Antithrombotic and proton pump inhibitor co-therapy in patients with atrial fibrillation and stable coronary disease: a post hoc analysis of the AFIRE trial

Background

Among patients with atrial fibrillation (AF) and stable coronary artery disease, bleeding events increased the cardiovascular events and mortality. We aimed to evaluate the effect of proton pump inhibitor (PPI) on the risk of bleeding events in these patients.

Methods

In the AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease), patients with non-valvular AF and coronary artery disease were recruited and randomized to receive the rivaroxaban monotherapy or combination therapy with rivaroxaban plus antiplatelet drug. The present sub-analysis evaluated the risks of any bleeding events.

Results

Among 2,225 patients, 1,357 (61.3%) were receiving a PPI at baseline. During follow-up, 384 bleeding events were occurred, and incidence of bleeding events were significantly lower in patients with PPI compared with those without PPI (p=0.03). Among combination therapy with rivaroxaban plus antiplatelet, effect of PPI for cumulative incidence of bleeding events were significantly different between groups (p=0.01), however, these differences were not shown among rivaroxaban monotherapy patients (p=0.50, Figure 1). Multivariate Cox hazard analysis showed that PPI use had significantly lower risk of bleeding events (hazard risk 0.79, 95% confidence interval 0.64–0.97, p=0.03). In addition to PPI, male, heart failure and combination therapy with rivaroxaban plus antiplatelet drug were independent predictors of bleeding events.

Conclusions

PPI use was significantly associated with lower risk of bleeding events among patients with AF and stable coronary artery disease. Especially, for patients at high bleeding risk, such as receiving both anticoagulant and antiplatelet drugs, PPI is useful to reduce bleeding events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The Japan Cardiovascular Foundation through a contract with Bayer Yakuhin.

Changes in Heart Rate Variability after Yoga are Dependent on Heart Rate Variability at Baseline and during Yoga: A Study Showing Autonomic Normalization Effect in Yoga-Naïve and Experienced Subjects

Background:

Yoga therapy is widely applied to the maintenance of health and to treatment of various illnesses. Previous researches indicate the involvement of autonomic control in its effects, although the general agreement has not been reached regarding the acute modulation of autonomic function.

Aim:

The present study aimed at revealing the acute effect of yoga on the autonomic activity using heart rate variability (HRV) measurement.

Methods:

Twenty-seven healthy controls participated in the present study. Fifteen of them (39.5 ± 8.5 years old) were naïve and 12 (45.1 ± 7.0 years old) were experienced in yoga. Yoga skills included breath awareness, two types of asana, and two types of pranayama. HRV was measured at the baseline, during yoga, and at the resting state after yoga.

Results:

In both yoga-naïve and experienced participants, the changes in low-frequency (LF) component of HRV and its ratio to high-frequency (HF) component (LF/HF) after yoga were found to be correlated negatively with the baseline data. The changes in LF after yoga were also correlated with LF during yoga. The changes in HF as well as the raw HRV data after yoga were not related to the baseline HRV or the HRV during yoga.

Conclusion:

The results indicate that yoga leads to an increase in LF when LF is low and leads to a decrease in LF when it is high at the baseline. This normalization of LF is dependent on the autonomic modulation during yoga and may underlie the clinical effectiveness of yoga therapy both in yoga-naïve and experienced subjects.

P960Non-inducible ventricular arrhythmia soon after ventricular tachycardia ablation predicts long-term recurrence in patients with reduced ejection fraction

Introduction

Radiofrequency (RF) ablation for ventricular arrhythmia in patients with reduced left ventricular ejection fraction (LVEF) is recognized to be one of the important strategies for suppressing the fatal arrhythmia events. Although, RF ablation for those patients has been performed for decades, the optimal endpoint remains unclear.

Hypothesis

We assessed the hypothesis that non-inducibility of any ventricular tachycardia (VT) or ventricular fibrillation (VF) immediately after VT ablation predicts long-term recurrence free rate of ventricular arrhythmia in patients who were diagnosed sustained VT with reduced LVEF. 

Methods

From January 2014 to August 2019, we conducted a single center retrospective analysis for 127 consecutive patients with right or left ventricular arrhythmia who performed the first time RF ablation. Exclusion criteria were LVEF >50% and RF ablations for premature ventricular contraction or for non-sustained VT. Then 26 patients (age 69 ± 7, male 92%) were enrolled. All of the ablation procedures were performed using irrigated RF catheters and 3D mapping systems. We defined non-inducible group as the patients without monomorphic VT (clinical monomorphic VT or non-clinical monomorphic VT with any cycle length), polymorphic VT and VF by electrophysiological study (EPS) immediately after the ablation. The primary endpoint of this study was a recurrence of any sustained VT and VF during the follow up period.

Results

All of 26 patients were followed for a mean of 30.9 ± 22.3months.Of those patients, 7 patients were non-inducible group and 19 patients were inducible group. Age, sex, body mass index, coronary risk factors, LVEF (non-inducible:42 ± 5% vs inducible:35 ± 10%, p = 0.12), renal function and the etiology of LV dysfunction did not differ between patients with non-inducible group and inducible group (all non-significant). Catheter ablation procedural characteristics including activation mapping (non-inducible:29% vs inducible:36%, p = 1.00), entrainment mapping (14% vs 42%, p = 0.19), substrate mapping (86% vs 95%, p = 0.47), pace-mapping (86% vs 68%, p = 0.63), RF time (21 ± 13vs 18 ± 21min, p = 0.70), number of RF applications (27 ± 13vs 27 ± 32, p = 0.89), fluoroscopy time (77 ± 50vs 87 ± 42min, p = 0.59) and procedure time (309 ± 87vs 282 ± 61min, p = 0.37) did not differ between two groups. Medications before and after the VT ablation did not differ between two groups. The recurrence of any sustained VT and VF significantly lower in patients with non-inducible group than those with inducible group (Figure).

Conclusion

This study demonstrated that, in patients with reduced LVEF presenting sustained VT who performed RF ablation, non-inducibility of any VT and VF immediately after RF ablation predicts long-term decreased risk of recurrence of any sustained VT and VF. Not only clinical but also non-clinical VT and VF may be targeted as well at the first time VT ablation for those patients.

Abstract Figure

4939Clinical significance of global strain estimated by 3D speckle tracking acutely after onset of ST-elevation myocardial infarction on prediction of long term prognosis

Background

Three-dimensional (3D) speckle tracking echocardiography (STE) is a novel method for assessing cardiac function because of free form out-of-plane motion effects.

Aim

To explore the role of 3D-STE for prediction of the long term prognosis in patients with a first-time ST elevation acute myocardial infarction (STEMI).

Methods

A total of 238 patients (mean age 64.6 years) with a first-time STEMI treated with reperfusion therapy were enrolled in our study. Twenty four hours after admission, standard 2D echocardiography and 3D full volume imaging were obtained and strain parameters (GLS: global longitudinal strain, GCS: global circumferential strain) were calculated using 4D LV analysis. Infarct size was measured with single-photon emission computed tomography imaging 7 to 14 days after onset. We followed them for median 94 months (inter quartile range: 69–109 months). The primary end point was the major adverse cardiac and cerebrovascular events (MACE: cardiac death, non-fatal MI, heart failure requiring intravenous diuretics administration and stroke). The patients with persistent chronic atrial fibrillation, poor image quality, emergency bypass surgery were excluded.

Results

During follow up periods, 78 patients experienced MACE (26 cardiac death, 48 heart failure, 29 non-fatal MI, 5 stroke) and 48 patients died (22 non-cardiac death). In multivariate analysis, 3D-GLS was the strongest predictor for MACE. Kaplan-Meier Curve demonstrated that 3D-GLS >−11.4 was the independent predictor for MACE (Log-rank χ2=73.818, p<0.0001). When combined with 3D-GCS >−19.2, the patients with higher value both of 3D-GLS and 3D-GCS were extremely high risk.

The figure shows the Kaplan-Meier curve according to the 4 groups based on the cut-off values determinded by ROC curves.

Conclusions

Global strain estimated by 3D-STE immediately onset of STEMI was useful tool for the prediction of long term prognosis.

Acknowledgement/Funding

None

Foramen of Morgagni hernia in identical twins: is this an inheritable defect?

Twins with Down's syndrome, foramen of Morgagni hernias, and similar cardiac anomalies are described. While diaphragmatic hernias are not uncommon, the occurrence of this congenital defect in twins with very similar congenital anomalies raises the possibility that diaphragmatic hernias may result from an inheritable defect.

Profile of clinical pharmacologists in the United States

The need for clinical pharmacology in research and education, drug development, and health care delivery is well known. However, a current profile of those working in the field is not available. The ACCP authorized a survey of clinical pharmacologists to provide such a profile. Members of the ACCP or ASCPT were solicited by mail with a self-assessment questionnaire. A response rate of 37% was obtained. Demographic findings agree well with a previous study2 limited to those with the M.D. Our results reveal that most clinical pharmacologists are between 30-59 years of age, have an MD, PhD or PharmD degree; most of those with MDs list their primary specialty as internal medicine, pediatrics, psychiatry, or anesthesiology. They affiliate with the respective departments (including pharmacology) in academia or hold positions in industry or government, but few are in clinical therapeutics per se. About 20% of those with only a MD or PharmD degree cite employment in health care delivery. However, a higher percentage of these respondents work in research and education rather than in drug development or health care delivery. For those with only a PhD, more work in drug development and research and education than in health care delivery. The highest proportion of respondents with any doctoral degree work in the Northeast. The average income is a function of rank, doctoral degree, specialty, department appointment, and type and location of employer. The profile of a typical clinical pharmacologist is presented. An analysis of clinical pharmacology manpower from several perspectives reveals a marked deficit, but the field itself is professionally and economically attractive. Lack of a well defined career track in academia and a poorly defined clinical role for MD clinical pharmacologists are proposed as reasons limiting entry of trainees. These and other results of the survey support an increased emphasis on training programs. Clinical pharmacologist involvement in health care delivery and drug development must be increased if the safe and effective use of new drugs is to be realized. Nine assessments and initiatives are formulated to accomplish this goal within the next decade.

Analgesic and tolerance studies with AP-237, a new analgesic

1-n-Butyryl-4-cinnamylpiperazine hydrochloride, AP-237, is a new analgesic that has been reported in both Japan and the United States to have good analgesic activity in animals and is currently undergoing clinical trials. A detailed study of the analgesic and side effect profile of this compound is presented. AP-237 was an effective analgesic in a variety of species by several different routes of administration. Results of studies in an inflamed paw pressure and tail flick test in rats, hot plate and writhing test in mice, tooth pulp test in rabbits and intra-arterial bradykinin test in dogs are reported. AP-237 had a low physical dependence liability in rodents as measured by a mouse jumping test and a lack of withdrawal syndrom. Tolerance and cross tolerance results are reported. AP-237 is compared to morphine and pentazocine in most tests.

General pharmacology of a new analgesic-AP-237

1-n-Butyryl-4-cinnamylpiperazine hydrochloride, AP-237, was studied in a variety of general screening tests. Several routes of administration, including oral, subcutaneous, intraperitoneal, and intra-muscular, were employed. It was compared to morphine and pentazocine in many tests. It was found to be a potent analgesic in rats and mice with better oral efficacy than the reference agents. It did not exhibit anti-inflammatory, antipyretic, or anticonvulsant activity but appeared to have some tranquilizing properties. Its general pharmacology resembles the reference agents morphine and pentazocine, but with several differences.