: 10.1080/00015385.2020.1720197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We investigated the risk of ischaemic stroke in patients with 1 another stroke risk factor (i.e. CHA2DS2-VASc score =1 [males] or 2 [females]) and the impact of different component risk factors. METHODS Database were collected from two hospitals in the city of Hohhot in china. Among 3148 Nonvalvular AF patients not on antiplatelet or anticoagulant therapy, we evaluated males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2. The clinical endpoint was the occurrence of ischaemic stroke. RESULTS Among 546 AF male patients with a CHA2DS2-VASc score of 1, there were 44 patients (8.06%) who experienced ischaemic stroke during follow-up (3.4 ± 2.1 years) with an annual stroke rate of 2.62%. The risk of ischaemic stroke ranged from 1.86%/year for patients with vascular diseases to 3.33%/year for those age 65-74 years of age. For the female patients with 653 AF, 54 (8.27%) experienced ischaemic stroke during follow-up (3.4 ± 2.1 years) , for an annual stroke rate of 2.76%. The risk of ischaemic stroke increased from 1.96%/year for patients with vascular diseases to 3.38%/year for those 65-74 years of age. CONCLUTIONS The risk of each factor is not equal in CHA2DS2-VASc score, with age 65-74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 another stroke risk factor given their high risk of ischaemic stroke.Article summary:The risk of each factor is not equal in CHA2DS2-VASc score.Atrial fibrillation is a risk factor of ischaemic stroke.Oral anticoagulation should be considered for AF patients with 1 another stroke risk factor given their high risk of ischaemic stroke.It is the retrospective nature of the study.We were not able to clearly confirm the cause of ischaemic stroke because it can be due to AF-related thromboembolism or atherosclerosis and thrombosis of the cerebral artery.
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Affiliation(s)
- XiuFeng Xie
- Southern Medical University, Guangzhou, China
- The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - TianChang Li
- Southern Medical University, Guangzhou, China
- The Sixth Medical Center of PLA General Hospital, Beijing, China
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Tseng AS, Girardo M, Firth C, Bhatt S, Liedl D, Wennberg P, Shen WK, Cooper LT, Shamoun FE. Lower Extremity Arterial Disease as a Predictor of Incident Atrial Fibrillation and Cardiovascular Events. Mayo Clin Proc 2021; 96:1175-1183. [PMID: 33958054 DOI: 10.1016/j.mayocp.2020.07.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/22/2020] [Accepted: 07/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the relationship between peripheral arterial disease (PAD) and incident atrial fibrillation (AF) and its clinical and pathophysiologic implications on ischemic stroke and all-cause mortality. PATIENTS AND METHODS We identified all adult patients in the Mayo Clinic Health System without a previous diagnosis of AF undergoing ankle-brachial index (ABI) testing for any indication from January 1, 1996, to June 30, 2018. Retrospective extraction of ABI data and baseline echocardiographic data was performed. The primary outcome of interest was incident AF. The secondary outcomes of interest were incident ischemic stroke and all-cause mortality. RESULTS A total of 33,734 patients were included in the study. After adjusting for demographic and comorbidity variables, compared with patients who had normal ABI (1.0 to 1.39), there was an increased risk of incident AF in patients with low ABI (<1.0) (adjusted hazard ratio, 1.14; 95% CI, 1.06 to 1.22) and elevated ABI (≥1.4) (adjusted hazard ratio, 1.18; 95% CI, 1.06 to 1.31). The risk was greater in patients with increasing severity of PAD. Patients with abnormal ABIs had an increased risk of ischemic stroke and all-cause mortality. We found that patients with PAD and incident AF have certain baseline echocardiographic abnormalities. CONCLUSION In this large cohort of ambulatory patients undergoing ABI measurement, patients with PAD were at increased risk for incident AF, ischemic stroke, and mortality. In these high-risk patients with abnormal ABI, particularly severe PAD and cardiac structural abnormalities, routine monitoring for AF and management of cardiovascular risk factors may be warranted.
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Affiliation(s)
- Andrew S Tseng
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Marlene Girardo
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ
| | - Christine Firth
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ
| | - Shubhang Bhatt
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - David Liedl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Paul Wennberg
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Win-Kuang Shen
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL
| | - Fadi E Shamoun
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ.
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13
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Peripheral Arterial Disease in Patients with Atrial Fibrillation: The AFFIRM Study. Am J Med 2021; 134:514-518. [PMID: 32956630 DOI: 10.1016/j.amjmed.2020.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Peripheral arterial disease has been linked with worse outcomes in patients with atrial fibrillation. The aim of this study is to assess the impact of peripheral arterial disease on mortality and stroke in a cohort of patients with atrial fibrillation. METHODS This was an ancillary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A comparison of baseline characteristics was made between patients with atrial fibrillation with and without diagnosed peripheral arterial disease. Multivariate cox regression analysis was performed to compare the risk of stroke, death, and cardiovascular death among the two groups. RESULTS The prevalence of peripheral arterial disease in the whole cohort of 4060 patients with atrial fibrillation was 6.7%. Patients with peripheral arterial disease tended to be older; had higher prevalence of diabetes mellitus, hypertension, and smoking; and were more likely to have a history of coronary artery disease, heart failure, cardiac surgery or cardiac intervention, and stroke or transient ischemic attack (all P < .05). After multivariate adjustment, peripheral arterial disease was significantly associated with overall higher mortality (hazard ratio 1.34, 95% confidence interval 1.06-1.70, P = .016) in patients with atrial fibrillation, but the rates of ischemic stroke were similar in the two groups (3.9% vs 3.5%, P = 0.874). Subgroup analysis confined to the patients with non-anticoagulated atrial fibrillation showed that peripheral arterial disease was an independent predictor of ischemic stroke (hazard ratio 3.37, 95% confidence interval 1.25-9.09, P < .016). CONCLUSION Peripheral arterial disease predicts higher mortality in atrial fibrillation, and was an independent predictor of ischemic stroke in patients with non-anticoagulated atrial fibrillation. Proactive surveillance and optimization of medical management in this group of patients is warranted, given the high risks associated with peripheral arterial disease where atrial fibrillation is also present.
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15
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Gawałko M, Lodziński P, Budnik M, Tymińska A, Wancerz A, Ozierański K, Kapłon-Cieślicka A, Grabowski M, Opolski G, Lenarczyk R, Kalarus Z, Lip GYH, Balsam P. Vascular disease in patients with atrial fibrillation. A report from Polish participants in the EORP-AF General Long-Term Registry. Int J Clin Pract 2021; 75:e13701. [PMID: 32915461 DOI: 10.1111/ijcp.13701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/06/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022] Open
Abstract
AIMS This study aimed to (1) define the prevalence of vascular disease (VD; coronary (CAD) and/or peripheral artery disease (PAD)) and associated risk factors in patients with atrial fibrillation (AF); (2) establish the relationship of VD and associated treatment patterns on adverse events in AF. METHODS Data from 701 Polish AF patients enrolled in the EORP-AF General Long-Term Registry in the years 2013-2016 were included in this analysis. During the one-year follow-up, the occurrence of major adverse events (MAE; all-cause death, thromboembolic event, myocardial infraction) and its components was evaluated. RESULTS VD was recorded in 293 (44%) patients and based on multivariate logistic analysis was associated with age >75, diabetes, hypercholesterolemia, heart failure (HF). There was no significant difference in rates of MAE between patients with and without VD based on Fisher's exact test (8.8% vs 5.7%, P = .16), as well as between patients with concomitant CAD and PAD, PAD and CAD alone based on the Chi-square test (21% vs 7.5% vs 6.7%; P = .09). A higher risk of MAE was associated with HF, chronic kidney disease (in all study group), age >75, HF, diabetes (VD group),chronic obstructive pulmonary disease (non-VD group) based on the multivariate logistic analysis. Relative to patients with VD on vitamin K antagonists (VKA), those treated with non-VKA-oral anticoagulants (NOAC) had lower absolute rate of MAE according to Fisher's exact test (1.4% vs 10%, P = .02) but similar risks for thromboembolic and hemorrhagic events. The concomitant use of triple therapy was associated with increased risk of MAE as compared with those on OAC alone or dual therapy based on the Chi-square test (20% vs 4.8%, 3.2%, P = .02). CONCLUSION VD was prevalent in almost two-fifths of AF patients. The incidence of MAE was higher in patients with VD on VKA (vs NOAC) and on triple therapy (vs dual therapy, OAC alone) within one-year follow-up.
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Affiliation(s)
- Monika Gawałko
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Lodziński
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Monika Budnik
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Agata Tymińska
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Wancerz
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Radosław Lenarczyk
- 1st Department of Cardiology and Angiology, Silesian Center for Heart Disease, Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, DMS in Zabrze, Medical University of Silesia, Katowice, Poland, Zabrze, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Paweł Balsam
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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16
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Wang TKM, Chan N, Cremer PC, Kanj M, Baranowski B, Saliba W, Wazni OM, Jaber WA. Incorporating coronary calcification by computed tomography into CHA2DS2-VASc score: impact on cardiovascular outcomes in patients with atrial fibrillation. Europace 2021; 23:1211-1218. [PMID: 33585883 DOI: 10.1093/europace/euab032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/27/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS CHA2DS2-VASc score is widely utilized for risk stratification and guiding anticoagulation in patients with atrial fibrillation (AF). Cardiac computed tomography (CCT) routinely performed for pulmonary vein isolation (PVI) can also identify coronary artery calcifications (CAC). We evaluated the frequency and outcomes of incorporating CAC into the CHA2DS2-VASc score in AF patients undergoing PVI. METHODS AND RESULTS Consecutive patients in a prospective PVI registry during 2014-18 having CCT within 1 year of PVI were studied. Reclassification of CHA2DS2-VASc score and associations between CAC as a binary variable detected on CCT with clinical characteristics, stroke as primary endpoint, death, myocardial infarction, and major adverse cardiovascular events (MACE) were analysed. Amongst 3604 AF patients, 2238 (62.1%) had CAC detected on CCT and was associated with most traditional cardiovascular risk factors. Coronary artery calcification was independently associated with all pre-specified endpoints adjusting for clinical parameters in multivariable analysis. Adjusting for CHA2DS2-VASc score, CAC was associated with stroke (hazards ratio 3.64, 95% confidence interval 1.25-10.6, P = 0.018), death (2.26, 1.29-3.98, P = 0.006), and MACE (2.08, 1.36-3.16, P = 0.001) during 2.8 ± 1.6-year follow-up. Incorporating CAC as a vascular disease parameter of CHA2DS2-VASc score, anticoagulation decision-making would be revised in 723 (20.1%) patients, including an additional 488 (13.5%) patients where anticoagulation would be now indicated. CONCLUSION Coronary artery calcification is prevalent in AF patients undergoing PVI and independently associated stroke, death and MACE even when adjusted for traditional CHA2DS2-VASc score. Adding CAC as vascular component to the CHA2DS2-VASc score requires further research as it potentially modified the anticoagulation management in 20% of our AF cohort.
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Affiliation(s)
- Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 9500 Euclid Avenue, Main Campus J1-5, Cleveland Clinic, Cleveland,OH 44195, USA
| | - Nicholas Chan
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 9500 Euclid Avenue, Main Campus J1-5, Cleveland Clinic, Cleveland,OH 44195, USA
| | - Paul C Cremer
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 9500 Euclid Avenue, Main Campus J1-5, Cleveland Clinic, Cleveland,OH 44195, USA
| | - Mohamed Kanj
- Section of Cardiac Electrophysiology and Pacing, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland,OH, USA
| | - Bryan Baranowski
- Section of Cardiac Electrophysiology and Pacing, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland,OH, USA
| | - Walid Saliba
- Section of Cardiac Electrophysiology and Pacing, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland,OH, USA
| | - Oussama M Wazni
- Section of Cardiac Electrophysiology and Pacing, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland,OH, USA
| | - Wael A Jaber
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 9500 Euclid Avenue, Main Campus J1-5, Cleveland Clinic, Cleveland,OH 44195, USA
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17
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5092] [Impact Index Per Article: 1697.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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18
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Tomoi Y, Takahara M, Soga Y, Fujihara M, Iida O, Kawasaki D, Kozuki A, Ando K. Prognostic Value of the CHA 2DS 2-VASc Score after Endovascular Therapy for Femoral Popliteal Artery Lesions. J Atheroscler Thromb 2021; 28:1153-1160. [PMID: 33487619 PMCID: PMC8592701 DOI: 10.5551/jat.60772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aim:
Originally developed for predicting the risk of stroke in patients with atrial fibrillation (AF), the CHA
2
DS
2
-VASc score also has the potential to predict the risk of other cardiovascular disease. This study aimed to investigate the prognostic value of the CHA
2
DS
2
-VASc score in patients with peripheral artery disease (PAD) requiring Femoral popliteal (FP) endovascular therapy (EVT).
Methods:
This multicenter, retrospective study analyzed the clinical database of 2190 patients who underwent FP EVT for symptomatic PAD (Rutherford categories 2–4) between January 2010 and December 2018. We calculated the CHA
2
DS
2
-VASc score and then investigated the association between the score, as well as AF, and their prognosis. Outcome measures were major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs).
Results:
During a median follow-up of 3.0 years (interquartile range, 1.5–5.0 years), 532 MACEs and 562 MALEs occurred. The CHA
2
DS
2
-VASc score and AF were independently associated with an increased risk of MACEs; their adjusted hazard ratios [95% confidence intervals] were 1.28 [1.20–1.36] (
P
<0.001) per 1-point increase and 1.49 [1.06–2.09] (
P
=0.022), respectively. The CHA
2
DS
2
-VASc score was almost linearly associated with MACEs, without any clear threshold point. On the other hand, these variables were not associated with MALEs risk (
P
=0.32 and 0.48).
Conclusion:
The CHA
2
DS
2
-VASc score and AF were independently associated with the increased risk of MACEs but not of MALEs in patients with symptomatic PAD who underwent FP EVT. The score might be useful in stratifying the MACEs risk in this type of patients.
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Affiliation(s)
- Yusuke Tomoi
- Department of Cardiology, Kokura Memorial Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine
| | | | | | - Osamu Iida
- Department of Cardiology, Kansai Rosai Hospital
| | | | - Amane Kozuki
- Department of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
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Proietti M, Lane DA, Boriani G, Lip GY. Stroke Prevention, Evaluation of Bleeding Risk, and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines. Can J Cardiol 2019; 35:619-633. [DOI: 10.1016/j.cjca.2019.02.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
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Oladiran O, Nwosu I. Stroke risk stratification in atrial fibrillation: a review of common risk factors. J Community Hosp Intern Med Perspect 2019; 9:113-120. [PMID: 31044042 PMCID: PMC6484493 DOI: 10.1080/20009666.2019.1593781] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 03/07/2019] [Indexed: 12/20/2022] Open
Abstract
Atrial Fibrillation (AF) has become a major global health concern being the most common sustained arrhythmia in clinical practice. Risk factors for AF include congestive heart failure, hypertension, increasing age and diabetes. Many of these factors also increase the risk for thromboembolism and ischemic stroke in AF patients. Great efforts have been made from the latter part of the 20th century towards developing an ideal stroke risk stratification tool in AF with the aim of reducing the incidence of stroke in AF patients and the limiting unnecessary use of thromboprophylaxis. The thromboembolic risks posed by AF with valvular heart disease are an important subgroup that contributes to a significant proportion of stroke in AF patients globally. We review the evolution of stroke risk stratification and summarize the guidelines for stroke prevention in non-valvular AF as well as AF with valvular heart disease, and the most recent recommendations on stroke prevention in AF patients. Abbreviations: AF: Atrial Fibrillation; ACS: Acute Coronary Syndrome; CAD: Coronary Artery Disease; CCF: Congestive Cardiac Failure; DM: Diabetes Mellitus; EHRA: Evaluated Heartvalves, Rheumatic or Artificial; ICH: Intracranial Hemorrhage; NOACs: Novel Oral Anticoagulants; OAC: Oral Anticoagulants; PAD: Peripheral Arterial Disease ; TIA: Transient Ischemic Attack; VHD: Valvular Heart Disease.
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Affiliation(s)
- Oreoluwa Oladiran
- Department of Internal Medicine, Reading Hospital, Tower health system, West Reading, PA, USA
| | - Ifeanyi Nwosu
- Department of Internal Medicine, Leighton Hospital NHS Trust, Crewe, Cheshire, UK
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21
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Proietti M, Laroche C, Nieuwlaat R, Crijns HJGM, Maggioni AP, Lane DA, Boriani G, Lip GYH. Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: A comparison between EORP-AF pilot and EHS-AF registries. Eur J Intern Med 2018; 55:28-34. [PMID: 29778588 DOI: 10.1016/j.ejim.2018.05.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/13/2018] [Accepted: 05/09/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND In 2002, the European Society of Cardiology conducted the Euro Heart Survey (EHS), while in 2014concluded 1-year follow-up of the EURObservational Research Programme AF (EORP-AF) Pilot Registry. METHODS We analysed differences in clinical profiles, therapeutic approaches and outcomes between these two cohorts after propensity score matching (PSM). RESULTS After PSM, 5206 patients were analysed. In EORP-AF there were more elderly patients than EHS (p < .001). EORP-AF patients were more burdened with cardiovascular (CV) and non-CV comorbidities, with a higher proportion of patients with high thromboembolic risk. EORP-AF patients used more oral-anticoagulant (OAC) (p < .001). At 1-year follow-up EORP-AF patients had lower risk for thromboembolic and CV events, readmission for AF and other CV reasons (all p < .001), showing conversely a higher risk for CV death (p = .015). Kaplan-Meier curves showed that EORP-AF patients had higher risk for CV death (p < .0001) and all-cause death (p = .0019). Cox regression confirmed that EORP-AF patients were at higher risk for CV death (p = .021). CONCLUSIONS We found significant changes in AF epidemiology over a decade in Europe, with older patients, more burdened with comorbidities. A greater use of OAC was found. Despite a reduction in risk for thromboembolic events, a high risk of CV-related death was still evident.
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Affiliation(s)
- Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Cécile Laroche
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France
| | - Robby Nieuwlaat
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Aldo P Maggioni
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France; ANMCO Research Center, Firenze, Italy
| | - Deirdre A Lane
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Giuseppe Boriani
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy; Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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22
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Prognostic and therapeutic implications of vascular disease in patients with atrial fibrillation. Pharmacol Res 2018; 132:149-159. [DOI: 10.1016/j.phrs.2018.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 01/22/2018] [Accepted: 04/20/2018] [Indexed: 01/04/2023]
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23
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Guo Y, Wang Y, Li X, Shan Z, Shi X, Xi G, Lip GYH. Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry: protocol for a prospective, observational nationwide cohort study. BMJ Open 2018; 8:e020191. [PMID: 29730624 PMCID: PMC5942423 DOI: 10.1136/bmjopen-2017-020191] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a worldwide healthcare burden that is associated with the ageing population. Elderly patients with AF with multiple comorbidities usually present with a high risk of thromboembolism and bleeding. Limited prospective data are available from Asian cohorts on the epidemiology and complications of AF. The present prospective cohort study aims to explore contemporary antithrombotic strategies among the elderly Chinese population in the new era of non-vitamin K antagonist oral anticoagulants and to compare the clinical characteristics and outcomes between Chinese and European AF populations. METHODS AND ANALYSIS The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry will recruit 5000 patients with AF over 65 years of age in China. AF-related risks, including stroke/systemic thromboembolism and bleeding outcomes, will be assessed. Medical history, risk factors, demographic information and management will be collected at baseline, and clinical events during 1 year follow-up will be recorded. Follow-up will be conducted for at least 1 year and then annually thereafter. As our registry has a common protocol to the European Society of Cardiology EURObservational Research Programme AF general registry programme, preplanned analyses comparing the clinical profiles and outcomes will be performed. The ChiOTEAF registry offers an opportunity to provide a better understanding of the clinical profiles and adverse outcomes of patients with AF in China and allow for comparisons with a contemporary European population. ETHICS AND DISSEMINATION Ethics approval was granted by the Central Medical Ethic Committee of Chinese PLA General Hospital (approval no S2014-065-01). The (inter)national research presentations, peer-reviewed publications and media coverage of the research will be sued for dissemination of the results.
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Affiliation(s)
- Yutao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yutang Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoying Li
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Zaoliang Shan
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiangmin Shi
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Guorong Xi
- Health Division of Guard Bureau, Chinese PLA General Staff Department, Beijing, China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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Carotid atherosclerosis and risk for ischemic stroke in patients with atrial fibrillation on oral anticoagulant treatment. Atherosclerosis 2018. [DOI: 10.1016/j.atherosclerosis.2018.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Pastori D, Pignatelli P, Sciacqua A, Perticone M, Violi F, Lip GYH. Relationship of peripheral and coronary artery disease to cardiovascular events in patients with atrial fibrillation. Int J Cardiol 2017; 255:69-73. [PMID: 29290420 DOI: 10.1016/j.ijcard.2017.12.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 12/02/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND To investigate the impact of concomitant asymptomatic peripheral artery disease (PAD) and pre-existing coronary artery disease (CAD) on cardiovascular events (CVEs) in atrial fibrillation (AF) patients. METHODS Prospective multicenter study including 1138 anticoagulated AF patients. PAD was diagnosed by can ankle-brachial index (ABI)≤0.9, and CAD as a documented myocardial infarction (MI) or cardiac revascularization. The cohort was divided into 4 groups: group 0 (n=717) with no previous CAD and ABI >0.9; group 1 (n=168) no previous CAD and ABI≤0.9; group 2 (n=183) previous CAD and ABI >0.9: and group 3 (n=70) previous CAD and ABI≤0.9. The primary endpoint was a composite of CVEs. RESULTS Mean age was 72.6years and 41.3% were female. History of CAD was present in 253 (22.2%) patients, and 238 (20.9%) had an ABI≤0.9. Patients with previous CAD were more likely to have a low ABI compared to those without (OR:1.6, 95%CI 1.2-2.3, P=0.003). Median follow-up was 35.9months (IQR 19.2-57.2, 3819 patient-years), and 145 CVEs were recorded (3.8%/year 95%CI 3.2-4.5). Survival analysis showed a progressive increase in the rate of CVEs in the four groups (log-rank test P<0.001). Multivariable Cox regression analysis showed that as compared to group 0, group 1 (HR:1.8, 95%CI 1.1-2.9, P=0.01), group 2 (HR:2.2, 95%CI 1.4-3.4, P=0.001) and group 3 (HR:2.4, 95%CI 1.4-4.4, P=0.003) were associated with progressive greater risk of CVEs. CONCLUSION Patients with concomitant CAD and asymptomatic PAD are at high risk of CVEs, with a progressive risk with vascular disease burden where PAD was associated with CAD.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Maria Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Eckardt M, Brettschneider C, van den Bussche H, König HH. Analysis of Health Care Costs in Elderly Patients with Multiple Chronic Conditions Using a Finite Mixture of Generalized Linear Models. HEALTH ECONOMICS 2017; 26:582-599. [PMID: 26989851 DOI: 10.1002/hec.3334] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 01/26/2016] [Accepted: 02/05/2016] [Indexed: 06/05/2023]
Abstract
In this paper we analysed healthcare costs in a sample of elderly patients suffering from multimorbidity. On the one hand, multimorbid individuals consume a disproportionally large share of healthcare resources. On the other hand, the patient specific number and combination of co-occurring single diseases result in inhomogeneous data leading to biased estimates when using traditional regression techniques. Therefore, we applied a mixture of regressions in order to control for unobserved heterogeneity focussing on the identification of multimorbidity patterns. We used a subsample of N = 1050 patients from a multicentre prospective cohort study of randomly selected multimorbid primary care patients aged 65 to 85 years in Germany (ISRCTN 89818205) who completed a detailed questionnaire on healthcare utilization during the 6-month period preceding the interview. Disease combinations of 1047 were included. We detected four different groups of patients with regard to total costs. These groups corresponded largely to findings from the epidemiological literature. The effect of the presence of an additional disease on costs differed between groups. Moreover, two diametrically opposed cost trends were detected with respect to the number of co-occurring diseases. While in one group costs increased with the number of co-occurring diseases, in a second group cost tended to decrease. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Matthias Eckardt
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik van den Bussche
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Qi Z, Chen H, Wen Z, Yuan F, Ni H, Gao W, Shen J, Li J, Lin Y, Shan Y, Jin B, Yan P, Shi H, Luo X. Relation of Low-Density Lipoprotein Cholesterol to Ischemic Stroke in Patients With Nonvalvular Atrial Fibrillation. Am J Cardiol 2017; 119:1224-1228. [PMID: 28215412 DOI: 10.1016/j.amjcard.2016.12.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/14/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
Low-density lipoprotein cholesterol (LDL-C) has been demonstrated as an independent risk factor of ischemic stroke, but the association of LDL-C with ischemic stroke in patients with nonvalvular atrial fibrillation (AF) remains uncertain. Our objective was to explore whether LDL-C could refine stroke stratification in patients with AF. A total of 424 nonvalvular patients with AF with ischemic stroke and 391 ones without ischemic stroke were enrolled. No patient had received antithrombotic therapy. Multivariate logistic regression analysis showed that LDL-C was an independent predictor of ischemic stroke in patients with AF, with the adjusted odds ratio of 2.004 (95% confidence interval 1.624 to 2.473; p <0.001). The receiver operating characteristic analysis revealed that the best cut-off value of LDL-C to predict ischemic stroke in patients with AF was 2.48 mmol/L with 56.3% sensitivity and 66.3% specificity (area under the curve: 0.651, p <0.001). In the subgroup analysis based on different CHA2DS2-VASc scores, the predictive value of LDL-C remained significant in patients with a CHA2DS2-VASc score of ≤5. In conclusion, LDL-C was an independent predictor of ischemic stroke, which could potentially refine stroke stratification in patients with AF. A prospective study with a large number of patients is required to validate the current findings.
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Voukalis C, Shantsila E, Lip GY. Clinical Stroke prevention in atrial fibrillation. J R Coll Physicians Edinb 2017; 47:13-23. [PMID: 28569277 DOI: 10.4997/jrcpe.2017.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Oral anticoagulation therapy has reduced the risk of ischaemic stroke and improved the outcomes for patients with atrial fibrillation considerably. The emergence of the non-vitamin K oral anticoagulants as alternatives to vitamin K antagonists has significantly changed the practice of stroke prevention in atrial fibrillation. As the main complication with antithrombotic therapy is bleeding, physicians should always balance the risk of ischaemic stroke against intracranial haemorrhage and intervene where appropriate to reduce both risks. Individual approach is often mandatory due to heterogeneity of the risks and patient preferences. The purpose of this review is to summarise the current knowledge of the oral anticoagulation therapy in atrial fibrillation patients and guide physicians with the management of anticoagulants based on data from clinical trials and systematic reviews.
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Affiliation(s)
- C Voukalis
- GYH Lip, University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK.
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Clinical characteristics of complex aortic plaque in patients with non-valvular atrial fibrillation. Int J Cardiol 2016; 230:85-90. [PMID: 28038818 DOI: 10.1016/j.ijcard.2016.12.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/01/2016] [Accepted: 12/16/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although complex aortic plaque (CxAoP) is a component of the CHA2DS2-VASc score in patients with atrial fibrillation (AF), it is underestimated without detection by trans-esophageal echocardiogram (TEE). We have evaluated the incidence and significance of CxAoP among patients with non-valvular AF (NVAF). METHODS We included 981 patients with NVAF who underwent catheter ablation (59.1±11.1years old, 73.7% male, 70.2% paroxysmal AF). All of the patients underwent pre-procedural TEE evaluation. Left atrial (LA)-cardioembolic (CE) milieu was defined as a dense spontaneous echo-contrast or LA appendage flow velocity≤20cm/s. RESULTS CxAoP was present in 8.3% of patients, and independently associated with age (OR 1.07, 95% CI 1.03-1.10, p<0.001), male sex (OR 2.34, 95% CI 1.29-4.24, p=0.005), and CHA2DS2-VASc score≥2 (OR 3.33, 95%CI 1.42-7.77, p=0.005). The presence of LA-CE milieu overlapped with CxAoP in only 11% of patients. Patients with CxAoP had a higher prevalence of hypertension (p=0.004), smoking history (p=0.008), paroxysmal AF (PAF, p<0.001), and a smaller LA volume index (p<0.001) than those with LA-CE milieu. The prevalence of persistent AF among patients with a history of stroke was significantly lower in the presence of CxAoP than in those with LA-CE milieu (p=0.014). CHA2DS2-VASc score was underestimated in 11% of high-risk patients (CHA2DS2-VASc score≥2) due to undetected CxAoP. CONCLUSIONS CxAoP may contribute to the risk of stroke by a different mechanism than LA-CE milieu in patients with NVAF. Imaging assessment for CxAoP affects thromboembolic risk stratification and decision making for stroke prevention in patients with NVAF.
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Proietti M, Raparelli V, Laroche C, Dan GA, Janion M, Popescu R, Sinagra G, Vijgen J, Boriani G, Maggioni AP, Tavazzi L, Lip GY. Adverse outcomes in patients with atrial fibrillation and peripheral arterial disease: a report from the EURObservational research programme pilot survey on atrial fibrillation. Europace 2016; 19:1439-1448. [DOI: 10.1093/europace/euw169] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/17/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
- Marco Proietti
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham B18 7QH, UK
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza-University of Rome, Rome, Italy
| | - Cécile Laroche
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France
| | - Georghe-Andrei Dan
- University of Medicine, ‘Carol Davila’, Colentina University Hospital, Bucharest, Romania
| | - Marianna Janion
- Świętokrzyskie Cardiology Centre, Faculty of Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Raluca Popescu
- University of Medicine, ‘Carol Davila’, Colentina University Hospital, Bucharest, Romania
| | - Gianfranco Sinagra
- Cardiovascular Department, University Hospital Cattinara, AOU Ospedali Riuniti, Trieste, Italy
| | - Johan Vijgen
- Department of Cardiology, Jessa Hospitals, Hasselt, Belgium
| | - Giuseppe Boriani
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Aldo P. Maggioni
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France
- ANMCO Research Center, Firenze, Italy
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care and Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy
| | - Gregory Y.H. Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham B18 7QH, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Xing Y, Ma Q, Ma X, Wang C, Zhang D, Sun Y. CHADS2 score has a better predictive value than CHA2DS2-VASc score in elderly patients with atrial fibrillation. Clin Interv Aging 2016; 11:941-6. [PMID: 27478371 PMCID: PMC4951063 DOI: 10.2147/cia.s105360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aim The study aims to compare the ability of CHA2DS2-VASc (defined as congestive heart failure, hypertension, age ≥75 years [two scores], type 2 diabetes mellitus, previous stroke, transient ischemic attack, or thromboembolism [TE] [doubled], vascular disease, age 65–74 years, and sex category) and CHADS2 (defined as congestive heart failure, hypertension, age ≥75 years, type 2 diabetes mellitus, previous stroke [doubled]) scores to predict the risk of ischemic stroke (IS) or TE among patients with nonvalvular atrial fibrillation (NVAF). Methods A total of 413 patients with NVAF aged ≥65 years, and not on oral anticoagulants for the previous 6 months, were enrolled in the study. The predictive value of the CHA2DS2-VASc and CHADS2 scores for IS/TE events was evaluated by the Kaplan–Meier method. Results During a follow-up period of 1.99±1.29 years, 104 (25.2%) patients died and 59 (14.3%) patients developed IS/TE. The CHADS2 score performed better than the CHA2DS2-VASc score in predicting IS/TE as assessed by c-indexes (0.647 vs 0.615, respectively; P<0.05). Non-CHADS2 risk factors, such as vascular disease and female sex, were not found to be predictive of IS/TE (hazard ratio 1.518, 95% CI: 0.832–2.771; hazard ratio 1.067, 95% CI: 0.599–1.899, respectively). No differences in event rates were found in patients with the CHADS2 scores of 1 and 2 (7.1% vs 7.8%). It was observed that patients with a CHADS2 score of ≥3 were most in need of anticoagulation therapy. Conclusion In patients with NVAF aged ≥65 years, the CHADS2 score was found to be significantly better in predicting IS/TE events when compared to the CHA2DS2-VASc score. Patients with a CHADS2 score of ≥3 were associated with high risk of IS/TE events.
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Affiliation(s)
- Yunli Xing
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qing Ma
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaoying Ma
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Cuiying Wang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dai Zhang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ying Sun
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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Fauchier L, Lecoq C, Clementy N, Bernard A, Angoulvant D, Ivanes F, Babuty D, Lip GY. Oral Anticoagulation and the Risk of Stroke or Death in Patients With Atrial Fibrillation and One Additional Stroke Risk Factor. Chest 2016; 149:960-8. [DOI: 10.1378/chest.15-1622] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/06/2015] [Accepted: 09/02/2015] [Indexed: 11/01/2022] Open
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Melgaard L, Gorst-Rasmussen A, Rasmussen LH, Lip GYH, Larsen TB. Vascular Disease and Risk Stratification for Ischemic Stroke and All-Cause Death in Heart Failure Patients without Diagnosed Atrial Fibrillation: A Nationwide Cohort Study. PLoS One 2016; 11:e0152269. [PMID: 27015524 PMCID: PMC4807813 DOI: 10.1371/journal.pone.0152269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/13/2016] [Indexed: 11/24/2022] Open
Abstract
Background Stroke and mortality risk among heart failure patients previously diagnosed with different manifestations of vascular disease is poorly described. We conducted an observational study to evaluate the stroke and mortality risk among heart failure patients without diagnosed atrial fibrillation and with peripheral artery disease (PAD) or prior myocardial infarction (MI). Methods Population-based cohort study of patients diagnosed with incident heart failure during 2000–2012 and without atrial fibrillation, identified by record linkage between nationwide registries in Denmark. Hazard rate ratios of ischemic stroke and all-cause death after 1 year of follow-up were used to compare patients with either: a PAD diagnosis; a prior MI diagnosis; or no vascular disease. Results 39,357 heart failure patients were included. When compared to heart failure patients with no vascular disease, PAD was associated with a higher 1-year rate of ischemic stroke (adjusted hazard rate ratio [HR]: 1.34, 95% confidence interval [CI]: 1.08–1.65) and all-cause death (adjusted HR: 1.47, 95% CI: 1.35–1.59), whereas prior MI was not (adjusted HR: 1.00, 95% CI: 0.86–1.15 and 0.94, 95% CI: 0.89–1.00, for ischemic stroke and all-cause death, respectively). When comparing patients with PAD to patients with prior MI, PAD was associated with a higher rate of both outcomes. Conclusions Among incident heart failure patients without diagnosed atrial fibrillation, a previous diagnosis of PAD was associated with a significantly higher rate of the ischemic stroke and all-cause death compared to patients with no vascular disease or prior MI. Prevention strategies may be particularly relevant among HF patients with PAD.
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Affiliation(s)
- Line Melgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Anders Gorst-Rasmussen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Hvilsted Rasmussen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y. H. Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- * E-mail:
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Voukalis C, Lip GY, Shantsila E. Emerging Tools for Stroke Prevention in Atrial Fibrillation. EBioMedicine 2016; 4:26-39. [PMID: 26981569 PMCID: PMC4776061 DOI: 10.1016/j.ebiom.2016.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023] Open
Abstract
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.
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Key Words
- Atrial fibrillation
- CKD, chronic kidney disease
- CrCl, creatinine clearance
- DM, diabetes mellitus
- ESRF, end stage renal failure
- HF, heart failure
- HTN, hypertension
- ICH, intracranial haemorrhage
- INR, international normalised ratio
- LV, left ventricle
- NCB, net clinical benefit
- NICE, National institute for Health and Care Excellence
- NVAF, non-valvular atrial fibrillation
- Net clinical benefit
- Non-vitamin K oral anticoagulants
- Oral anticoagulation
- PCI, percutaneous coronary intervention
- RSM, risk stratification model
- Risk stratification
- SE, systemic embolism
- Stroke prevention
- TE, thromboembolic episode
- TIA, transient ischaemic attack
- TTR, time in therapeutic range
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
| | | | - Eduard Shantsila
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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Wasmer K, Unrath M, Köbe J, Malyar NM, Freisinger E, Meyborg M, Breithardt G, Eckardt L, Reinecke H. Atrial fibrillation is a risk marker for worse in-hospital and long-term outcome in patients with peripheral artery disease. Int J Cardiol 2015. [DOI: 10.1016/j.ijcard.2015.06.094] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Senoo K, Lip GYH. Not all thromboembolism comes from the left atrial appendage in atrial fibrillation. Heart 2015; 101:830-1. [DOI: 10.1136/heartjnl-2015-307451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chao TF, Liu CJ, Wang KL, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chen TJ, Lip GY, Chen SA. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation? J Am Coll Cardiol 2015; 65:635-42. [DOI: 10.1016/j.jacc.2014.11.046] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/03/2014] [Accepted: 11/11/2014] [Indexed: 11/26/2022]
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Lip GY, Nielsen PB, Skjøth F, Rasmussen LH, Larsen TB. Atrial Fibrillation Patients Categorized as “Not for Anticoagulation” According to the 2014 Canadian Cardiovascular Society Algorithm Are Not “Low Risk”. Can J Cardiol 2015; 31:24-8. [DOI: 10.1016/j.cjca.2014.10.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 10/13/2014] [Accepted: 10/13/2014] [Indexed: 01/26/2023] Open
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Kosiuk J, Kornej J, Bollmann A, Piorkowski C, Myrda K, Arya A, Sommer P, Richter S, Rolf S, Husser D, Gaspar T, Lip GY, Hindricks G. Early cerebral thromboembolic complications after radiofrequency catheter ablation of atrial fibrillation: Incidence, characteristics, and risk factors. Heart Rhythm 2014; 11:1934-40. [DOI: 10.1016/j.hrthm.2014.07.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Indexed: 10/25/2022]
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Sugioka K, Fujita S, Iwata S, Ito A, Matsumura Y, Hanatani A, Doi A, Takagi M, Naruko T, Ueda M, Yoshiyama M. Relationship between CHADS2 score and complex aortic plaques by transesophageal echocardiography in patients with nonvalvular atrial fibrillation. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2358-2364. [PMID: 25023106 DOI: 10.1016/j.ultrasmedbio.2014.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 04/16/2014] [Accepted: 05/07/2014] [Indexed: 06/03/2023]
Abstract
The CHADS2 score is widely used for risk stratification of thromboembolism in patients with non-valvular atrial fibrillation (NVAF). Although the correlation of CHADS2 score with left atrial (LA) abnormality as detected by transesophageal echocardiography (TEE) has been reported in previous studies, the relationship between CHADS2 score and complex aortic plaque, which is also a significant risk factor for thromboembolism, has not been fully investigated. We assessed aortic plaques by TEE in 150 patients age ≥ 55 y with NVAF. The prevalence of complex aortic plaques increased along with increases in CHADS2 score (p = 0.001). In a multivariate analysis that included atherosclerotic risk factors and LA abnormality, a CHADS2 score ≥2 was independently associated with the presence of complex aortic plaques (odds ratio [OR] 3.39; 95% confidence interval [CI], 1.29-8.90). A high CHADS2 score is closely associated with the presence of complex aortic plaques, which explains, in part, the increased risk of thromboembolism in NVAF patients with high CHADS2 score.
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Affiliation(s)
- Kenichi Sugioka
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Suwako Fujita
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinichi Iwata
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Asahiro Ito
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Matsumura
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akihisa Hanatani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Doi
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masahiko Takagi
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takahiko Naruko
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Makiko Ueda
- Department of Pathology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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'Real-world' antithrombotic treatment in atrial fibrillation: The EORP-AF pilot survey. Am J Med 2014; 127:519-29.e1. [PMID: 24486284 DOI: 10.1016/j.amjmed.2013.12.022] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 12/24/2013] [Accepted: 12/26/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current guidelines strongly recommend that oral anticoagulation should be offered to patients with atrial fibrillation and ≥1 stroke risk factors. The guidelines also recommend that oral anticoagulation still should be used in the presence of stroke risk factors irrespective of rate or rhythm control. METHODS In an analysis from the dataset of the EURObservational Research Programme on Atrial Fibrillation Pilot Survey (n = 3119), we examined antithrombotic therapy prescribing, with particular focus on the risk factors determining oral anticoagulation or antiplatelet therapy use. RESULTS When oral anticoagulation was used among admitted patients in whom no pharmacologic cardioversion, electrical cardioversion, or catheter ablation was performed or planned, vitamin K antagonist therapy was prescribed in the majority (72.2%), whereas novel oral anticoagulants were used in the minority (7.7%). There was no significant difference in bleeding risk factors among the patients treated with the different types of antithrombotic therapies, except for those with chronic kidney disease, in whom oral anticoagulation was less commonly used (P = .0318). Antiplatelet therapy was more commonly used in patients with a high Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly score (≥2) (P < .0001). More oral anticoagulation use was associated with female gender (P = .0245). Less novel oral anticoagulant use was associated with valvular heart disease (P < .0001), chronic heart failure (P = .0010), coronary artery disease (P < .0001), and peripheral artery disease (P = .0092). Coronary artery disease was the strongest reason for combination therapy with oral anticoagulation plus antiplatelet drug (odds ratio, 8.54; P < .0001). When the Congestive heart failure, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [female] score was used, 95.6% of patients with a score ≥1 received antithrombotic therapy, with 80.5% of patients with a score ≥1 receiving oral anticoagulation. Of note, 83.7% of those with a score ≥2 received antithrombotic therapy. Of the latter, 70.9% of those with a score ≥2 received oral anticoagulation, vitamin K antagonists were used in 64.1%, and novel oral anticoagulants were used in 6.9%. CONCLUSIONS The EURObservational Research Programme on Atrial Fibrillation Pilot Survey provides contemporary data on oral anticoagulation prescribing by European cardiologists for atrial fibrillation. Although the uptake of oral anticoagulation (mostly vitamin K antagonist therapy) has improved since the Euro Heart Survey a decade ago, antiplatelet therapy is still commonly prescribed, with or without oral anticoagulation, whereas elderly patients are commonly undertreated with oral anticoagulation.
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