This study sought to evaluate impact of new-onset and pre-existing atrial fibrillation (AF) on transcatheter aortic valve replacement (TAVR) long-term outcomes compared with patients without AF.
...Pre-existing and new-onset AF in patients undergoing TAVR are associated with poor outcomes.
The study identified 72,660 patients ≥65 years of age who underwent nonapical TAVR between 2014 and 2016 using Medicare inpatient claims. History of AF was defined by diagnoses on claims during the 3 years preceding the TAVR, and new-onset AF was defined as occurrence of AF during the TAVR admission or within 30 days after TAVR in a patient without prior history of AF. Outcomes included all-cause mortality, and readmission for bleeding, stroke, and heart failure (HF).
Overall, 40.7% had pre-existing AF (n = 29,563) and 6.8% experienced new-onset AF (n = 2,948) after TAVR. Mean age was 81.3, 82.4, and 83.8 years in patients with no AF, pre-existing, and new-onset AF, respectively. Pre-existing AF patients had the highest burden of comorbidities. After follow-up of 73,732 person-years, mortality was higher with new-onset AF compared with pre-existing and no AF (29.7, 22.6, and 12.8 per 100 person-years, respectively; p < 0.001). After adjusting for patient characteristics and hospital TAVR volume, new-onset AF remained associated with higher mortality compared with no AF (adjusted hazard ratio: 2.068, 95% confidence interval CI: 1.92 to 2.20; p < 0.01) and pre-existing AF (adjusted hazard ratio: 1.35; 95% CI: 1.26 to 1.45; p < 0.01). In competing risk analysis, new-onset AF was associated with higher risk of bleeding (subdistribution hazard ratio sHR: 1.66; 95% CI: 1.48 to 1.86; p < 0.01), stroke (sHR: 1.92; 95% CI: 1.63 to 2.26; p < 0.01), and HF (sHR: 1.98; 95% CI: 1.81 to 2.16; p < 0.01) compared with pre-existing AF.
In patients undergoing TAVR, new-onset AF is associated with increased risk of mortality and bleeding, stroke, and HF hospitalizations compared with pre-existing AF or no AF.
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Venous stenosis is a common complication of transvenous lead implantation, but the risk factors for venous stenosis have not been well defined to date. This study was designed to evaluate the ...incidence of and risk factors for venous stenosis in a large consecutive cohort.
A total of 212 consecutive patients (136 male, 76 female; mean age 69 years) with existing pacing or implantable cardioverter-defibrillator systems presented for generator replacement, lead revision, or device upgrade with a mean time since implantation of 6.2 years. Venograms were performed and percentage of stenosis was determined. Variables studied included age, sex, number of leads, lead diameter, implant duration, insulation material, side of implant, and anticoagulant use. Overall, 56 of 212 patients had total occlusion of the subclavian or innominate vein (26%). There was a significant association between the number of leads implanted and percentage of venous stenosis (P=0.012). Lead diameter, as an independent variable, was not a risk factor; however, greater sum of the lead diameters implanted was a predictor of subsequent venous stenosis (P=0.009). Multiple lead implant procedures may be associated with venous stenosis (P=0.057). No other variables approached statistical significance.
A significant association exists between venous stenosis and the number of implanted leads and also the sum of the lead diameters. When combined with multiple implant procedures, the incidence of venous stenosis is increased.
This study was conducted to assess the safety and effectiveness of cardiac resynchronization therapy (CRT) when combined with an implantable cardioverter defibrillator (ICD).
Long-term outcome of CRT ...was measured in patients with symptomatic heart failure (HF), intraventricular conduction delay, and malignant ventricular tachyarrhythmias (ventricular tachycardia/ventricular fibrillation VT/VF) requiring therapy from an ICD.
Patients (n = 490) were implanted with a device capable of providing both CRT and ICD therapy and randomized to CRT (n = 245) or control (no CRT, n = 245) for up to six months. The primary end point was progression of HF, defined as all-cause mortality, hospitalization for HF, and VT/VF requiring device intervention. Secondary end points included peak oxygen consumption (VO2), 6-min walk (6 MW), New York Heart Association (NYHA) class, quality of life (QOL), and echocardiographic analysis.
A 15% reduction in HF progression was observed, but this was statistically insignificant (p = 0.35). The CRT, however, significantly improved peak VO2(0.8 ml/kg/min vs. 0.0 ml/kg/min, p = 0.030) and 6 MW (35 m vs. 15 m, p = 0.043). Changes in NYHA class (p = 0.10) and QOL (p = 0.40) were not statistically significant. The CRT demonstrated significant reductions in ventricular dimensions (left ventricular internal diameter in diastole = −3.4 mm vs. −0.3 mm, p < 0.001 and left ventricular internal diameter in systole = −4.0 mm vs. −0.7 mm, p < 0.001) and improvement in left ventricular ejection fraction (5.1% vs. 2.8%, p = 0.020). A subgroup of patients with advanced HF (NYHA class III/IV) consistently demonstrated improvement across all functional status end points.
The CRT improved functional status in patients indicated for an ICD who also have symptomatic HF and intraventricular conduction delay.
Atrial fibrillation (AF) is associated with elevated risk for ischemic stroke and myocardial infarction (MI). The aim of the study is to assess the role of insulin use on the risk of stroke and MI in ...AF patients with diabetes.
We identified Medicare beneficiaries with new AF in 2011 to 2013. Primary outcomes were ischemic stroke and MI. Multivariate Cox regression models were used to assess the association between AF and time to stroke and MI. We adjusted for anticoagulant as a time-dependent covariate.
Out of 798,592 AF patients, 53,212 (6.7%) were insulin-requiring diabetics (IRD), 250,214 (31.3%) were non-insulin requiring diabetics (NIRD) and 495,166 (62%) were non-diabetics (ND). IRD had a higher risk of stroke when compared to NIRD (adjusted HR: 1.15, 95% CI 1.10-1.21) and ND (aHR 1.24, 95% CI 1.18-1.31) (P < .01 for both). The risk of stroke was higher in NIRD compared to ND (aHR 1.08, 95% CI 1.05-1.12). For the outcome of MI, IRD had a higher risk compared to NIRD (aHR 1.24, 95% CI 1.18-1.31) and ND (aHR 1.46, 95% CI 1.38-1.54). NIRD had a higher risk compared to ND (aHR 1.17, 95% CI 1.13-1.22). Anticoagulation were most effective at preventing stroke in ND 0.72 (0.69-0.75), and NIRD 0.88 (0.85-0.92), but were not associated with significant reduction in stroke in IRD 0.96 (0.89-1.04).
There is an incremental risk of ischemic stroke and MI from non-diabetics to non-insulin diabetics with the highest risk in insulin users. Protective effect of anticoagulation is attenuated with insulin use.
Catheter ablation is being increasingly performed for rhythm control of atrial fibrillation (AF). Heart failure (HF) frequently coexists with AF because they share common risk factors.
This study ...aims at identifying the characteristics and procedural outcomes of patients with HF undergoing catheter ablation of AF.
In this retrospective cohort study, we analyzed 264 consecutive patients who underwent catheter ablation for AF. Seventy-three patients (28%) had a known history of stage C HF either with reduced ejection fraction or preserved ejection fraction.
We compared procedural outcomes between patients who had known HF with those who did not.
Patients with HF were more likely to have higher rates of atrial fibrillation recurrence at both 3 months (odds ratio 2.9, confidence interval = 1.5-5.7, P = 0.0022) and 1 year after the procedure (odds ratio 2.3, confidence interval 1.2-4.3, P = 0.0097) and risk factors for recurrence of AF including left atrial enlargement, persistent AF, and a higher CHA2DS2-VASc score. However, on logistic regression analysis adjusting for left atrial size, atrial fibrillation type (persistent vs. paroxysmal), and CHA2DS2-VASc score as covariates, there was no significant difference in AF recurrence rates at both 3 months and 1 year. Recurrence rates did not differ significantly between patients with HF either with reduced ejection fraction or preserved ejection fraction. Among patients with paroxysmal AF, HF was predictive of AF recurrence at both 3 months and 1 year after ablation. The procedure length was longer in patients with HF, but there were no differences in periprocedural complications.
Patients with HF undergoing catheter ablation of AF tend to have more risk factors for recurrence, but after adjustment for risk factors, the recurrence rates were similar at 3 months and 1 year. Among patients with paroxysmal atrial fibrillation, HF was predictive of higher recurrence rates.
In this case report, we describe a patient with fibromuscular dysplasia who suffered spontaneous bilateral carotid artery dissections. This was followed by significant variations in blood pressure ...and heart rates during her admission. Unfortunately, during an episode of bradycardia, a premature ventricular contraction occurred during the T wave which resulted in polymorphic ventricular tachycardia. As described in the case and in graphic depiction, this hemodynamic instability resolved after stenting of the carotid artery.
Patients with non-valvular atrial fibrillation (NVAF) need prophylactically antithrombotic therapies to reduce the risk of stroke. We hypothesized that the prognostic benefits of prophylactic ...antithrombotic therapies outweighed the bleeding risk among very elderly (≥85 years old) patients.
We analyzed clinical characteristics and outcomes of patients with NVAF in different age groups who had received different prophylactic antithrombotic therapies. We enrolled 3895 consecutive NVAF patients in the Macau Special Administrative Region (Macau SAR) of China from January 1, 2010, to December 31, 2018. Among 3524 patients including 1252 (35.53%) very elderly patients who completed the entire study, 2897 (82.21%) patients had a CHA2DS2-VASc score ≥ 2, 2274 (64.53%) had HAS-BLED score < 3, and 1659 (47.08%) had both of the above. The follow-up time was 3.80 (median, interquartile range 1.89–6.56) years. The primary outcome was the first occurrence of ischemic stroke, major bleeding, clinically relevant non-major gastrointestinal bleeding (CRNM-GIB), and all-cause mortality.
A total of 2012 patients (57.09%) received no antithrombotic (NAT), 665 (18.87%) received antiplatelet (AP) agents, 371 (10.53%) received vitamin K antagonist (VKA), and 476 (13.51%) received non-vitamin K antagonist oral anticoagulants (NOACs). Eventually, 610 (17.31%) patients experienced thromboembolic events, with 167 (4.74%) strokes and 483 (13.71%) transient ischemia attack (TIA)/strokes. Bleeding events occurred in 614 (17.42%) patients, with 131 (3.72%) major bleeding, 381 (10.81%) CRNM-GIB and 102 (2.89%) minor bleeding events. All-cause deaths occurred in 483 (13.71%) patients. Compared with patients receiving NAT, patients receiving NOACs and VKA had fewer strokes (hazard ratio HR: 0.038; 95 %CI 0.004–0.401; p = 0.006 and HR: 0.544; 95 %CI 0.307–0.965; p = 0.037, respectively), and lower all-cause mortality (HR: 0.270; 95 %CI 0.170–0.429; p < 0.001 and HR: 0.531; 95 %CI 0.373–0.756; p < 0.001, respectively). Of note, very elderly patients with NVAF receiving NOACs had fewer strokes (adjust hazard ratio adjHR: 0.042; 95 %CI 0.002–1.003; p = 0.050) and lower all-cause mortality (adjHR: 0.308; 95 %CI 0.158–0.601; p = 0.001). Meanwhile, despite higher CRNM-GIB events (adjHR: 1.736; 95 %CI 1.042–2.892; p = 0.034), major bleeding events (adjHR: 1.045; 95 %CI 0.366–2.979; p = 0.935) did not significantly increase. VKA neither reduced strokes (adjHR: 1.015; 95 %CI 0.529–1.948; p = 0.963), nor improved all-cause mortality (adjHR: 0.995; 95 %CI 0.641–1.542; p = 0.981) in very elderly patients with NVAF.
Antithrombotic treatment (VKA and NOACs) reduces stroke and improves prognosis in patients in different age groups with NVAF. The prognostic benefits of NOACs outweigh their bleeding risks in very elderly patients with NVAF.
Persistent and long-standing persistent atrial fibrillation (AF) often requires extensive and/or repeat radiofrequency (RF) ablation procedures.
The Tailored Treatment of Persistent Atrial ...Fibrillation (TTOP-AF) study assessed the effectiveness and safety of the phased RF system in a randomized controlled comparison of medical therapy against phased RF ablation for the management of persistent and long-standing persistent AF.
Patients who had failed at least 1 antiarrhythmic drug (AAD) were randomized (2:1) to ablation management (AM) or medical management (MM). AM patients were allowed up to 2 ablations. Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated atrial electrograms. MM patients received AAD changes and/or cardioversion. The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation.
At 6 months, a greater proportion of AM patients achieved effectiveness off AAD (77 of 138 55.8%) compared to MM patients (19 of 72 26.4%) (P < .0001). Acutely, 92.8% (128/138) of the procedures were successful while 12.3% (17/138) experienced a serious procedure and/or device-related adverse event. The predefined acute safety end point was not met. The proportion of patients with chronic safety events did not differ significantly between groups.
Catheter ablation of persistent/long-standing persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM. More intense anticoagulation strategies, careful attention to catheter placement relative to the pulmonary vein ostia, and elimination of electrode interaction are expected to reduce the risk of stroke, pulmonary vein stenosis, and asymptomatic cerebral emboli.
Arithmetic results on orbits of linear groups Giudici, Michael; Liebeck, Martin W.; Praeger, Cheryl E. ...
Transactions of the American Mathematical Society,
04/2016, Letnik:
368, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Let p a subgroup of GL_d(p) to be pexceptional if it has order divisible by p. We obtain a classification of p \frac {1}{2}.
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