Dose reduction of apixaban is applied in atrial fibrillation (AF) patients fulfilling ≥ 2 of the following criteria: (1) age ≥ 80 years, (2) body weight ≤ 60 kg and (3) serum creatinine ≥ 1.5 mg/dL. ...However, the clinical significance of each criterion remains unclear. The J-ELD AF Registry is a prospective observational study of elderly (≥ 75 years) Japanese AF patients receiving on-label dose of apixaban. In patients receiving the standard dose (5 mg bid,
n
= 1243), the incidence rates (% per patient-year) of stroke or systemic embolism in those fulfilling none
n
= 516 or one of the above criteria (1)
n
= 328, (2)
n
= 378 and (3)
n
= 21 were 1.24, 2.32, 1.41 and 4.93 (log-rank
P
= 0.422), respectively, and those of bleeding requiring hospitalization were 1.03, 0.99, 1.98 and 4.93 (
P
= 0.318), respectively. In patients receiving a reduced dose (2.5 mg bid,
n
= 1,515), the incidences of stroke or systemic embolism in those fulfilling (1)/(2)
n
= 1,331, (1)/(3)
n
= 65, (2)/(3)
n
= 23 and all three criteria
n
= 96 were 1.38, 1.64, 4.67 and 3.51 (
P
= 0.295), respectively, and those of bleeding requiring hospitalization were 2.04, 1.64, 0.00 and 4.71 (
P
= 0.318), respectively. Univariate analysis demonstrated that the types or combinations of each criterion was not significantly associated with the incidence of thromboembolic or bleeding events. The types or combinations of the three apixaban dose reduction criteria did not have significant impact on effectiveness and safety in Japanese elderly AF patients receiving on-label dose of apixaban, although the impact of the creatinine criterion remains uncertain due to the few number of the patients.
Background Blood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit-to-visit variability on adverse events in patients with ...nonvalvular atrial fibrillation, a post hoc analysis of the J-RHYTHM Registry was performed. Methods and Results Of 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2-year follow-up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all-cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP-SD (<8.20, 8.20-10.49, 10.50-13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15-3.49,
=0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36-4.97,
=0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11-3.07,
=0.018 for all-cause death) after adjusting for components of the CHA
DS
-VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP-coefficient of variation was used instead of BP-SD. Conclusions Systolic BP visit-to-visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation. Registration URL: https://www.umin.ac.jp/ctr/; Unique Identifier: UMIN000001569.
•Boerhaave syndrome is a life-threatening condition that usually requires surgical management.•Endoscopic clipping is useful for localized spontaneous esophageal ruptures in selected ...patients.•Endoscopic clipping may also be useful for Boerhaave syndrome with pleural rupture.•Non-operative management of localized spontaneous esophageal rupture may be appropriate in some patients.
Spontaneous esophageal rupture is a life-threatening condition which is difficult to diagnose early, and is usually treated surgically. Prolonged hospitalization is common. Non-operative treatment of esophageal rupture localized to the mediastinum has been reported. We report three patients with spontaneous esophageal rupture successfully managed with endoscopic clipping.
Two patients had ruptures localized to the mediastinum, and were discharged within one week of undergoing closure. The third patient presented with Boerhaave’s syndrome with a leak into the pleural space and needed prolonged hospitalization (34days), but she did not need surgery and began oral intake two days after endoscopic clipping. The patient had an uneventful recovery.
Antiarrhythmic drugs exert their effects by inhibiting the ion channels of cardiomyocytes. However, these effects could also modify the ionic environment around them, and thereby affect the ...expression of ion channels, leading to biochemical enhancement or attenuation of the antiarrhythmic effects. To test this hypothesis, the physiological and biochemical effects of cibenzoline were evaluated in a rapid atrial pacing model in rats. In rats with rapid atrial pacing, pretreatment with cibenzoline significantly inhibited the increases in Kv1.5 mRNA at 2 hours and immunoreactive protein at 4 hours by 35 ± 15% and 30 ± 10%, respectively. These effects were observed only in the rapid atrial pacing group, not in the sham-operated group. With cibenzoline pretreatment, 4-hour rapid atrial pacing resulted in significant prolongation of the atrial refractory period compared to the untreated group even after removal of cibenzoline. In contrast, the sham and rapid atrial pacing model with and without cibenzoline pretreatment showed similar acute physiological responses to cibenzoline. In conclusion, in addition to the acute physiological effects, pretreatment with cibenzoline exerted pleiotropic effects of inhibition of Kv1.5 channel upregulation by rapid pacing, implying differences in the cibenzoline effects when administered before and after onset of paroxysmal atrial fibrillation.
Multivariate analysis of the total cohort showed a significant interaction between resting HR and rhythm status for peak VO2 after adjustments for age, sex, ejection fraction, structural heart ...diseases, and HR-lowering drugs.
Background Both peak VO2 and brain natriuretic peptide (BNP) have been well known to be potent independent predictors in patients with heart failure (HF).
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