Aim The aim of this study was to evaluate the antithrombotic treatment adopted after coronary stenting in patients requiring long-term anticoagulation.
Methods and results We analysed retrospectively ...all consecutive patients on warfarin therapy (n = 239, mean age 70 years, men 74%) who underwent percutaneous coronary intervention (PCI) in 2003-04 in six hospitals. An age- and sex-matched control group with similar disease presentation (unstable or stable symptoms) was selected from the study period. Primary endpoint was defined as the occurrence of death, myocardial infarction, target vessel revascularization, or stent thrombosis at 12 months. Warfarin treatment was an independent predictor of both primary endpoint (OR 1.7, 95% CI 1.0-3.0, P = 0.05) and major bleeding (OR 3.4, 95% CI 1.2-9.3, P = 0.02). Triple therapy with aspirin and clopidogrel was the most common (48%) option in stented patients in warfarin group, and there was a significant (P = 0.004) difference between the drug combinations in stent thrombosis with the highest (15.2%) incidence in patients receiving warfarin plus aspirin combination.
Conclusion Our study shows that the prognosis is unsatisfactory in warfarin-treated patients irrespective of the drug combination used. Aspirin plus warfarin combination seems to be inadequate to prevent stent thrombosis.
The anti-ischemic agent trimetazidine improves ejection fraction in heart failure that is hypothetically linked to inhibitory effects on cardiac free fatty acid (FFA) oxidation. However, FFA ...oxidation remains unmeasured in humans. We investigated the effects of trimetazidine on cardiac perfusion, efficiency of work, and FFA oxidation in idiopathic dilated cardiomyopathy.
Nineteen nondiabetic patients with idiopathic dilated cardiomyopathy on standard medication were randomized to single-blind trimetazidine (n=12) or placebo (n=7) for 3 months. Myocardial perfusion, FFA, and total oxidative metabolism were measured using positron emission tomography with (15)OH(2)O, (11)Cacetate, and (11)Cpalmitate. Cardiac function was assessed echocardiographically; insulin sensitivity was assessed by the homeostasis model assessment index. Trimetazidine increased ejection fraction from 30.9+/-8.5% to 34.8+/-12% (P=0.027 versus placebo). Myocardial FFA uptake was unchanged, and beta-oxidation rate constant decreased only 10%. Myocardial perfusion, oxidative metabolism, and work efficiency remained unchanged. Trimetazidine decreased insulin resistance (glucose: 5.9+/-0.7 versus 5.5+/-0.6 mmol/L, P=0.047; insulin: 10+/-6.9 versus 7.6+/-3.6 mU/L, P=0.031; homeostasis model assessment index: 2.75+/-2.28 versus 1.89+/-1.06, P=0.027). The degree of beta-blockade and trimetazidine interacted positively on ejection fraction. Plasma high-density lipoprotein concentrations increased 11% (P<0.001).
In idiopathic dilated cardiomyopathy with heart failure, trimetazidine increased cardiac function and had both cardiac and extracardiac metabolic effects. Cardiac FFA oxidation modestly decreased and myocardial oxidative rate was unchanged, implying increased oxidation of glucose. Trimetazidine improved whole-body insulin sensitivity and glucose control in these insulin-resistant idiopathic dilated cardiomyopathy patients, thus hypothetically countering the myocardial damage of insulin resistance. Additionally, the trimetazidine-induced increase in ejection fraction was associated with greater beta1-adrenoceptor occupancy, suggesting a synergistic mechanism.
Atrial fibrillation may remain undiagnosed until an ischemic stroke occurs. In this retrospective cohort study we assessed the prevalence of ischemic stroke or transient ischemic attack as the first ...manifestation of atrial fibrillation in 3,623 patients treated for their first ever stroke or transient ischemic attack during 2003-2012. Two groups were formed: patients with a history of atrial fibrillation and patients with new atrial fibrillation diagnosed during hospitalization for stroke or transient ischemic attack. A control group of 781 patients with intracranial hemorrhage was compiled similarly to explore causality between new atrial fibrillation and stroke. The median age of the patients was 78.3 13.0 years and 2,009 (55.5%) were women. New atrial fibrillation was diagnosed in 753 (20.8%) patients with stroke or transient ischemic attack, compared to 15 (1.9%) with intracranial hemorrhage. Younger age and no history of coronary artery disease or other vascular diseases, heart failure, or hypertension were the independent predictors of new atrial fibrillation detected concomitantly with an ischemic event. Thus, ischemic stroke was the first clinical manifestation of atrial fibrillation in 37% of younger (<75 years) patients with no history of cardiovascular diseases. In conclusion, atrial fibrillation is too often diagnosed only after an ischemic stroke has occurred, especially in middle-aged healthy individuals. New atrial fibrillation seems to be predominantly the cause of the ischemic stroke and not triggered by the acute cerebrovascular event.
Aims To assess the efficacy and safety of bone marrow cell (BMC) therapy after thrombolytic therapy of an acute ST-elevation myocardial infarction (STEMI). Methods and results Patients with STEMI ...treated with thrombolysis followed by percutaneous coronary intervention (PCI) 2–6 days after STEMI were randomly assigned to receive intracoronary BMCs (n = 40) or placebo medium (n = 40), collected and prepared 3–6 h prior PCI and injected into the infarct artery immediately after stenting. Efficacy was assessed by the measurement of global left ventricular ejection fraction (LVEF) by left ventricular angiography and 2-D echocardiography, and safety by measuring arrhythmia risk variables and restenosis of the stented vessel by intravascular ultrasound. At 6 months, BMC group had a greater absolute increase of global LVEF than placebo group, measured either by angiography (mean ± SD increase 7.1 ± 12.3 vs. 1.2 ± 11.5%, P = 0.05) or by 2-D echocardiography (mean ± SD increase 4.0 ± 11.2 vs. −1.4 ± 10.2%, P = 0.03). No differences were observed between the groups in the adverse clinical events, arrhythmia risk variables, or the minimal lumen diameter of the stented coronary lesion. Conclusion Intracoronary BMC therapy is associated with an improvement of global LVEF and neutral effects on arrhythmia risk profile and restenosis of the stented coronary lesions in patients after thrombolytic therapy of STEMI.
Abstract Electrical cardioversion (ECV) is the standard treatment for acute atrial fibrillation (AF), but identification of patients with increased risk of ECV failure or early AF recurrence is of ...importance for rational clinical decision-making. The objective of this study was to derive and validate a clinical risk stratification tool for identifying patients at high risk for unsuccessful outcome following ECV for acute AF. Data on 2,868 patients undergoing 5,713 ECVs of acute AF in three Finnish hospitals from 2003 through 2010 (the FinCV study data) were included in the analysis. Patients from western (n=3716 cardioversions) and eastern (n=1997 cardioversions) hospital regions were used as derivation and validation datasets, respectively. The composite of cardioversion failure and recurrence of AF within 30 days after ECV was recorded. A clinical scoring system was created using logistic regression analyses with a repeated measures model in the derivation dataset. A multivariable analysis for prediction of the composite end-point resulted in identification of five clinical variables for increased risk: A ge (odds ratio OR: 1.31; confidence interval CI: 1.13 to 1.52), not the F irst AF (OR: 1.55; CI: 1.19 to 2.02), C ardiac failure (OR: 1.52; CI: 1.08 to 2.13), V ascular disease (OR: 1.38 ; CI: 1.11 to 1.71), and S hort interval from previous AF episode (within one month before ECV, OR: 2.31; CI: 1.83 to 2.91) hence, the acronym, AF-CVS. The c-index for the AF-CVS score was 0.67 (95% CI: 0.65 to 0.69) with Hosmer-Lemeshow p-value 0.84. With high (>5) scores (i.e. 12 to 16% of the patients), the rate of composite end point was ∼40% in both cohorts and amongst low risk patients (score <3), the composite end point rate was ∼10%. In conclusion, the risk of ECV failure and early recurrence of AF can be predicted with simple patient and disease characteristics.
This study sought to explore the incidence and risk factors of thromboembolic complications after cardioversion of acute atrial fibrillation.
Anticoagulation therapy is currently recommended after ...cardioversion of acute atrial fibrillation in patients with risk factors for stroke, but the implementation of these new consensus-based guidelines has been slow.
A total of 7,660 cardioversions were performed in 3,143 consecutive patients with atrial fibrillation lasting <48 h in 3 hospitals. For this analysis, embolic complications were evaluated during the 30 days after 5,116 successful cardioversions in 2,481 patients with neither oral anticoagulation nor peri-procedural heparin therapy.
There were 38 (0.7%; 95% confidence interval CI: 0.5% to 1.0%) definite thromboembolic events (31 strokes) within 30 days (median 2 days, mean 4.6 days) after cardioversion. In addition, 4 patients suffered transient ischemic attack after cardioversion. Age (odds ratio OR: 1.05; 95% CI: 1.02 to 1.08), female sex (OR: 2.1; 95% CI: 1.1 to 4.0), heart failure (OR: 2.9; 95% CI: 1.1 to 7.2), and diabetes (OR: 2.3; 95% CI: 1.1 to 4.9) were the independent predictors of definite embolic events. Classification tree analysis showed that the highest risk of thromboembolism (9.8%) was observed among patients with heart failure and diabetes, whereas patients with no heart failure and age <60 years had the lowest risk of thromboembolism (0.2%).
The incidence of post-cardioversion thromboembolic complications is high in certain subgroups of patients when no anticoagulation is used after cardioversion of acute atrial fibrillation. (Safety of Cardioversion of Acute Atrial Fibrillation FinCV; NCT01380574).
OBJECTIVE
The aim of this study was to evaluate the impact of re-exploration for bleeding after cardiac surgery on the immediate postoperative outcome.
METHODS
Systematic review of the literature and ...meta-analysis of data on re-exploration for bleeding after adult cardiac surgery were performed.
RESULTS
The literature search yielded eight observational studies reporting on 557 923 patients and were included in the present analysis. Patients requiring re-exploration were significantly older, more frequently males, had a higher prevalence of peripheral vascular disease and preoperative exposure to aspirin, and more frequently underwent urgent/emergency surgery. Re-exploration was associated with significantly increased risk ratio (RR) of immediate postoperative mortality (RR 3.27, 95% confidence interval (CI) 2.44-4.37), stroke, need of intra-aortic balloon pump, acute renal failure, sternal wound infection, and prolonged mechanical ventilation. The pooled analysis of four studies (two being propensity score-matched pairs analysis) reporting adjusted risk for mortality led to an RR of 2.56 (95%CI 1.46-4.50). Studies published during the last decade tended to report a higher risk of re-exploration-related mortality (RR 4.30, 95%CI 3.09-5.97) than those published in the 1990s (RR 2.75, 95%CI 2.06-3.66).
CONCLUSIONS
This study suggests that re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity.
Patients with mechanical aortic valve replacement (AVR) require lifelong vitamin K antagonist (VKA) therapy for stroke and systemic embolism prevention. However, VKA treatment predisposes patients to ...various types of bleeding. In the present study, we sought to assess the success of antithrombotic therapy and the occurrence and timing of strokes and bleeding events after mechanical AVR. A total of 308 patients who underwent isolated mechanical AVR were included in the study, and follow-up data were completed for 306 patients (99.4%). The median follow-up time was 7.3 (interquartile range 4.2 to 10.9) years. The risk for major bleeding was 5-fold compared with major stroke (6.2% vs 1.3% and 20.9% vs 4.0%, respectively; events rates 3.1 vs 0.5 per 100 patient-years, respectively) at 30-day and long-term follow-up, indicating good efficacy but inadequate safety of stroke prevention. At the time of the early postoperative major bleeding, the international normalized ratio was under the therapeutic range in 73.7% of the patients. However, most patients were on triple antithrombotic treatment consisting of subcutaneous enoxaparin, VKA, and a tail effect of discontinued aspirin. During the long-term follow-up, the most common site of bleeding was gastrointestinal (41.7%), followed by genitourinary bleeding (23.3%) and intracranial hemorrhage (18.3%). Furthermore, mortality was relatively high, with a 10-year survival estimate of 78.3%. In conclusion, although ischemic stroke is a well-identified adverse event after mechanical AVR, it seems that major bleeding is a frequent clinically relevant complication during perioperative and long-term follow-up. This finding underscores the recognition and management of modifiable bleeding risk factors.
The risk for major bleeding after aortic valve replacement was 5-fold compared with major stroke.Early bleeding was associated with the use of triple antithrombotic medication.During the long-term follow-up, 1/6 of the major bleeding events were intracranial hemorrhages.A total of 1/10 of the patients died within 30 days after their first major bleeding event.
Myocardial infarction (MI) and atrial fibrillation (AF) are commonly seen in the same patient. In this study, we evaluated the temporal relations and prognosis of MI and AF. This is a substudy of the ...nationwide registry-based Finnish Anticoagulation in Atrial Fibrillation (FinACAF) study, comprising all Finnish patients with new-onset AF from 2010 to 2017. Patients with MI and AF were divided into groups depending on the temporal relation between the disease onsets: (1) MI before AF (MI<AF), (2) MI ± 30 days before or after AF (MI=AF), (3) MI after AF (MI>AF), and (4) no MI. The 1-year mortality in the groups were studied with the Cox proportional hazards model. Of the 153,207 patients with new-onset AF (mean age 72.7 years, 50.0% women), 16,265 (10.6%) were diagnosed with MI. Altogether, 8,889 (54.7%) of the patients with MI were in the MI<AF group, 4,278 (26.3%) were in the MI=AF group, and 3,098 (19.1%) were in the MI>AF group. Of all MIs, 42.2% were diagnosed within 1 year from new-onset AF. The MI>AF group had the worst survival, with an adjusted hazard ratio for death of 3.08 (confidence interval CI 2.89 to 3.27) compared with patients without MI. For the MI<AF and MI=AF groups, the hazard ratios were 1.34 (CI 1.27 to 1.41) and 1.69 (CI 1.59 to 1.81). In conclusion, the diagnoses of MI and AF accumulated close to one another, and the survival of patients with concomitant AF and MI varied, with the worst outcome found in patients with MI diagnosed after the new-onset AF.
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