Abstract
Background
Acute myocardial infarction (AMI) remains the leading cause of mortality worldwide. The majority of patients who suffer an AMI have a history of at least one of the standard ...modifiable risk factors (SMuRFs): smoking, hypertension, dyslipidemia, and diabetes mellitus. However, emerging scientific evidence recognizes a clinically significant and increasing proportion of patients presenting with AMI without any SMuRF (SMuRF-less patients). This study aims to define specific risk factors or biomarkers associated with the development of AMI in this subpopulation.
Methods
This is an analysis of the prospective ‘‘Beyond-SMuRFs" study reporting preliminary data of the first 350 consecutive patients with AMI fulfilling inclusion criteria. More than 300 clinical, laboratory, echocardiographic and angiographic parameters-variables were compared between patients with and without SMuRFs. Multivariable logistic regression analysis was implemented to investigate independent prognostic factors associated with the occurrence of SΜuRF-less AMIs. Only univariably-significant (P<0.05) and clinically-relevant variables were inserted in in the models. Restricted spline curve models were utilized to demonstrate the association of significant continuous predictors with the risk of SMuRF-less AMI occurrence.
Results
Out of the 350 patients (mean age 60.8±12.0 years, 74.6% males) suffering AMI, 76 patients (21.7%) had no history of SMuRFS at baseline. Increased soluble urokinase plasminogen activator receptor (suPAR) levels, history of rheumatic or autoimmune disease, values of self-reported mental health status component of SF-36 questionnaire ≤50 prior to AMI and decreased age were univariably associated with increased risk for SMuRF-less AMI. In the multivariable regression model, increased suPAR levels (aOR= 1.001; 95% CI= 1.000-1.003; p=0.02 β=0.001), history of rheumatic or autoimmune disease (aOR= 2.634; 95% CI= 2.309-4.440; p<0.001; β=1.848) and impaired mental health status retained their statistical significance (aOR= 0.413, 95% CI= 0.229-0.746; p=0.003; β=0.884).
Conclusions
In this prospective cohort of 350 consecutive patients with AMI, more than a fifth of them were SMuRF-less. History of prior rheumatic or autoimmune disease, increased suPAR levels and decline in self-reported mental health status metrics prior to AMI were found to be independent predictors of SMuRF-less AMI.Multivariable logistic regression modelRestricted spline curve models
Abstract
Background
Atrial fibrillation (AF) and valvular heart disease (VHD) are frequently encountered in clinical practice, and often coexist, especially in the elderly population. Both conditions ...are associated with increased mortality and morbidity. Recent guidelines suggest careful evaluation of patients with AF and VHD due to the puzzling nature of their coexistence.
Purpose
To evaluate the prognostic effect of significant valvular heart disease (sVHD) among patients with non-valvular AF.
Methods
This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction.
Results
In total, 983 patients with non-valvular AF (median age 76 years) were analyzed over a median follow-up period of 32 months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 1.6%/yr; adjusted HR aHR 1.55, 95% confidence interval CI 1.17–2.06; p=0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR1.70, 95% CI 1.09–2.66; p=0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35–4.63; p=0.02). The prognostic effect of sVHD was particularly evident in patients aged <80 years and in those without history of heart failure (p for interaction <0.05, in both subgroups) Figure 1. After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization Figure 2. AS was the only independent predictor of valve intervention during follow-up (aHR 10.78, 95% CI 4.80–24.22; p<0.001). Mixed aortic valve disease (AS+AR) had superior prognostic power across patterns of combined VHD.
Conclusions
Among patients with non-valvular AF, sVHD was highly prevalent, and beared high prognostic value across a wide spectrum of clinical outcomes. AS, MR, TR and mixed aortic valve disease were associated with worse prognosis.
Funding Acknowledgement
Type of funding sources: None. Subgroup analyses by VHD statusPrognostic impact of valve lesions
Abstract
Background/Introduction
Atrial fibrillation (AF) and cancer often co-exist and have been independently associated with increased risk of arterial thromboembolism (TE), all cause death and ...bleeding; however, no cumulative data exist regarding the clinical course of AF patients with comorbid cancer.
Purpose
The aim of this systematic review and meta-analysis is to synthesize the available data regarding the incidence of major adverse cardiovascular events in AF patients in association with concurrent cancer.
Methods
The composite outcome of any TE (ischemic stroke, transient ischemic attack, or arterial thrombosis) was defined as the primary study outcome, while all-cause mortality and major or clinically relevant non-major bleeding occurrence as the secondary ones. Literature search was conducted in PubMed (MEDLINE), WebOfScience, Scopus, CENTRAL, OpenGrey, and EThOS databases. A random-effects model meta-analysis was performed. Subgroup analyses were conducted assessing the effect of active cancer history and various cancer subtypes on the outcomes of interest. Meta-regression analyses were also performed to examine the relative impact of CHA2DS2VASC and HASBLED prognostic scores on the risk of TE and bleeding, respectively.
Results
Overall 17 studies were included in our analysis, encompassing a total of 3,151,861 AF patients. Comorbid cancer was non-significantly associated with lower odds of TE than AF alone (pooled odds ratio (pOR) = 0.85, 95% confidence interval (CI): 0.69–1.03, I2=87%). The likelihood for all-cause death and bleeding occurrence was significantly higher in AF patients with cancer (pOR = 2.27, 95% CI: 1.69–3.06, I2=99%); pOR = 1.58, 95% CI: 1.26–1.97, I2=97% respectively) compared to those without cancer. Subgroup analysis on active cancer status did not yield any substantial difference, marginally improving the heterogeneity of our analysis. The highest all-cause mortality likelihood was observed in Liver-Pancreas-Gallbladder category (pOR = 10.58, 95% CI: 4.69–23.88, I2=98%) while the highest bleeding likelihood was encountered in Genitourinary cancer (pOR = 1.90, 95% CI: 1.42–2.55, I2=71.9%). The performed meta-regression analyses did not yield any significant results.
Conclusions
Our meta-analysis of 17 eligible studies demonstrated that cancer does not seem to be associated with increased risk of TE, while with increased all-cause death and bleeding occurrence in AF patients. This correlation might be explained by higher cancer-driven mortality rates (competing risk), many cases of TE being left undiagnosed within the scope of palliative cancer care, misdiagnosed episodes of TE due to the presence of brain metastases, optimal cardio-oncology monitoring, and more frequent usage of prophylactic anticoagulation treatment for cancer-associated venous thromboembolism. Nonetheless, further competing-risk survival analyses are warranted before reaching definite conclusions.
Funding Acknowledgement
Type of funding sources: None.
Abstract
Background
Thyroid disease (THD) has often been associated with atrial fibrillation (AF) triggering, through endocrine mechanisms. Still, data on the impact of hypothyroidism on AF are ...contradictory. Our aim was to correlate the THD profile with the incidence of hard clinical endpoints in AF patients.
Methods
This post- hoc analysis of the MISOAC-AF RCT included hospitalized patients with AF and available history of THD. Patients were classified by categories of thyroid disease history (hyperthyroidism, hypothyroidism, euthyroidism). Unadjusted and adjusted hazard ratios (aHRs) were calculated using Cox regression models. Comparison groups included euthyroid compared to hypothyroid and hyperthyroid AF patients, respectively. All-cause mortality, cardiovascular death (CVD) and hospitalizations were the outcomes of interest. Survival analysis with the Kaplan-Meier curves was performed to analyze time-to-event data.
Results
A total of 496 AF patients followed-up for a mean of 2.7 years period, had available THD history and were included in the study. Of them, 16 patients (3.2%) were hyperthyroid, 141 (28.4%) hypothyroid, and 339 (68.4%) euthyroid. Patients with hypothyroidism had higher hospitalization rates during follow-up (aHR: 1.57, 95% CI: 1.12 to 2.20, p=0.008, p=0.025) compared to the euthyroid group. Higher TSH levels were correlated with an increased risk of CVD (aHR: 1.03, 95%CI: 1.01 to 1.05, p=0.007) and hospitalizations (aHR: 1.06, 95%CI: 1.01 to 1.12, p=0.03), while lower T3 levels were correlated with higher all-cause mortality rates (aHR: 0.51, 95%CI: 0.31 to 0.82, p=0.006) and CVD risk (aHR: 0.42, 95%CI: 0.23 to 0.77, p=0.005).
Conclusions
In AF patients, hypothyroidism was associated with increased hospitalizations, while elevated TSH levels and decreased T3 levels were associated with increased CVD and all-cause mortality respectively.Hypothyroidism and clinical outcomes
Abstract
Introduction
In adults with congenital heart disease (ACHD), atrial arrhythmias (AA) confer an increased risk of thromboembolic events. Data regarding treatment with non-vitamin K oral ...anticoagulants (NOACs) of patients with ACHD and AA are limited.
Methods
A prospective, multicenter, observational study of ACHD patients with AA (atrial fibrillation, atrial flutter, or intra-atrial re-entrant tachycardia) treated with apixaban from 2019 to 2022 was performed (PROTECT-AR, NCT03854149). Comparisons were made with a historical vitamin-K antagonist (VKA) treatment cohort from 2002 to 2014. The primary efficacy endpoint was the composite of stroke or thromboembolism. The primary safety endpoint was major bleeding.
Results
The apixaban-treated cohort consisted of 215 patients (median follow-up 28 months) and the historical VKA-treated cohort consisted of 229 patients with ACHD and AA (median follow-up 48 months). The burden of age and comorbidities was higher in the apixaban versus the VKA treatment group (Table). Comparing the apixaban with the VKA treatment group yielded no significant differences in the annualized rate of stroke or thromboembolism (1.2% vs. 1.4%, respectively; p=0.24) and major bleeding (1.2% vs. 4.4%, respectively; p=0.08) (Figure).
Conclusion
In ACHD patients with AA treated with apixaban as part of routine care, the risk of major thromboembolic and bleeding events was low. This risk was comparable with historical cohort data on VKA. Prospective studies directly comparing NOAC and VKA-treated patients are needed.
Abstract
Background
Oral anticoagulation (OAC) is paramount to effective thromboprophylaxis; yet adherence to OAC remains largely suboptimal in patients with atrial fibrillation (AF).
Purpose
We ...aimed to assess the impact of an educational, motivational intervention on the adherence to OAC in patients with non-valvular AF.
Methods
Hospitalised patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing and tailored counseling on medication adherence. The primary study outcome was adherence to OAC at 1-year, evaluated as Proportion of Days Covered (PDC) by OAC regimens and assessed through nationwide prescription registers. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, proportion of VKA-takers with labile INR (defined as time to therapeutic range<70%) and clinical events.
Results
A total of 1009 patients were randomised, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group had good adherence (PDC>80%), compared with 55% (280/509) in the control group (adjusted odds ratio 2.84, 95% confidence interval 2.14–3.75; p<0.001). Mean PDC±SD was 0.85±0.26 and 0.75±0.31, respectively (p<0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year, while usual medical care was associated with more major (≥3 months) treatment gaps Figure. Among 212 VKA-takers, patients in the intervention group were less likely to have labile INR compared with those in the control group 21/120 (17.1%) vs 34/92 (37.1%), OR 0.33 95% CI 1.15–0.72, p=0.005. Clinical events over a median follow-up period of 2 years occurred at a numerically lower, yet non-significant, rate in the intervention group Table.
Conclusions
In patients receiving OAC therapy for non-valvular AF, a motivational intervention significantly improved patterns of medication adherence, without significantly affecting clinical outcomes.
Primary and secondary outcomes
Funding Acknowledgement
Type of funding source: None
Abstract
Background
The association of heart failure (HF) with the prognosis of atrial fibrillation (AF) remains unclear.
OBJECTIVES
To assess all-cause mortality in patients following ...hospitalization with comorbid AF in relation to the presence of HF.
Methods
We performed a cross-sectional analysis of data from 977 patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018 and followed for a median of 2 years. The association between HF and the primary endpoint of death from any cause was assessed using multivariable Cox regression.
Results
HF was documented in 505 (51.7%) of AF cases at discharge, including HFrEF (17.9%), HFmrEF (16.5%) and HFpEF (25.2%). A primary endpoint event occurred in 212 patients (42%) in the AF-HF group and in 86 patients (18.2%) in the AF-no HF group (adjusted hazard ratio aHR 2.27; 95% confidence interval CI, 1.65 to 3.13; P<0.001). HF was associated with a higher risk of the composite secondary endpoint of death from any cause, AF or HF-specific hospitalization (aHR 1.69; 95% CI 1.32 to 2.16 p<0.001). The associations of HF with the primary and secondary endpoints were significant and similar for AF-HFrEF, AF-HFmrEF, AF-HFpEF.
Conclusions
HF was present in half of the patients discharged from the hospital with comorbid AF. The presence of HF on top of AF was independently associated with a significantly higher risk of all-cause mortality than did absence of HF, irrespective of HF subtype.
Funding Acknowledgement
Type of funding source: None
Abstract
Funding Acknowledgements
Type of funding sources: None.
Aims.The data on echocardiography, cardiac magnetic resonance (CMR) and ferritin predicting long-term survival in haemoglobinopathies ...are scarce. The current study evaluated the association of these parameters with the 10-years survival in haemoglobinopathies.
Methods.This prospective study included stable consecutive haemoglobinopathy patients .Demographics, ferritin, echocardiography and CMR parameters were prospectively collected.
Results. In total, 83 patients (mean age 38.4 ± 12.0 years, 46% male) with haemoglobinopathies were included and dichotomized based on their survival status after a follow-up of 9.8 ± 1.4 years. Patients who died were older (45.3 ± 11.6 vs 37.1 ± 11.7 years, p = 0.025), had higher ferritin levels (2498 vs 754 ng/ml, p = 0.001), higher right ventricular systolic pressure (RVSP) (41 ± 10 vs 31 ± 11mmHg, p = 0.001), more frequently elevated left ventricular (LV) end-diastolic pressure (70 vs 35%, p = 0.039) and lower CMR T2* values (23 ± 12 vs 35 ± 12ms, p = 0.007). Older age (HR: 1.053, p = 0.018), ferritin >2000ng/ml (HR: 3.517, p = 0.03), and >950ng/ml (HR: 11,135, p = 0.02), elevated LV end-diastolic pressure (HR: 3.977, p = 0.046), RVSP >34mmHg(HR: 10,134, p = 0.003), CMR T2* <20msec (HR: 4.900, p = 0.018) and <36msec (HR: 9.376, p = 0.035) were associated with increased all-cause mortality. A baseline model including age was created andit became more predictive of worse survival by adding RVSP >34mmHg than elevated LV end-diastolic pressure (C index 0.777 vs. 0.757 respectively) or ferritin >950ng/ml than >2000ng/ml (C index 0.805 vs. 0.770 respectively) or CMR T2*<36msec than <20msec (C index 0.825 vs. 0.810 respectively).
Conclusions. In haemoglobinopathy patients, RVSP >34mmHg, ferritin >2000ng/ml and CMR T2* <20ms were associated with worse long term survival.In the current era of advanced chelation therapy, aiming for ferritin <950ng/ml and CMR T2* >36ms appears to improve their prognosis.
Abstract Figure.
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