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De Caterina R, De Groot J, Weiss T, Kelly P, Monteiro P, Deharo J, De Asmundis C, Lopez-De-Sa E, Waltenberger J, Steffel J, Levy P, Bakhai A, Pecen L, Kirchhof P. Age-adjusted risk factors are independently associated with an increased risk of ischaemic stroke, transient ischaemic stroke and systemic embolism in the ETNA-AF-Europe registry. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Oral anticoagulation is highly effective in preventing ischaemic stroke in patients with atrial fibrillation, but 1–2% of the patients suffer an ischaemic stroke upon anticoagulation. Outcomes are further influenced by various factors, and recent research has focussed on identifying risk factors that could be helpful in predicting stroke outcomes in anticoagulated patients. This could further assist clinicians in timely identification and management of high-risk patients.
Purpose
The present analysis aims to assess the age-adjusted risk predictors of ischaemic stroke and systemic embolic events (SEE) (including transient ischaemic attack [TIA]) during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.
Methods
ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and stroke and SEE after adjusting for age, given that age is a well-known, strong predictor of stroke.
Results
A total of 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. The mean weight was 81.0±17.3 kg, estimated glomerular filtration rate was 74.4±30.5 ml/min/1.73m2 and males were 56.6%. The mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively.
Univariate analysis demonstrated that history of TIA at baseline was the strongest age-adjusted predictor of stroke and SEE (Wald Chi-square: 77.69; p<0.0001) (Figure 1), followed by CHA2DS2-VASc score (41.09; p<0.0001) (Figure 2), history of ischaemic stroke (29.47; p<0.0001), history of any stroke (all strokes combined including stroke of unknown/unspecified type) (29.18; p<0.0001), subjective frailty as assessed by physician (20.60; p<0.0001), and HAS-BLED score (17.22; p<0.0001).
Conclusion
History of TIA, CHA2DS2-VASc score, history of stroke, frailty and HAS-BLED score are independently associated with an increased age-adjusted risk of ischaemic stroke, TIA and SEE in anticoagulated patients with AF. These findings highlight the importance of optimising anticoagulation therapy in secondary prevention of TIA and in patients with high CHA2DS2-VASc scores, ensuring the correct use of NOACs - adherence and correct dosing - in this high-risk population. These findings also suggest that additional therapies could be needed to prevent stroke in this population.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. History of TIA as a predictorFigure 2. CHA2DS2-VASc score as a predictor
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Affiliation(s)
- R De Caterina
- University of Pisa, Chair of Cardiology, Pisa, Italy
| | - J.R De Groot
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - T.W Weiss
- Karl Landsteiner Institute, Institute for Cardiometabolic Diseases, St. Polten, Austria
| | - P Kelly
- University College Dublin, Department of Neurology, HRB Stroke Clinical Trials Network Ireland, Dublin, Ireland
| | - P Monteiro
- Centro Hospitalar e Universitario de Coimbra, Department of Cardiology, Coimbra, Portugal
| | - J.C Deharo
- AP-HM, Aix Marseille University, Hospital Timone, Cardiologie, Rythmologie, Marseille, France
| | - C De Asmundis
- Universitair Ziekenhuis Brussels, Department of Cardiology, Brussels, Belgium
| | - E Lopez-De-Sa
- Hospital Universitario La Paz, IDIPAZ, CIBERCV, Cardiological Intensive Care Unit, Cardiology Service, Madrid, Spain
| | - J Waltenberger
- University of Munster, Department of Cardiovascular Medicine, Munster, Germany
| | - J Steffel
- University Hospital Zurich, Department of Cardiology, Zurich, Switzerland
| | - P Levy
- Universite Paris-Dauphine, PSL Research University, LEDa-LEGOS, Department of Economics, Paris, France
| | - A Bakhai
- Royal Free London NHS Foundation Trust, Department of Cardiology, London, United Kingdom
| | - L Pecen
- Institute of Computer Science of the Czech Academy of Science, the Czech Academy of Science, Prague, Czechia
| | - P Kirchhof
- University Heart & Vascular Center Hamburg, Department of Cardiology, Hamburg, Germany
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Kirchhof P, De Groot J, Weiss T, Kelly P, Monteiro P, Deharo J, De Asmundis C, Lopez-De-Sa E, Waltenberger J, Steffel J, Levy P, Bakhai A, Pecen L, De Caterina R. Age-adjusted risk factors are independently associated with an increased risk of major bleeding during the two-year follow-up of the ETNA-AF-Europe registry. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Non-vitamin K antagonist oral anticoagulants (NOACs) are a preferred treatment option over warfarin for anticoagulation in patients with atrial fibrillation (AF). Management decisions for thromboprophylaxis in AF need to balance the risk of stroke against the risk of bleeding. Various patient characteristics have been identified as independent risk factors for bleeding. A substantial number of bleeding events might be prevented if independent predictors of bleeding were identified.
Purpose
The present analysis aims at assessing age-adjusted risk predictors of major bleeding during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.
Methods
ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and major bleeding after adjusting for age, given that age is a well-known, strong predictor of anticoagulation-related bleeding in patients with AF.
Results
Overall, 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. Mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively. 438 (3.3%) patients had a history of bleeding events at baseline, of which 138 (1.0%) had a history of major bleeding event.
Univariate analysis demonstrated that recalculated glomerular filtration rate (Cockcroft-Gault Equation) (GFR-CG) at baseline was the strongest age-adjusted predictor of major bleeding (Wald Chi-Square: 31.84; p<0.0001) (Figures 1 and 2), followed by history of major or clinically relevant non-major (CRNM) bleeding (24.08; p<0.0001), HAS-BLED score (21.10; p<0.0001), history of heart failure (derived) (16.59; p<0.0001), subjective frailty as assessed by physician (17.35; p=0.0002), history of major bleeding (14.14; p=0.0002), chronic obstructive pulmonary disease (COPD) (12.84; p=0.0003), CHA2DS2-VASc (12.14; p=0.0005), history of myocardial infarction (MI) (7.79; p=0.005), and left ventricular ejection fraction (LVEF) categorised by 40% (5.45; p=0.02).
Conclusion
Bleeding events on therapy with edoxaban can be predicted by quantifying kidney disease and capturing information on heart failure, frailty, prior bleeding, chronic obstructive lung disease and history of myocardial infarction. These data highlight the need for optimal management of anticoagulation therapy and close follow-up of patients with such risk profiles.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. GFR-CG as a predictor of major bleedingFigure 2. Predictors of major bleeding
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Affiliation(s)
- P Kirchhof
- University Heart & Vascular Center Hamburg, Department of Cardiology, Hamburg, Germany
| | - J.R De Groot
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - T.W Weiss
- Karl Landsteiner Institute, Institute for Cardiometabolic Diseases, St. Polten, Austria
| | - P Kelly
- University College Dublin, Department of Neurology, HRB Stroke Clinical Trials Network Ireland, Dublin, Ireland
| | - P Monteiro
- Centro Hospitalar e Universitario de Coimbra, Department of Cardiology, Coimbra, Portugal
| | - J.C Deharo
- AP-HM, Aix Marseille University, Hospital Timone, Cardiologie, Rythmologie, Marseille, France
| | - C De Asmundis
- Universitair Ziekenhuis, Department of Cardiology, Brussels, Belgium
| | - E Lopez-De-Sa
- Hospital Universitario La Paz, IDIPAZ, CIBERCV, Cardiological Intensive Care Unit, Cardiology Service, Madrid, Spain
| | - J Waltenberger
- University of Munster, Department of Cardiovascular Medicine, Munster, Germany
| | - J Steffel
- University Hospital Zurich, Department of Cardiology, Zurich, Switzerland
| | - P Levy
- Universite Paris-Dauphine, PSL Research University, LEDa-LEGOS, Department of Economics, Paris, France
| | - A Bakhai
- Royal Free London NHS Foundation Trust, Department of Cardiology, London, United Kingdom
| | - L Pecen
- Institute of Computer Science of the Czech Academy of Science, the Czech Academy of Science, Prague, Czechia
| | - R De Caterina
- University of Pisa, Chair of Cardiology, Pisa, Italy
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3
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De Caterina R, De Groot JR, Weiss TW, Kelly P, Monteiro P, Deharo JC, De Asmundis C, Lopez-De-Sa E, Waltenberger J, Steffel J, Levy P, Bakhai A, Kirchhof P. Safety and effectiveness of edoxaban in a real-world clinical setting: Two-year follow-up of the ETNA-AF-Europe study. Europace 2021. [DOI: 10.1093/europace/euab116.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe
OnBehalf
ETNA-AF-Europe investigators
Background
Oral anticoagulation (OAC) for stroke prevention is essential in the management of patients with atrial fibrillation (AF). The assessment of OAC use in routine clinical care and the effects of this therapy on outcomes and safety are important. Purpose: We analysed two-year outcome data with adjudicated follow-up results in 13,417 patients with AF treated with edoxaban. Methods: ETNA-AF-Europe (Clinicaltrials.gov: NCT02944019) enrolled 13,417 consecutive patients with AF treated with edoxaban in 825 centres in 10 European countries and 2-year prospectively collected, real world data is presented. Results: Edoxaban was prescribed according to licence recommendations in 83.1% (n = 11,146) of patients (Table). Whilst three quarters of patients were prescribed edoxaban 60 mg (n = 10,248, 76.4%), the quarter prescribed edoxaban 30 mg were older (79.5 versus 71.8 years), had a higher stroke risk (CHA2DS2-VASc score: 3.9 versus 3.0) and a higher bleeding risk (HAS-BLED score: 2.9 versus 2.4). Thromboembolic and bleeding events were more common in patients receiving edoxaban 30 mg OD without differences in intracranial haemorrhage (ICH) (Figure). Patients prescribed a non-recommended dose of edoxaban had a numerically higher stroke risk (CHA2DS2-VASc score: 3.6 versus 3.1) with subsequent higher rates of ischemic stroke and mortality, however they also had higher bleeding rates, with the exception of ICH (table) despite a similar initial bleeding risk (HAS-BLED score: 2.7 versus 2.5). Conclusions: In this large, European data set reporting two-year outcomes on edoxaban therapy, no additional safety signals were observed and event rates were in line with those observed in ETNA-AF after 1 year and in ENGAGE AF-TIMI 48, re-affirming the safety and effectiveness of edoxaban licence recommendations in a real world setting of patients with AF. All key events of interest, other than intracranial haemorrhage, were numerically lower in patients prescribed the licenced recommended dose. Outcomes with rec. vs non-rec. dosesn (%/year [95%CI])Recommended dose (n = 11,146; 83.1%)Non-recommended dose (n = 2271; 16.9%)Any stroke/SEE138 (0.68 [0.57;0.80])31 (0.76 [0.51;1.07])Ischaemic stroke99 (0.48 [0.39;0.59])26 (0.63 [0.41; 0.93])Major bleeding189 (0.93 [0.80;1.07])49 (1.20 [0.89;1.59])Intracranial haemorrhage43 (0.21 [0.15;0.28])7 (0.17 [0.07;0.35])All-cause mortality729 (3.55 [3.30;3.82])208 (5.04 [4.38;5.78])CV mortality405 (1.97 [1.79;2.18])113 (2.74 [2.26;3.30])CI, confidence interval; CV, cardiovascular; rec., recommended; SEE, systemic embolic event.Abstract Figure. Annualised event rates at 2-year FU
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Affiliation(s)
| | - JR De Groot
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - TW Weiss
- Karl Landsteiner Institute for Cardiometabolics and SFU, Vienna, Austria
| | - P Kelly
- HRB Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - P Monteiro
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - JC Deharo
- Hôpital de la Timone, Marseille, France
| | | | - E Lopez-De-Sa
- Hospital Universitario La Paz, IDIPAZ, Madrid, Spain
| | - J Waltenberger
- University of Munster and SRH Central Hospital Suhl, Munster, Germany
| | - J Steffel
- University Hospital Zurich, Zurich, Switzerland
| | - P Levy
- Université Paris-Dauphine, PSL Research University, Paris, France
| | - A Bakhai
- Royal Free London NHS Foundation Trust, Barnet Hospital, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kirchhof
- University Heart & Vascular Center Hamburg, Hamburg, Germany
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4
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Marco Clement I, Cossiani Martinez M, Castrejon Castrejon S, Alvarez Ortega C, Martin Polo L, Merino Argos C, Tebar D, Poveda ID, Arbas E, Caro Codon J, Lopez-De-Sa E, Peinado Peinado R, Merino Llorens JL. Long-term impact of transient atrioventricular block during atrioventricular nodal re-entrant tachycardia ablation. Europace 2021. [DOI: 10.1093/europace/euab116.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Ablation of atrioventricular nodal re-entrant tachycardia (AVNRT) is an extremely safe procedure, being complete atrioventricular (AV) block the most feared complication. Transient AV or ventriculoatrial (VA) block during ablation is considered a risk marker of immediate AV permanent block.
Purpose
To study whether TB (transient block) during AVNRT ablation is associated with a higher risk of AV permanent block and pacemaker implantation during long term follow-up.
Methods
Retrospective analysis of all patients who underwent ablation for AVNRT in our center and had a minimum five years follow-up. Patients carrying a cardiac pacing device were excluded. Data was extracted from electronic medical records and follow-up was performed by telephone contact. TB was defined as AV or VA loss of conduction of at least 1 beat during energy delivery.
Results
We included 689 patients who underwent AVNRT ablation from March 1995 to December 2015: mean age 52.6 ± 18.6 years; 240 (34.8%) male; 677 radiofrequency and 12 cryotherapy ablations. TB was observed in 106 (15,4%) patients. Baseline characteristics are described in Table 1. Within the TB group, 44 (41.5%) patients presented with AV block, 60 (56.6%) with VA block, and 2 patients presented with both. TB concerned more than one beat in 65 (61.9%) cases and persisted after cessation of energy delivery in 15 (14.2%) cases. Two patients did not recover AV conduction, requiring pacemaker implantation before discharge.
During a median 12.5 years follow-up (IQR 9.5-16.6), 3 of the remaining 104 TB patients required pacemaker implantation due to AV block. All 3 had presented AV TB and had undergone radiofrequency ablation; they were not significantly older (67.0 ± 9.3 vs 48.8 ± 19.8, p = 0.12) but presented longer basal PR (237.0 ± 115.2 vs 152.6 ± 26.5, p < 0.001) and HV (57.3 ± 6.7 vs 44.2 ± 7.6, p = 0.004) intervals. When compared to the non-TB group, there were no differences in pacemaker implantation due to AV block during follow-up (7 (1.2%) p = 0.19). However, median time to pacemaker implantation was shorter in TB patients than in non-TB: 0.7 [0.1-1.4] vs 13.7 [5.2-22.0], p = 0.02.
Conclusion
Long term incidence of permanent AV block did not differ between TB and non-TB groups, however AV block occurred significantly earlier in TB patients. Non-TB group(n = 583) TB group(n = 106) p Age (mean ± SD) 53.2 ± 18.3 49.3 ± 19.8 0.05 PR (mean ± SD) 153.0 ± 28.4 155.0 ± 33.8 0.54 AH (mean ± SD) 83.3 ± 23.6 82.1 ± 22.2 0.64 HV (mean ± SD) 44.4 ± 7.8 44.6 ± 7.9 0.76
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Affiliation(s)
| | | | | | | | | | | | - D Tebar
- University Hospital La Paz, Madrid, Spain
| | - ID Poveda
- University Hospital La Paz, Madrid, Spain
| | - E Arbas
- University Hospital La Paz, Madrid, Spain
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5
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Caro Codon J, Rodriguez Sotelo L, Rey Blas JR, Gonzalez Fernandez O, Rosillo Rodriguez SO, Armada Romero E, Iniesta Manjavacas A, Ruiz Cantador J, Casas Sanchez B, Fernandez De Bobadilla J, Marco Clement I, Martin Polo L, Merino Argos C, Lopez-Sendon JL, Lopez-De-Sa E. P2829Arrhythmia burden during long-term follow-up in a large cohort of patients surviving out-of-hospital cardiac arrest. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Data regarding incidence of ventricular (VA) and atrial arrhythmias (AA) in survivors after out-of-hospital cardiac arrest (OHCA) are scarce.
Purpose
To assess incidence of VA and AA in OHCA patients during long-term follow-up and to identify relevant predictive factors during the index hospital admission.
Methods
All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA from August 2007 to January 2019 and surviving until hospital discharge were included. Cox proportional hazard models and logistic regression analysis were used to investigate clinical variables related to the incidence of VA and AA.
Results
The final analysis included 201 patients. Mean age was 57.6±14.2 years and 168 (83.6%) were male. The majority of patients experienced witnessed arrests related to shockable rhythms (176, 87.6%). Thirty-six patients (17.9%) died after a median follow-up of 40.3 months (18.9–69.1), but only 4 presented another cardiac arrest. Eighteen patients (9.0%) suffered new VA and 37 (18.4%) developed atrial fibrillation/atrial flutter. History of coronary heart disease [HR 3.59 (1.37–9.42), p=0.010] and non-acute coronary syndrome-related arrhythmia [HR 5.17 (1.18–22.60), p=0.029] were independent predictors of VA during follow-up. The optimal predictive model for atrial arrhythmias included age at the time of OHCA, LVEF at hospital discharge and non-acute coronary syndrome-related arrhythmias (p<0.001).
Table 1 Variable Without VA With VA p value Age, mean ± DS, years 57.4±14.2 60.8±14.7 0.336 Male sex, n (%) 150 (83.3) 15 (83.3) 1.000 Coronary heart disease, n (%) 36 (20.0) 11 (61.1) <0.001 Cardiomyopathy, n (%) 27 (15.0) 8 (44.4) 0.006 Shockable rhythm, n (%) 157 (87.2) 16 (88.9) 1.000 ACS-related arrhythmia (Primary VF), n (%) 83 (46.1) 2 (11.1) 0.004 LVEF at hospital discharge (%) 47.5±13.9 38.3±16.5 0.010 Death during follow-up 32 (17.8) 3 (16.7) 0.603 Cardiac arrest during follow-up 2 (1.1) 2 (11.1) 0.042 CV hospital admission during follow-up 39 (21.7) 14 (77.8) <0.001 Atrial arrhythmias during follow-up 28 (15.6) 9 (50.0) <0.001
Figure 1
Conclusions
Despite low incidence of recurrent cardiac arrest, OHCA survivors face a high incidence of VA and AA. Several clinical characteristics during index hospital admission may be useful to identify patients at high risk.
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Affiliation(s)
- J Caro Codon
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | - J R Rey Blas
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | | | - E Armada Romero
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | - J Ruiz Cantador
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | | | - I Marco Clement
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | - L Martin Polo
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | - C Merino Argos
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | - J L Lopez-Sendon
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | - E Lopez-De-Sa
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
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6
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Rodriguez L, Caro-Codon J, Rey-Blas JR, Rosillo SO, Gonzalez O, Martinez LA, Garcia De Veas JM, Casas B, Iniesta AM, Ruiz J, Rial V, Merino C, Armada E, Lopez-Sendon JL, Lopez-De-Sa E. P6471Pronostic impact of significant valvular disease in long-term survivors of out-of-hospital-cardiac arrest. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
There is scarce evidence about the prevalence and clinical relevance of moderate to severe valvular heart disease (VHD) in survivors of out of hospital cardiac arrest (OHCA).
Purpose
To determine whether VHD influence prognosis of OHCA survivors.
Methods
All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Univariate and multivariate Cox-proportional hazard models were employed.
Results
A total of 201 patients were included in the analysis. Mean age was 57.6±14.2 years and 168 (83.6%) were male. Eighteen patients (9.0%) had moderate or severe VHD during index admission (Table 1). Patients with VHD were less frequently of male sex, [11 (61.1%) vs 157 (85.8%), p=0.014], experienced less acute coronary syndrome-related arrhytmias [2 (11.1%) vs 85 (46.5%), p=0.005], and had a lower pH at hospital admission (6.9±1.6 vs 7.2±0.15, p=0.008). During a median follow-up of 40.3 (18.9–69.1) months, patients with VHD showed higher mortality [7 (38.9%) vs 28 (15.3%), p=0.004] and more heart failure-related admissions [7 (38.9%) vs 15 (8.2%), p<0.001]. Only five patients received surgical or percutaneous treatment for VHD during follow-up, with no deaths in this subgroup. Moderate or severe VHD proved to be an independent predictor of global cardiovascular events and specifically heart failure episodes (Figure 1).
Table1 Variable With valvular disease Without valvular disease p value Age, mean±DS, years 63.5±13.2 57.0±14.1 0.066 Hypertension, n (%) 12 (66.7) 95 (51.9) 0.231 Diabetes, n (%) 5 (27.8) 24 (13.1) 0.149 Dyslipidaemia, n (%) 7 (38.9) 79 (43.2) 0.726 Smokin habit, n (%) 4 (22.2) 90 (49.2) 0.045 Witnessed cardiac arrest, n (%) 18 (100) 175 (95.6) 1.000 Time from CA to ROSC, mean±DS, minute 19.1±7.5 21.2±13.1 0.506 Shockable rhythm, n (%) 13 (72.2) 163 (89.1) 0.055 LVEF at hospital discharge (%) 42.8±12.1 46.9±14.6 0.254
Figure 1
Conclusion
The presence of significant VHD in survivors after OHCA is a predictor of poor outcomes. Specific management of VHD may be specially relevant in this high-risk patients and guideline-oriented therapy, including surgery and percutaneous intervention should be encouraged when indicated.
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Affiliation(s)
- L Rodriguez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - J Caro-Codon
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - J R Rey-Blas
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - S O Rosillo
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - O Gonzalez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - L A Martinez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | | | - B Casas
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - A M Iniesta
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - J Ruiz
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - V Rial
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - C Merino
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - E Armada
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - J L Lopez-Sendon
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - E Lopez-De-Sa
- University Hospital La Paz, Cardiology department, Madrid, Spain
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7
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Caro Codon J, Rodriguez Sotelo L, Rey Blas JR, Rosillo Rodriguez SO, Gonzalez Fernandez O, Iniesta Manjavacas A, Armada Romero E, Fernandez De Bobadilla J, Ruiz Cantador J, Casas Sanchez B, Rivas Perez A, Martinez Marin LA, Garcia De Veas JM, Lopez-Sendon JL, Lopez-De-Sa E. P2664Long-term follow-up in a large cohort of survivors after out-of-hospital cardiac arrest: global mortality and comparison with age-specific mortality rate in the general population. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Data regarding long-term clinical outcomes after out-of-hospital cardiac arrest (OHCA) are scarce.
Purpose
To assess long-term mortality rate in OHCA patients, compare it with the general population age-specific mortality rate and identify relevant predictive factors.
Methods
All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA from August 2007 to January 2019 and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Stepwise regression techniques and Cox proportional hazards models were used to investigate clinical variables related to long-term survival. The study population was divided into four quartiles according to their age and their mortality rate was compared with age-specific data from the Spanish National Statistics Institute.
Results
The final analysis included 201 patients. Mean age was 57.6±14.2 years and 168 (83.6%) were male. The majority of patients experienced witnessed arrests related to shockable rhythms (176, 87.6%). Median time to ROSC was 18 (IQR 12–27) minutes and 14 patients (7.0%) were discharged in a poor neurological condition (CPC 3–4). Thirty-six patients (17.9%) died after a median follow-up of 40.3 months (18.9–69.1). A prognostic multivariate Cox model was developed and is shown in Table 1. Mortality was mainly driven by neurologic (33.%), cardiovascular (30.6%) and oncologic (30.6%) causes. Annual mortality rate per 1000 patients was statistically superior to that in the general population among the first three age quartiles: 18.08 (6.78–48.16) vs 0.64; 29.62 (12.33–71.16) vs 3.30; 63.07 (33.94–117.22) vs 7.77. Nevertheless, no significant differences were observed among the oldest patients, ranging from 68.6 to 90.7 years: 70.93 (43.45–115.78) vs 54.95.
Table 1. Cox proportional hazard model Variable Hazard Ratio Std. Err. p value 95% Confidence Interval Time from CA to CPR (per minute) 1.06 0.03 0.06 1.00–1.13 Non-shockable rhythm 2.93 1.11 0.01 1.39–6.16 Poor LVEF at discharge (per %) 1.03 0.01 0.01 1.01–1.06 Age at time of CA (per year) 1.04 0.01 0.01 1.01–1.06 CPC 3–4 at hospital discharge 3.50 1.43 <0.01 1.58–7.78
Figure 1
Conclusions
OHCA survivors face significant mortality during follow-up, and its long term prognostic impact may be higher among younger patients. Age at the time of CA, time from CA to CPR, non-shockable rhythm, poor LVEF and poor neurological condition at discharge are independent predictors of long term mortality.
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Affiliation(s)
- J Caro Codon
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | - J R Rey Blas
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | | | | | - E Armada Romero
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | - J Ruiz Cantador
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | - A Rivas Perez
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | | | | | - J L Lopez-Sendon
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
| | - E Lopez-De-Sa
- University Hospital La Paz, Department of Cardiology, Madrid, Spain
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8
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Rodriguez L, Martinez LA, Rosillo SO, Martin L, Merino C, Marco I, Velez A, Caro-Codon J, Garcia De Veas JM, Iniesta AM, Rial V, Gonzalez O, Armada E, Lopez-Sendon JL, Lopez-De-Sa E. P5349Platelet/lymphocyte ratio as an inflammatory marker and predictor of short-term neurological outcomes in survivors after cardiac arrest. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Platelet/lymphocyte ratio (PLR), an inflammatory marker associated with poor outcomes in different clinical situations, may play a role in the proinflammatory state triggered during hypoxic-ischemic brain injury secondary to cardiac arrest.
Purpose
To study PLR dynamics and its relationship with neurologic outcomes in survivors after CA treated with target-temperature-management (TTM).
Methods
Observational retrospective study from a prospective database of survivors of in-hospital and out-of-hospital CA admitted to our Acute Cardiac Care Unit between August 2006 to December 2018. All patients received TTM according to our local protocol.
Results
A total of 466 patients were included. Mean age was 62.7±14.4 years and 102 (21.9%) were women. Baseline characteristics are shown in Table 1. 430 (92.2%) of CA were witnessed, 312 (67.0%) had ventricular fibrillation as initial cardiac rhythm. Among them, 236 (51.1%) survived until hospital discharge and 208 (45.1%) presented favorable neurological outcomes (a score 1 or 2 on cerebral performance category (CPC)). The mean value of PLR at admission and during targeted temperature was 100.4±5.2 and 224.5±7.3 respectively (mean difference 123.1±7.1, p<0.0001). This increase in PLR was significantly higher among patients with worse neurological outcomes (CPC 3–5, mean DPLR 138.2±5.5) at 3 months compared with survivors with CPC 1–2 (mean DPLR 108.2±6.3, p=0.0348 for paired comparison between both groups).
Table 1 Hypertension, n (%) 235 (54.9) Diabetes, n (%) 113 (26.4) Dyslipidaemia, n (%) 171 (40.0) Smocking habit, n (%) 208 (48.5) Time to ROSC mean ± SD, min 26.6±18.6 Mean arterial pressure at HA mean±DS, mmHg 81.3±22.1 pH at HA mean ± SD 7.18±0.16 Lactic at HA mean ± SD 6.37±4.42 ROSC: return of spontaneus circulation; HA: hospital admission.
Conclusion
Our findings reflect the impact of inflammation in neurological outcomes after OHCA treated with TTM. Major increases of PLR constitute a novel marker of poor prognosis during early assessment of OHCA patients.
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Affiliation(s)
- L Rodriguez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - L A Martinez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - S O Rosillo
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - L Martin
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - C Merino
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - I Marco
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - A Velez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - J Caro-Codon
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | | | - A M Iniesta
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - V Rial
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - O Gonzalez
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - E Armada
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - J L Lopez-Sendon
- University Hospital La Paz, Cardiology department, Madrid, Spain
| | - E Lopez-De-Sa
- University Hospital La Paz, Cardiology department, Madrid, Spain
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9
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De Caterina R, Kelly P, Monteiro P, Deharo JC, De Asmundis C, Lopez-De-Sa E, Weiss T, Waltenberger J, Steffel J, De Groot JR, Levy P, Bakhai A, Kirchhof P. P1257ETNA-AF Europe: First 1-year follow-up snapshot analysis of more than 7,500 AF patients treated with edoxaban in routine clinical practice. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Edoxaban has been approved for stroke prevention in patients with atrial fibrillation based on its comparable efficacy and superior safety compared to warfarin in the pivotal ENGAGE AF-TIMI 48 trial. ETNA-AF Europe (NCT02944019) was initiated in agreement with the EMA to evaluate benefits and risks of edoxaban treatment in unselected patients in routine clinical practice.
Methods
13,980 patients from across 825 hospital and office-based physicians from 10 European countries (Austria, Belgium, Germany, Ireland, Italy, The Netherlands, Portugal, Spain, Switzerland and United Kingdom) were enrolled, and will be followed-up for 4 years. This snapshot analysis includes baseline and first outcome data of 7,672 patients (56.3% of all enrolled patients) that have completed their first 1-year follow-up visit (mean follow-up: 343.5 days).
Results
The average age of patients was 73.4 years, the mean weight was 81.9 kg (Table 1). Frequent comorbidities include hypertension (77.2%), valvular heart disease (17.4%), congestive heart failure (5.8%) and history of myocardial infarction (4.2%). Patients receiving the 30 mg dose (22.9%) were older, had a lower creatinine clearance and had a higher risk for both stroke and bleeding as compared to those on the 60 mg dose (77.1%). Overall, the incidence of clinical events was low: all-cause mortality: 3.56%/y, major bleeding 0.95%/y, intracranial haemorrhage 0.28%/y, any stroke or systemic embolic events 0.88%/y.
Patient characteristics at Year 1 Patient characteristics All patients Edoxaban 60 mg Edoxaban 30 mg [7,672] [5,916 (77.1%)] [1,756 (22.9%)] Age [years] mean (SD) 73.4 (9.26) 71.8 (8.98) 79.1 (7.81) Body weight [kg] mean (SD) 81.9 (17.33) 84.1 (16.80) 74.3 (16.93) CrCl (CG) [mL/min] mean (SD) 75.0 (30.29) 82.5 (29.14) 51.2 (19.75) CHA2DS2-VASc mean (SD) 3.1 (1.38) 2.9 (1.34) 3.8 (1.28) HAS-BLED mean (SD) 2.5 (1.10) 2.4 (1.07) 2.9 (1.08) First occurrence of all-cause mortality (n, %/year) 257 (3.56%) 129 (2.31%) 128 (7.90%) First occurrence of intracranial haemorrhage (n, %/year) 20 (0.28%) 16 (0.29%) 4 (0.25%) First occurrence of major bleeding (n, %/year) 68 (0.95%) 49 (0.88%) 19 (1.18%) First occurrence of stroke/SEE (n, %/year) 63 (0.88%) 45 (0.81%) 18 (1.11%) CG, Cockcroft-Gault; CrCl, creatinine clearance; SD, standard deviation; SEE, systemic embolic events.
Conclusions
We found low bleeding and stroke rates in 7,672 unselected, mainly elderly AF patients treated with edoxaban in routine clinical practice. These findings were consistent across edoxaban doses and reinforce the effectiveness and safety of NOACs such as edoxaban in routine clinical care in Europe.
Acknowledgement/Funding
Daiichi Sankyo Europe GmbH, Munich, Germany
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Affiliation(s)
| | - P Kelly
- University College Dublin, HRB Stroke Clinical Trials Network Ireland, Dublin, Ireland
| | - P Monteiro
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | | | - E Lopez-De-Sa
- Hospital Universitario La Paz, IDIPAZ, Madrid, Spain
| | - T Weiss
- Karl Landsteiner Institute for Cardiometabolics and SFU, Vienna, Austria
| | | | - J Steffel
- University Hospital Zurich, Zurich, Switzerland
| | - J R De Groot
- Amsterdam University Medical Centres/University of Amsterdam, Amsterdam, Netherlands (The)
| | - P Levy
- Université Paris-Dauphine, PSL Research University, Paris, France
| | - A Bakhai
- Royal Free London NHS Foundation Trust, Chase Farm Hospital, London, United Kingdom
| | - P Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, United Kingdom
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10
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Weiss T, De Caterina R, Kelly P, Monteiro P, Deharo JC, De Asmundis C, Lopez-De-Sa E, Waltenberger J, Steffel J, De Groot JR, Levy P, Bakhai A, Kirchhof P. P4766Edoxaban Treatment in routiNe clinical prActice for patients with atrial fibrillation (AF) in Europe (ETNA-AF-Europe): 1-year follow-up according to body mass index. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) have substantially improved anticoagulation therapy for prevention of stroke and systemic embolism in patients with atrial fibrillation (AF), and available routine care data have so far broadly confirmed the safety of different NOACs in routine practice. However, such data for edoxaban are scarce, especially in extremely low and high body weight (BW). These extreme BWs may affect the bioavailability, distribution, and half-life of NOACs and, consequently, outcomes of treatment.
Methods
We analysed outcomes in normal-weight (BMI 18.5–25) vs overweight (BMI 25–30) and obese (BMI >30) patients enrolled into the ETNA-AF-Europe observational study (NCT02944019) collecting information on patients treated with edoxaban in 825 sites in 10 European countries. This snapshot analysis set includes data of 7,672 patients (56.3% of all enrolled patients) which have completed their 1-year follow-up visit (mean follow-up: 343.5 days).
Results
Median patient age was 74 years for all patients, 76 years for patients with a BMI 18.5–25 (group 1), 75 years for patients with BMI 25–30 (group 2), and 72 for patients with a BMI >30 (group 3). CrCl was 64 mL/min for patients with a BMI 18.5–25, 68 mL/min for patients with BMI 25–30, and 72 mL/min for patients with a BMI >30. The CHA2DS2-VASc (mean 3.1±1.38) and HAS-BLED (mean 2.5±1.10) score did not differ significantly between groups. As expected, diabetes and hypertension were significantly less prevalent in leaner patients and - accordingly - inversely correlated to age.
There was no correlation between body weight and life-threatening bleeding (group 1: 0.28%; group 2: 0.40%; group 3: 0.14%). Also, stroke rates (group 1: 0.74%; group 2: 0.81%; group 3: 0.76%) did not differ between groups.
Conclusion
BMI, within the range here assessed, does not affect 1-year outcomes in European AF patients treated with edoxaban.
Acknowledgement/Funding
Daiichi Sankyo Europe GmbH, Munich, Germany
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Affiliation(s)
- T Weiss
- Karl Landsteiner Institute for Cardiometabolics, Vienna, Austria
| | | | - P Kelly
- HRB Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - P Monteiro
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | | | - E Lopez-De-Sa
- Hospital Universitario La Paz, IDIPAZ, Madrid, Spain
| | | | - J Steffel
- University Hospital Zurich, Zurich, Switzerland
| | - J R De Groot
- Amsterdam University Medical Centres/University of Amsterdam, Amsterdam, Netherlands (The)
| | - P Levy
- Université Paris-Dauphine, PSL Research University, Paris, France
| | - A Bakhai
- Royal Free London NHS Foundation Trust, Chase Farm Hospital, London, United Kingdom
| | - P Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, United Kingdom
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11
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Monedero Martin MC, Rosillo Rodriguez SO, Armada Romero E, Martinez-Losas P, Martinez-Marin L, Lopez-Sendon JL, Lopez-De-Sa E. P2738Resuscitative efforts in cardiac arrest: time is not everything. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Iniesta Manjavacas AM, Lopez-De-Sa E, Rosillo Rodriguez SO, De-Torres Alba F, Del-Prado Diaz S, Gemma D, Rey Blas JR, Armada Romero E, Lopez-Sendon JL. Incidence of infectious complications in patients treated with mild therapeutic hypothermia according to standardized diagnostic criteria. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht311.5911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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13
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Rosillo Rodriguez SO, Lopez-De-Sa E, Iniesta Manjavacas AM, De Torres Alba F, Del Prado Diaz S, Gemma D, Rey JR, Armada E, Lopez-Sendon J. Analysis of the mode of death after admission following in and out-of-hospital cardiac arrest in the era of therapeutic hypothermia. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht309.p4030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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