Regional and country differences in anticoagulation are evident, with highest uptake in Europe (90%) and lowest in Asia (<60%) 5. ...oral anticoagulation is given to approximately 50% of patients ...with no risk factors. ...the article of Gomez-Outes et al. Some nationwide attempts, novel technology, teamwork, as well as clinical and basic research will be needed to resolve and prevent the increasing burden of AF worldwide. 1 A. Gomez-Outes, L. Suarez-Gea, J.M. Garcia-Pinilla, Causes of death in atrial fibrillation: challenges and opportunities, Trends Cardiovasc Med, 2017, this issue 2 K.H. Kuck, J. Brugada, A. Furnkranz, Cryoablation or radiofrequency ablation for paroxysmal atrial fibrillation, N Engl J Med, Vol. 374, 2016, 2235-2245 3 A. Verma, R. Mantovan, L. Macle, Substrate and trigger ablation for reduction of atrial fibrillation (STAR AF): a randomized, multicenter, international trial, Eur Heart J, Vol. 31, 2010, 1344-1356 4 R. Zakeri, A.R. Van Wagoner, H. Calkins, The burden of proof: the current state of atrial fibrillation and treatment trials, Heart Rhythm, Vol. 14, 2017, 763-782 5 M. Mazurek, M.V. Huisman, G.Y.H. Lip, Registries in atrial fibrillation: from trials to real-life clinical practice, Am J Med, Vol. 130, 2017, 135-145 6 E. Fung, M.-R.
The objective of the present analysis was to systematically examine the effect of intracoronary bone marrow cell (BMC) therapy on left ventricular (LV) function after ST-segment elevation myocardial ...infarction in various subgroups of patients by performing a collaborative meta-analysis of randomized controlled trials.
We identified all randomized controlled trials comparing intracoronary BMC infusion as treatment for ST-segment elevation myocardial infarction. We contacted the principal investigator for each participating trial to provide summary data with regard to different pre-specified subgroups age, diabetes mellitus, time from symptoms to percutaneous coronary intervention, infarct-related artery, LV end-diastolic volume index (EDVI), LV ejection fraction (EF), infarct size, presence of microvascular obstruction, timing of cell infusion, and injected cell number and three different endpoints change in LVEF, LVEDVI, and LV end-systolic volume index (ESVI). Data from 16 studies were combined including 1641 patients (984 cell therapy, 657 controls). The absolute improvement in LVEF was greater among BMC-treated patients compared with controls: 2.55% increase, 95% confidence interval (CI) 1.83-3.26, P < 0.001. Cell therapy significantly reduced LVEDVI and LVESVI (-3.17 mL/m², 95% CI: -4.86 to -1.47, P < 0.001; -2.60 mL/m², 95% CI -3.84 to -1.35, P < 0.001, respectively). Treatment benefit in terms of LVEF improvement was more pronounced in younger patients (age <55, 3.38%, 95% CI: 2.36-4.39) compared with older patients (age ≥ 55 years, 1.77%, 95% CI: 0.80-2.74, P = 0.03). This heterogeneity in treatment effect was also observed with respect to the reduction in LVEDVI and LVESVI. Moreover, patients with baseline LVEF <40% derived more benefit from intracoronary BMC therapy. LVEF improvement was 5.30%, 95% CI: 4.27-6.33 in patients with LVEF <40% compared with 1.45%, 95% CI: 0.60 to 2.31 in LVEF ≥ 40%, P < 0.001. No clear interaction was observed between other subgroups and outcomes.
Intracoronary BMC infusion is associated with improvement of LV function and remodelling in patients after ST-segment elevation myocardial infarction. Younger patients and patients with a more severely depressed LVEF at baseline derived most benefit from this adjunctive therapy.
This study sought to describe the clinical correlates and heritability of the early repolarization pattern (ERP) in 2 large, population-based cohorts.
There is growing recognition that ERP is ...associated with adverse outcomes.
Participants of the Framingham Heart Study (FHS) (N = 3,995) and the Health 2000 Survey (H2K) (N = 5,489) were included. ERP was defined as a J-point elevation ≥0.1 mV in ≥2 leads in either the inferior (II, III, aVF) or lateral (I, aVL, V(4-6)) territory or both. We tested the association between clinical characteristics and ERP, and estimated sibling recurrence risk.
ERP was present in 243 of 3,955 (6.1%) of FHS and 180 of 5,489 (3.3%) of H2K subjects. Male sex, younger age, lower systolic blood pressure, higher Sokolow-Lyon index, and lower Cornell voltage were independently associated with the presence of ERP. In the FHS sample, siblings of individuals with ERP had an ERP prevalence of 11.6% (recurrence risk ratio of 1.89). Siblings of individuals with ERP had an increased unadjusted odds of ERP (odds ratio: 2.22, 95% confidence interval: 1.01 to 4.85, p = 0.047).
ERP has strong association with clinical factors and has evidence for a heritable basis in the general population. Further assessment of the genetic determinants of ERP is warranted.
To test the hypothesis that in recipients of primary prophylactic implantable cardioverter-defibrillators (ICDs), the non-planarity of ECG vector loops predicts (a) deaths despite ICD protection and ...(b) appropriate ICD shocks.
Digital pre-implant ECGs were collected in 1948 ICD recipients: 21.4% females, median age 65 years, 61.5% ischaemic heart disease (IHD). QRS and T wave three-dimensional loops were constructed using singular value decomposition that allowed to measure the vector loop planarity. The non-planarity, that is, the twist of the three-dimensional loops out of a single plane, was related to all-cause mortality (n=294; 15.3% females; 68.7% IHD) and appropriate ICD shocks (n=162; 10.5% females; 87.7% IHD) during 5-year follow-up after device implantation. Using multivariable Cox regression, the predictive power of QRS and T wave non-planarity was compared with that of age, heart rate, left ventricular ejection fraction, QRS duration, spatial QRS-T angle, QTc interval and T-peak to T-end interval.
QRS non-planarity was significantly (p<0.001) associated with follow-up deaths despite ICD protection with HR of 1.339 (95% CI 1.165 to 1.540) but was only univariably associated with appropriate ICD shocks. Non-planarity of the T wave loop was the only ECG-derived index significantly (p<0.001) associated with appropriate ICD shocks with multivariable Cox regression HR of 1.364 (1.180 to 1.576) but was not associated with follow-up mortality.
The analysed data suggest that QRS and T wave non-planarity might offer distinction between patients who are at greater risk of death despite ICD protection and those who are likely to use the defibrillator protection.
Biomarkers have shown promising results in risk assessment of cardiovascular events. Their role in predicting the risk of sudden cardiac death (SCD) is not well established. We tested the performance ...of several biomarkers in risk assessment for SCD in patients with coronary artery disease (CAD) and preserved left ventricular function.
The study population consisted of 1,946 CAD patients (68% male; mean age 66.9±8.6 yrs; type 2 diabetes (T2D) 43%) enrolled in the ARTEMIS study. The study subjects underwent examinations with echocardiography and measurement of several biomarkers. The primary endpoint of the study was SCD. During the mean follow up of 76±20 months 50 patients experienced SCD. Elevated high sensitive CRP (hs-CRP, p = 0.001), soluble ST2 (sST2, p<0.001), B-type natriuretic peptide (BNP, p<0.001), and highly sensitive TroponinT (hs-TnT, p<0.001) predicted the occurrence of SCD in univariate analysis. Using the optimal cutoff points, elevated sST2 (≥27.45ng/mL; hazard ratio HR 2.7; 95%CI 1.4-5.1, p = 0.003) and hs-TnT (≥15 ng/mL; HR 2.9; 95% CI 1.5-5.6, p = 0.002) were the strongest predictors of SCD followed by hs-CRP (HR 2.4; 95% CI 1.3-4.4, p = 0.004) and BNP (HR 1.9; 95% CI 1.0-3.7, p = 0.046) in adjusted analysis. Combination of elevated hs-TnT and sST2 resulted in adjusted HR of 6.4 (95% CI 2.6-15.5, p<0.001).
Elevated sST2 and hs-TnT predict the occurrence of SCD among patients with CAD and preserved left ventricular function. The association between sST2, hs-TnT and SCD may be explained by an ongoing myocardial apoptosis followed by fibrosis leading to vulnerability to malignant arrhythmias.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Early repolarization (ER) in inferior/lateral leads of standard ECGs increases the risk of arrhythmic death. We tested the hypothesis that variations in the ST-segment characteristics after the ER ...waveforms may have prognostic importance.
ST segments after ER were classified as horizontal/descending or rapidly ascending/upsloping on the basis of observations from 2 independent samples of young healthy athletes from Finland (n=62) and the United States (n=503), where ascending type was the dominant and common form of ER. Early repolarization was present in 27/62 (44%) of the Finnish athletes and 151/503 (30%) of the US athletes, and all but 1 of the Finnish (96%) and 91/107 (85%) of US athletes had an ascending/upsloping ST variant after ER. Subsequently, ECGs from a general population of 10 864 middle-aged subjects were analyzed to assess the prognostic modulation of ER-associated risk by ST-segment variations. Subjects with ER ≥0.1 mV and horizontal/descending ST variant (n=412) had an increased hazard ratio of arrhythmic death (relative risk 1.43; 95% confidence interval 1.05 to 1.94). When modeled for higher amplitude ER (>0.2 mV) in inferior leads and horizontal/descending ST-segment variant, the hazard ratio of arrhythmic death increased to 3.14 (95% confidence interval 1.56 to 6.30). However, in subjects with ascending ST variant, the relative risk for arrhythmic death was not increased (0.89; 95% confidence interval 0.52 to 1.55).
ST-segment morphology variants associated with ER separates subjects with and without an increased risk of arrhythmic death in middle-aged subjects. Rapidly ascending ST segments after the J-point, the dominant ST pattern in healthy athletes, seems to be a benign variant of ER.
Heart rate variability (HRV) has been conventionally analysed with time- and frequency-domain methods, which measure the overall magnitude of RR interval fluctuations around its mean value or the ...magnitude of fluctuations in some predetermined frequencies. Analysis of heart rate dynamics by novel methods, such as heart rate turbulence after ventricular premature beats, deceleration capacity of heart rate and methods based on chaos theory and nonlinear system theory, have gained recent interest. Recent observational studies have suggested that some indices describing nonlinear heart rate dynamics, such as fractal scaling exponents, heart rate turbulence and deceleration capacity, may provide useful prognostic information in various clinical settings and their reproducibility may be better than that of traditional indices. For example, the short-term fractal scaling exponent measured by the detrended fluctuation analysis method has been shown to predict fatal cardiovascular events in various populations. Similarly, heart rate turbulence and deceleration capacity have performed better than traditional HRV measures in predicting mortality in post-infarction patients. Approximate entropy, a nonlinear index of heart rate dynamics, which describes the complexity of RR interval behaviour, has provided information on the vulnerability to atrial fibrillation. There are many other nonlinear indices which also give information on the characteristics of heart rate dynamics, but their clinical usefulness is not as well established. Although the concepts of nonlinear dynamics, fractal mathematics and complexity measures of heart rate behaviour, heart rate turbulence, deceleration capacity in relation to cardiovascular physiology or various cardiovascular events are still far away from clinical medicine, they are a fruitful area for research to expand our knowledge concerning the behaviour of cardiovascular oscillations in normal healthy conditions as well as in disease states.
Early repolarization (ER) in the inferior/lateral leads predicts mortality, but whether ER is a specific sign of increased risk for arrhythmic events is not known.
The purpose of this study was to ...study the association of ER and arrhythmic events and nonarrhythmic morbidity and mortality.
We assessed the prognostic significance of ER in a community-based general population of 10,846 middle-aged subjects (mean age 44 ± 8 years). The end-points were sustained ventricular tachycardia or resuscitated ventricular fibrillation (VT-VF), arrhythmic death, nonarrhythmic cardiac death, new-onset atrial fibrillation (AF), hospitalization for congestive heart failure, or coronary artery disease during mean follow-up of 30 ± 11 years. ER was defined as ≥0.1-mV elevation of J point in either inferior or lateral leads.
After including all risk factors of cardiac mortality and morbidity in Cox regression analysis, inferior ER (prevalence 3.5%) predicted VF-VT events (n = 108 1.0%) with a hazard ratio (HR) of 2.2 (95% confidence interval CI 1.1-4.5, P = .03) but not nonarrhythmic cardiac death (n = 1235 12.2%), AF (n = 1659 15.2%), congestive heart failure (n = 1752 16.1%), or coronary artery disease (n = 3592 32.9%) (P = NS for all). Inferior ER predicted arrhythmic death in cases without other QRS complex abnormalities (multivariate HR 1.68, 95 % CI 1.10-2.58, P = .02) but not in those with ER and other coexisting abnormalities in QRS morphology (HR 1.30, 95% CI 0.86-1.96, P = .22).
ER in the inferior leads, especially in cases without other QRS complex abnormalities, predicts the occurrence of VT-VF but not nonarrhythmic cardiac events, suggesting that ER is a specific sign of increased vulnerability to ventricular tachyarrhythmias.
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