Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Left ventricular aneurysm and intraventricular thrombi. Investigation and surgical correlations

Formation of a left ventricular aneurysm and intraventricular thrombus represents one of the dreaded sequelae of coronary artery disease and acute myocardial infarction. The present emphasis is to reduce the incidence by reduction of cholesterol and fats, elimination of smoking, improved detection and control of hypertension and diabetes mellitus. Earlier diagnosis is available with stress testing and other noninvasive techniques. Cardiac catheterization allows detection of occlusive lesions. The CASS and other studies increasingly prove that percutaneous angioplasty and coronary artery bypass surgery improve life expectancy and implicitly should reduce the incidence of acute myocardial infarction. In the setting of the latter, thrombolytic agents may reduce the amount of myocardial injury. Despite these measures, formation of left ventricular aneurysms remains a common occurrence. Diagnosis and management are critical issues to the cardiac surgeon.

Safety and efficacy of internal mammary artery grafts for left main coronary artery disease. A preliminary report

Questions regarding the relative safety and efficacy of internal mammary artery (IMA) grafts versus saphenous vein grafts (SVG) in patients with left main coronary artery disease (LMCAD) have not been specifically addressed in the literature. To elucidate this point, we analyzed 196 patients with LMCAD who underwent myocardial revascularization between January 1975 and December 1981, 98 by IMA and SVG and 98 by SVG, IMA was used most often to bypass the left anterior descending (LAD). Chi Square and "t" tests were performed on all demographic, cardiac and operative data comparing IMA to SVG. All results were non-significant, indicating that the two groups were comparable. Anginal pattern was progressive or unstable in 93%. IMA was used in 4 patients who were on intra-aortic balloon pump. The mean number bypass grafts per patient was 3.1. Postoperative complications were comparable for both groups, including early and late myocardial infarction. Overall operative mortality was 2.6%. Results of a survival analysis indicated no significant difference in the mortality rates of patients operated on by SVG versus IMA-SVG. Cumulative mortality rates at a mean followup of 20.5 months were 12.2% for SVG and 7.1% for IMA patients. Significant mortality risk factors were ejection fraction less than 55% (p less than 0.05); and perioperative myocardial infarction (p less than 0.001). Twenty-five patients with recurrent chest pain underwent repeat cardiac catheterization. This revealed 10 of 10 patent IMA grafts, 6 of 8 single patent SVG to LAD and 6 of 9 patent sequential vein grafts to the diagonal and LAD arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Advantages of superior approach for mitral valve surgery

Technical factors in mitral valve surgery (MVS) which may influence neurological complications, trauma to the left atrium and formation of atrial mural thrombi have not previously been described in detail. We have reviewed the records of 146 patients (pts) undergoing MVS through the superior approach between January 1974 and May 1981. The series consisted of 97 females and 49 males with a mean age of 57 +/- 18 years. All but 4 pts were in New York Heart Association functional class III or IV. Twenty-five pts underwent open mitral commissurotomy, 116 had valve replacement and 5 had annuloplasty. Concomitant procedures were coronary bypass in 47, aortic valve replacement in 18 and resection of left ventricular aneurysm in 3. Left atrial thrombi were removed in 21 pts. Thirteen pts (9%) died postoperatively. The causes of death were left ventricular failure in 7, arrhythmia in 4 and atrio-ventricular disruption in 2. Two of these pts also had cerebral dysfunction. Autopsy examination in 8 pts failed to reveal formation of fresh left atrial septal or posterior mural thrombus. Postoperative complications included transient neurologic injury presumed to be due to air embolus in 3 and postoperative bleeding from atrial suture line in one. The mean follow-up for the survivors has been 30 months. There have been 16 (12%) late deaths from 1 to 72 months (mean 15). Autopsy examination of 4 pts and surgical exploration in one other pt which failed to reveal organized left atrial mural thrombus. Only one late death was related to prosthetic thrombosis. This occurred following cessation of anticoagulations.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of mitral valve disease: pathologic findings and atrial dysrhythmia

One hundred fifty patients underwent surgery for mitral valve disease between January 1974 and May 1981. There were 98 female and 52 male patients with a mean age of 57 years (+/- 18.6). One hundred forty-six patients were in New York Heart Association functional class III or IV. Pathologic diagnoses included 67% rheumatic (55 calcified), 27% degenerative and fibrotic, 3.3% prosthetic valve malfunctions, and 2.6% acute papillary muscle dysfunction. Atrial biopsy material was normal in 72% (37/51) and Aschoff's bodies were present in 2% (1/51). Preoperative cardiac rhythm was regular sinus in 40%, atrial fibrillation in 59%, and pacemaker-induced in 1%. Valve replacement was performed in 119 patients, commissurotomy in 26, and annuloplasty in five. Left atrial thrombus was removed from 21 patients. Hospital mortality was 10%. The 135 survivors have been followed up for an average of 30.4 months. Of patients who were in regular sinus rhythm preoperatively, 90.7% maintained it postoperatively, and 9.3% converted to atrial fibrillation. Of patients in atrial fibrillation preoperatively, 33.8% converted to regular sinus rhythm postoperatively and 66.2% remained in atrial fibrillation. These data indicate that rheumatic mitral valve disease is still the most common finding in patients coming to surgery, followed by degenerative and fibrotic mitral valve disease. Acute papillary muscle dysfunction is uncommon. The chance of preserving preoperative regular sinus rhythm postoperatively is excellent (90.7%), and a 33% conversion rate of preoperative atrial fibrillation to postoperative regular sinus rhythm is encouraging.