Use of apixaban in adults with congenital heart disease and atrial arrhythmias: The PROTECT-AR study.

BACKGROUND: Adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) face an increased risk of thromboembolic events. Limited data exist on the use of non-vitamin K oral anticoagulants for thromboprophylaxis in ACHD. We aimed to assess the effectiveness and safety of apixaban in ACHD patients with AA. METHODS: PROTECT-AR (NCT03854149) was a prospective, multicenter, observational study conducted from 2019 to 2023. ACHD patients with atrial fibrillation, atrial flutter, or intra-atrial re-entrant tachycardia on routine apixaban treatment were included. The historical control group consisted of patients previously on vitamin K antagonist (VKA), who were analyzed prior to their transition to apixaban. The primary effectiveness endpoint was the composite of stroke or thromboembolism. The primary safety endpoint was major bleeding. RESULTS: The study enrolled 218 ACHD patients with AA on apixaban, of which 73 were previous VKA users. The analysis covered 527 patient-years of prospective exposure to apixaban and 169 patient-years of retrospective exposure to VKA. The annualized rate of stroke or thromboembolism was 0.6% in the apixaban group and 1.8% in the VKA group (absolute difference - 1.2%; upper limit of one-sided 95% confidence interval [CI] 0.9%, lower than the predefined non-inferiority margin of +1.8%, Pnon-inferiority < 0.001). The annualized rate of major bleeding was 1.5% in the apixaban group and 2.4% in the VKA group (hazard ratio 0.64; 95% CI 0.19-2.10, P = 0.48). CONCLUSION: In ACHD patients with AA, routine apixaban use exhibited a non-inferior rate of stroke or thromboembolism compared to historical VKA use, alongside a similar rate of major bleeding.

Accuracy of 24 h ambulatory blood pressure recordings for diagnosing high 44 h blood pressure in hemodialysis: a diagnostic test study.

Hypertension is highly prevalent in hemodialysis patients. Ambulatory-BP-monitoring(ABPM) during the 44 h interdialytic interval is recommended for hypertension diagnosis and management in these subjects. This study assessed the diagnostic accuracy of fixed 24 h ABPM recordings with 44 h BP in hemodialysis patients. 242 Greek hemodialysis patients that underwent valid 48 h ABPM(Mobil-O-Graph NG device) were included in the analysis. We used 44 h BP as reference method and tested the accuracy of the following BP metrics: 1st 24 h without HD period (20 h-1st), 1st 24 h including HD period (24 h-1st) and 2nd 24 h(24 h-2nd). All studied metrics showed strong correlations with 44 h SBP/DBP (20 h-1st: r = 0.973/0.978, 24 h-1st: r = 0.964/0.972 and 24 h-2nd: r = 0.978/0.977, respectively). In Bland-Altman analysis, small between-method differences (-1.70, -1.19 and +1.45 mmHg) with good 95% limits-of agreement([-10.83 to 7.43], [-11.12 to 8.74] and [-6.33 to 9.23] mmHg, respectively) for 20 h-1st, 24 h-1st and 24 h-2nd SBP were observed. The sensitivity/specificity and κ-statistic for diagnosing 44 h SBP ≥ 130 mmHg were high for 20 h-1st SBP(87.2%/96.0%, κ-statistic = 0.817), 24 h-1st SBP(88.7%/96.0%, κ-statistic = 0.833) and 24 h-2nd SBP (95.0%/88.1%, κ-statistic = 0.837). Similar observations were made for DBP. In ROC-analyses, all studied BP metrics showed excellent performance with high Area-Under-the- Curve values (20 h-1st: 0.983/0.992; 24 h-1st: 0.984/0.987 and 24 h-2nd: 0.982/0.989 for SBP/DBP respectively). Fixed 24 h ABPM recordings during either the first or the second day of interdialytic interval have high accuracy and strong agreement with 44 h BP in hemodialysis patients. Thus, ABPM recordings of either the first or the second interdialytic day could be used for hypertension diagnosis and management in these subjects.

Atrial Fibrillation Ablation in Congenital Heart Disease: Therapeutic Challenges and Future Perspectives.

The increasing prevalence of atrial fibrillation (AF) in adults with congenital heart disease raises significant questions regarding its management. The unique underlying anatomic and physiological background further adds to the difficulty in eliminating the AF burden in these patients. Herein, we provide an overview of the current knowledge on the pathophysiology and risk factors for AF in adult congenital heart disease, with a special focus on the existing challenges in AF ablation. Emerging imaging modalities and ablation techniques might have a role to play. Evidence regarding the safety and efficacy of AF ablation in adult congenital heart disease is summarized, especially for patients with an atrial septal defect, Ebstein anomaly of the tricuspid valve, tetralogy of Fallot, and Fontan circulation. Finally, any remaining gaps in knowledge and potential areas of future research are highlighted.

Multi-modality imaging of the systemic right ventricle in congenital heart disease.

A comprehensive and structured imaging approach in the evaluation of the systemic right ventricle (sRV) in patients with complete transposition of the great arteries (TGA) after atrial switch procedure and congenitally corrected transposition of the great arteries (ccTGA) is a key for their optimal lifelong surveillance. Despite the improvements in cardiovascular imaging of adults with congenital heart disease (ACHD), the imaging of sRV remains an ongoing challenge due to its complex morphology and the difficulty in applying the existing knowledge for the systemic left ventricle. While cardiac magnetic resonance (CMR) is considered the gold standard imaging method, echocardiographic evaluation is primarily preferred in everyday clinical setting. Although qualitative assessment of its systolic function is primarily used, the introduction of advanced echocardiographic techniques, such as speckle tracking echocardiography (STE) and three-dimensional echocardiography (3DE), has provided new insights into the optimal assessment of the sRV. Standardized quantitative parameters remain to be elucidated, and morphometric and mechanistic studies are warranted to validate reference ranges for the sRV. This review highlights the challenges in the optimal evaluation of sRV and summarizes the available imaging tools. HIGHLIGHTS: CMR is the gold standard imaging method of sRV. Qualitative assessment of the systolic function of sRV is primarily used. Advanced echocardiographic techniques (STE and 3DE) provide optimal sRV assessment. Reference ranges for the sRV indices are warranted to be validated.

Contribution of pressure and flow changes to resistance reduction after pulmonary arterial hypertension treatment: a meta-analysis of 3898 patients.

Background: Pulmonary arterial hypertension (PAH)-targeted therapies exert significant haemodynamic changes; however, systematic synthesis is currently lacking. Methods: We searched PubMed, CENTRAL and Web of Science for studies evaluating mean pulmonary artery pressure (mPAP), cardiac index/cardiac output (CI/CO) and pulmonary vascular resistance (PVR) of PAH-targeted therapies either in monotherapy or combinations as assessed by right heart catheterisation in treatment-naïve PAH patients. We performed a random-effects meta-analysis with meta-regression. Results: We included 68 studies (90 treatment groups) with 3898 patients (age 47.4±13.2 years, 74% women). In studies with small PVR reduction (<4 WU), CI/CO increase (R2=62%) and not mPAP reduction (R2=24%) was decisive for the PVR reduction (p<0.001 and p=0.36, respectively, in the multivariable meta-regression model); however, in studies with large PVR reduction (>4 WU), both CI/CO increase (R2=72%) and mPAP reduction (R2=35%) contributed significantly to the PVR reduction (p<0.001 and p=0.01, respectively). PVR reduction as a percentage of the pre-treatment value was more pronounced in the oral+prostanoid intravenous/subcutaneous combination therapy (mean difference -50.0%, 95% CI -60.8- -39.2%), compared to oral combination therapy (-41.7%, -47.6- -35.8%), prostanoid i.v./s.c. monotherapy (-31.8%, -37.6- -25.9%) and oral monotherapy (-21.6%, -25.4- -17.8%). Changes in haemodynamic parameters were significantly associated with changes in functional capacity of patients with PAH as expressed by the 6-min walking distance. Conclusion: Combination therapies, especially with the inclusion of parenteral prostanoids, lead to remarkable haemodynamic improvement in treatment-naïve PAH patients and may unmask the contribution of mPAP reduction to the overall PVR reduction in addition to the increase in CO.

Prognostic implications of thyroid disease in patients with atrial fibrillation.

Atrial fibrillation (AF) is often accompanied by thyroid disease (THD). This study aimed to explore the relationship between THD and the occurrence of significant clinical outcomes in patients with AF. This post hoc analysis utilized data from the MISOAC-AF trial (NCT02941978), which enrolled hospitalized patients with AF. Patients were categorized based on their THD history into hyperthyroidism, hypothyroidism, or euthyroidism. Cox regression models were employed to calculate unadjusted and adjusted hazard ratios (aHRs). The primary outcomes of interest included all-cause mortality, cardiovascular death, and hospitalizations during the follow-up period. The study included 496 AF patients (mean age 73.09 ± 11.10 years) with available THD data, who were followed-up for a median duration of 31 months. Among them, 16 patients (3.2%) had hyperthyroidism, 141 (28.4%) had hypothyroidism, and 339 (68.4%) had no thyroid disease. Patients with hypothyroidism exhibited higher rates of hospitalization during follow-up (aHR: 1.57, 95% CI 1.12 to 2.20, p = 0.025) compared to the euthyroid group. Elevated levels of thyroid-stimulating hormone (TSH) were correlated with an increased risk of cardiovascular mortality (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). Conversely, lower levels of triiodothyronine (T3) were associated with higher risks of all-cause mortality (aHR: 0.51, 95% CI 0.31 to 0.82, p = 0.006) and cardiovascular mortality (aHR: 0.42, 95% CI 0.23 to 0.77, p = 0.005). Among patients with AF, hypothyroidism was associated with increased hospitalizations. Furthermore, elevated TSH levels and decreased T3 levels were linked to higher cardiovascular and all-cause mortality risks, respectively.

Epicardial Versus Endocardial Pacing in Paediatric Patients with Atrioventricular Block or Sinus Node Dysfunction: A Systematic Review and Meta-analysis.

Pacing indications in children are clearly defined, but whether an epicardial (EPI) or an endocardial (ENDO) pacemaker performs better remains to be elucidated. This systematic review and meta-analysis aimed to directly compare the incidence of pacemaker (PM) lead-related complications, mortality, hemothorax and venous occlusion between EPI and ENDO in children with atrioventricular block (AVB) or sinus node dysfunction (SND). Literature search was conducted in MEDLINE (via PubMed), Scopus by ELSEVIER, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and OpenGrey databases until June 25, 2022. Random-effects meta-analyses were performed to assess the pacing method's effect on lead failure, threshold rise, post-implantation infection and battery depletion and secondarily on all-cause mortality, hemothorax and venous occlusion. Several sensitivity analyses were also performed. Of 22 studies initially retrieved, 18 were deemed eligible for systematic review and 15 for meta-analysis. Of 1348 pediatric patients that underwent EPI or ENDO implantation, 542 (40.2%) had a diagnosis of congenital heart disease (CHD). EPI was significantly associated with higher possibility of PM-lead failure [pooled odds ratio (pOR) 3.00, 95% confidence interval (CI) 2.05-4.39; I2 = 0%]; while possibility for threshold rise, post-implantation infection and battery depletion did not differ between the PM types. Regarding the secondary outcome, the mortality rates between EPI and ENDO did not differ. In sensitivity analyses the results were consistent results between the two PM types. The findings suggest that EPI may be associated with increased PM-lead failure compared to ENDO while threshold rise, infection, battery depletion and mortality rates did not differ.

Transcatheter closure of atrial septal defect in the elderly: a systematic review and meta-analysis.

OBJECTIVE: Despite the establishment of transcatheter closure as the treatment of choice in adults with secundum atrial septal defects (ASDs), the effectiveness of this approach in the elderly is disputed. This systematic review and meta-analysis aims to explore the impact of transcatheter ASD closure in patients ≥60 years old. METHODS: We systematically searched four major electronic databases (PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus and Web of Science), ClinicalTrials.gov, article references and grey literature. Primary outcomes were the right ventricular end-diastolic diameter (RVEDD) and the New York Heart Association functional class change, whereas secondary outcomes included systolic pulmonary arterial pressure (sPAP), left ventricular end-diastolic diameter (LVEDD), brain natriuretic peptide (BNP), tricuspid valve regurgitation (TR) change, as well as the rate of atrial arrhythmias and all-cause mortality. RESULTS: In total, 18 single-arm cohorts comprising 1184 patients were included. RVEDD was reduced after ASD closure (standardised mean difference (SMD) -0.9, 95% CI -1.2 to -0.7). Elderly patients had 9.5 times higher odds of being asymptomatic after ASD closure (95% CI 5.06 to 17.79). Furthermore, ASD closure improved sPAP (mean difference (MD) -10.8, 95% CI -14.6 to -7), LVEDD (SMD 0.8, 95% CI 0.7 to 1.0), TR severity (OR 0.39, 95% CI 0.25 to 0.60) and BNP (MD -68.3, 95% CI -114.4 to -22.1). There was a neutral effect of ASD closure on atrial arrhythmias. CONCLUSIONS: Transcatheter ASD closure is beneficial for the elderly population since it improves functional capacity, biventricular dimensions, pulmonary pressures, TR severity and BNP. However, the incidence of atrial arrhythmias did not change significantly after the intervention. PROSPERO REGISTRATION NUMBER: CRD42022378574.

Cardioselective versus Non-Cardioselective Beta-Blockers and Outcomes in Patients with Atrial Fibrillation and Chronic Obstructive Pulmonary Disease.

Background: Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) have been independently associated with increased mortality; however, there is no evidence regarding beta-blocker cardioselectivity and long-term outcomes in patients with AF and concurrent COPD. Methods: This post hoc analysis of the MISOAC-AF randomized trial (NCT02941978) included patients hospitalized with comorbid AF. At discharge, all patients were classified according to the presence of COPD; patients with COPD on beta-blockers were classified according to beta-blocker cardioselectivity. Adjusted hazard ratios (aHRs) were calculated by using multivariable Cox regression models. The primary outcome was all-cause mortality, and the secondary outcomes were cardiovascular mortality and hospitalizations. Results: Of 1103 patients with AF, 145 (13%) had comorbid COPD. Comorbid COPD was associated with an increased risk of all-cause (aHR, 1.33; 95% confidence interval (CI), 1.02 to 1.73) and cardiovascular mortality (aHR 1.47; 95% CI, 1.10 to 1.99), but not with increased risk of hospitalizations (aHR 1.10; 95% CI, 0.82 to 1.48). The use of cardioselective versus non-cardioselective beta-blockers was associated with similar all-cause mortality (aHR 1.10; 95% CI, 0.63 to 1.94), cardiovascular mortality (aHR 1.33; 95% CI, 0.71 to 2.51), and hospitalizations (aHR 1.65; 95% CI 0.80 to 3.38). Conclusions: In recently hospitalized patients with AF, the presence of COPD was independently associated with increased risk of all-cause and cardiovascular mortality. No difference between cardioselective and non-cardioselective beta-blockers, regarding clinical outcomes, was identified.

Prescription Rates and Prognostic Implications of Optimally Targeted Guideline-Directed Medical Treatment in Heart Failure and Atrial Fibrillation: Insights From The MISOAC-AF Trial.

ABSTRACT: Heart failure (HF) and atrial fibrillation (AF) commonly coexist in real-life clinical practice. Among patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF), guidelines call for evidence-based target doses of renin-angiotensin-aldosterone system inhibitors and beta-blockers. However, target doses of guideline-directed medical treatment (GDMT) are often underused in real-world conditions, including HF-AF comorbidity. This retrospective cohort study of a randomized trial (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with nonvalvular AF) included hospitalized patients with AF and HFrEF or HFmrEF. Optimally targeted GDMT was defined as intake of evidence-based target doses of renin-angiotensin-aldosterone system and beta-blockers at 3 months after discharge. Rates of optimally targeted GDMT achievement across the baseline estimated glomerular filtration rate (eGFR) were assessed. Independent predictors of nontargeted GDMT and its association with all-cause mortality and the composite of cardiovascular death or HF hospitalization were assessed by regression analyses. In total, 374 patients with AF and HFrEF or HFmrEF were studied. At 3 months after discharge, 30.7% received target doses of GDMT medications. The rate of optimally targeted GDMT was reduced by 11% for every 10 mg/min/1.73 m 2 decrease in baseline eGFR [adjusted ß = 0.99; 95% confidence interval (CI), 0.98-0.99] levels. After a median 31-month follow-up period, 37.8% patients in the optimally targeted GDMT group died, as compared with 67.8% (adjusted hazard ratio: 1.49; 95% CI, 1.05-2.13) in the nontargeted GDMT group. The risk of cardiovascular death or HF hospitalization was also higher in these patients (adjusted hazard ratio: 1.60; 95% CI, 1.17-2.20). Target doses of all HF drugs were reached in roughly one-third of patients with AF and HFrEF or HFmrEF 3 months after hospital discharge. Nontargeted GDMT was more frequent across lower eGFR levels and was associated with worse outcomes.

Prognostic implications of adherence to oral anticoagulants among patients with atrial fibrillation: Insights from MISOAC-AF trial.

OBJECTIVES: To explore the implications of adherence to oral anticoagulants (OACs) on all-cause mortality and cardiovascular outcomes in patients with atrial fibrillation (AF). METHODS: This post-hoc analysis of the MISOAC-AF trial included recently hospitalized patients with AF. Adherence to OACs was assessed by the proportion of days covered (PDC). Good adherence was defined as PDC >80 %. Cox regression models were used to associate PDC with clinical outcomes of all-cause death, cardiovascular death (CVD), stroke, and bleeding. A sub-analysis was performed among adherent patients to compare outcomes between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). RESULTS: During a median 31-month follow-up, 778 cardiac patients with comorbid AF who had been prescribed OACs upon hospital discharge were studied. The mean PDC was 0.78; 66 % of patients had good adherence (>80 %) which was associated with lower risk of all-cause death [adjusted hazard ratio (aHR): 0.64; 95 % confidence interval (CI): 0.46 to 0.84, p < 0.001] and CVD (aHR: 0.70; 95 % CI: 0.50 to 0.97, p = 0.03). The risk of stroke and major or non-major bleeding did not differ by adherence status. Among adherent patients to OACs, VKA use was associated with higher rates of all-cause death (p < 0.001), CVD (p < 0.001), and stroke (p = 0.01); no differences were found regarding major or non-major bleeding risk. CONCLUSIONS: In recently hospitalized patients with AF, good adherence to OACs was associated with a reduced risk of all-cause death and CVD. The rates of stroke or bleeding events were not significantly different. VKAs were associated with more adverse events compared to DOACs.

Association of Health Status Metrics with Clinical Outcomes in Patients with Adult Congenital Heart Disease and Atrial Arrhythmias.

The prognostic value of health status metrics in patients with adult congenital heart disease (ACHD) and atrial arrhythmias is unclear. In this retrospective cohort study of an ongoing national, multicenter registry (PROTECT-AR, NCT03854149), ACHD patients with atrial arrhythmias on apixaban are included. At baseline, health metrics were assessed using the physical component summary (PCS), the mental component summary (MCS) of the Short-Form-36 (SF-36) Health Survey, and the modified European Heart Rhythm Association (mEHRA) score. Patients were divided into groups according to their SF-36 PCS and MCS scores, using the normalized population mean of 50 on the PCS and MCS as a threshold. The primary outcome was the composite of mortality from any cause, major thromboembolic events, major/clinically relevant non-major bleedings, or hospitalizations. Multivariable Cox-regression analyses using clinically relevant parameters (age greater than 60 years, anatomic complexity, ejection fraction of the systemic ventricle, and CHA2DS2-VASc and HAS-BLED scores) were performed to examine the association of health metrics with the composite outcome. Over a median follow-up period of 20 months, the composite outcome occurred in 50 of 158 (32%) patients. The risk of the outcome was significantly higher in patients with SF-36 PCS ≤ 50 compared with those with PCS > 50 (adjusted hazard ratio (aHR), 1.98; 95% confidence interval [CI], 1.02−3.84; p = 0.04) after adjusting for possible confounders. The SF-36 MCS ≤ 50 was not associated with the outcome. The mEHRA score was incrementally associated with a higher risk of the composite outcome (aHR = 1.44 per 1 unit increase in score; 95% CI, 1.03−2.00; p = 0.03) in multivariable analysis. In ACHD patients with atrial arrhythmias, the SF-36 PCS ≤ 50 and mEHRA scores predicted an increased risk of adverse events.

Polypharmacy and Major Adverse Events in Atrial Fibrillation.

ABSTRACT: Patients with atrial fibrillation (AF) often receive multiple medications daily. The purpose of this study was to examine the prognostic implications of polypharmacy in patients with AF. This is a retrospective post hoc analysis of 1113 AF patients, enrolled in a randomized trial during an acute hospitalization (MISOAC-AF, NCT02941978). The presence of polypharmacy (use of >4 drugs daily) was assessed at hospital discharge. Regression analyses were performed to identify clinical predictors of polypharmacy and compare the outcomes of patients with or without confirmed polypharmacy. The coprimary outcomes were all-cause and cardiovascular (CV) mortality. Among patients with polypharmacy, the difference in the risk of mortality was also assessed per each added drug as a numeric variable. Polypharmacy was found in 36.9% of participants. Dyslipidemia, coronary artery disease, lower left ventricular ejection fraction, and higher glomerular filtration rates were independent predictors of polypharmacy. Polypharmacy was an independent predictor for all-cause death (adjusted hazard ratio [aHR]: 1.29, 95% confidence interval [CI]: 1.01-1.64) and CV death (aHR: 1.39, 95% CI: 1.05-1.84). Among patients with polypharmacy, each additional concomitant medication was independently associated with a 4% increased risk of all-cause mortality (aHR = 1.04, 95% CI: 1.00-1.08) and a 5% increased risk of CV mortality (aHR = 1.05, 95% CI: 1.00-1.10). Polypharmacy was common among patients with AF hospitalized in a tertiary hospital and was incrementally associated with higher rates of mortality.

Severe mitral regurgitation causing unilateral pulmonary edema: A case report.

This is a case of a 70-year-old male patient with a history of degenerative mitral valve disease who presented to the emergency department with progressively worsening dyspnea. Prominent findings were rapid atrial fibrillation and unilateral pulmonary edema. Transthoracic and transesophageal echocardiography revealed chordal rupture-related severe-eccentric mitral regurgitation. The patient underwent surgical mitral valve repair. Learning objectives: •To acknowledge that the clinical presentation may not be as dramatic when acute mitral regurgitation (MR) is superimposed on chronic MR, due to the increased left atrium compliance•To bear in mind that eccentric jets of severe MR can cause unilateral pulmonary infiltrates, mimicking a primary pulmonary process•To remind that rapid atrial fibrillation might be the result rather than the cause of acute cardiac decompensation.

Clinical outcomes in patients with atrial fibrillation treated with digoxin, according to the presence of heart failure: Insights from the MISOAC-AF trial.

BACKGROUND: Digoxin is widely used in atrial fibrillation (AF) and heart failure (HF). However, current evidence regarding its association with clinical outcomes is conflicting. AIM: To investigate the relationship between digoxin therapy and adverse outcomes in patients with AF, with or without HF, in a contemporary AF cohort. METHODS: We performed a retrospective analysis of data from 698 patients, who were followed over a median of 2.5 years. The primary outcome was all-cause mortality and the secondary outcome was all-cause hospitalization, in a time-to-event analysis. Propensity scores were used to derive matched populations, balanced on key baseline covariates. To limit potential confounding, inverse probability of treatment weighting (IPTW) analysis was performed. RESULTS: Among patients with HF, 39 (10.5%) were administered digoxin at baseline, whereas 331 (89.5%) were not. Digoxin administration was not associated with an increased risk of death (hazard ratio (HR) in the digoxin group, 1.21; 95% Confidence Interval (CI), 0.69 to 2.13, p = 0.50) or hospitalization of any cause (HR 1.15; 95% CI, 0.67 to 1.96; p = 0.60). Among patients without HF, 11 (3.5%) were administered digoxin, with neutral effects on all-cause mortality (HR: 3.25; 95% CI, 0.98 to 10.70), p = 0.06) and all-cause hospitalization (HR, 1.15; 95% CI, 0.67 to 1.96, p = 0.60). Qualitatively, consistent results were observed using IPTW. CONCLUSIONS: Among patients with AF, digoxin administration was not associated with an increased risk of death and hospitalization for any cause, irrespective of HF status.

Renal function and mortality in patients with atrial fibrillation.

AIM: The aim of this study is to examine the association of the presence of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) values with mortality in patients with atrial fibrillation. METHODS: This posthoc analysis of a randomized controlled trial consisted of hospitalized patients with atrial fibrillation who were followed up for a median of 2.7 years after discharge. Kaplan-Meier curves, multivariate Cox-regression and spline curves were utilized to assess the association of CKD, CKD stages 2-5 according to the KDOQI guidelines, and the continuum of eGFR values with the primary outcome of all-cause death, and the secondary outcome of cardiovascular mortality. RESULTS: Out of 1064 hospitalized patients with atrial fibrillation, 465 (43.7%) had comorbid CKD. The presence of CKD was associated with an increased risk for both all-cause and cardiovascular mortality following hospitalization [adjusted hazard ratio (aHR): 1.60; 95% confidence intervals (95% CIs): 1.25-2.05 and aHR: 1.74; 95% CI: 1.30-2.33, respectively]. The aHRs for all-cause mortality in CKD stages 2-5, as compared with CKD stage 1 were 2.18, 2.62, 4.20 and 3.38, respectively (all P < 0.05). In spline curve analyses, eGFR values lower than 50 ml/min/1.73 m2 were independent predictors of higher all-cause and cardiovascular mortality. CONCLUSION: In recently hospitalized patients with atrial fibrillation, the presence of CKD was independently associated with decreased survival, which was significant across CKD stages 2-5, as compared with CKD stage 1. Values of eGFR lower than 50 ml/min/1.73 m2 were incrementally associated with worse prognosis.

Education level predicts mortality and morbidity in hospitalised patients with atrial fibrillation.

AIM: Education level has been long considered a life-quality modifier, but little is known about its relation to life expectancy in patients with cardiovascular disease. This study aims to assess possible correlations between education level and survival in patients with atrial fibrillation (AF). METHODS: This retrospective cohort study used data from a randomised trial of 1082 hospitalised patients with AF (mean age of 75 ± 11 years) who were followed up after discharge. Patients were divided into three groups based on their education level: i) none or primary (NPEL), ii) secondary (SEL), and iii) tertiary education level (TEL). Kaplan-Meier curves and multivariable-adjusted hazard ratios (aHRs) were used to compare survival rates between groups. The primary outcome was all-cause mortality. The composite secondary outcome was cardiovascular mortality or any hospitalisation. RESULTS: After a median 31-month follow-up period, 289 (41.9%) patients died in the NPEL group, 75 (31.1%) in the SEL group, and 29 (19.1%) in the TEL group. The aHRs for all-cause mortality were 0.42 (95% CI, 0.27 to 0.66; p < 0.001) for the TEL group compared with the NPEL group, 0.55 (95% CI, 0.33 to 0.93; p = 0.02) for the TEL group compared with the SEL group, and 0.68 (95% CI, 0.50 to 0.93; p = 0.01) for the SEL group compared with the NPEL group. The corresponding aHRs for the composite secondary outcome were 0.36 (95% CI, 0.23 to 0.52; p < 0.001), 0.49 (95% CI, 0.29 to 0.80; p < 0.001), and 0.67 (95% CI, 0.50 to 9.91; p = 0.01). CONCLUSION: Higher education levels were independently associated with fewer fatal and non-fatal outcomes in recently hospitalised patients with AF.

Rhythm control versus rate control in patients with atrial fibrillation and heart failure across the left ventricular ejection fraction spectrum.

BACKGROUND: Rhythm control and rate control are both employed commonly in patients with atrial fibrillation (AF) and heart failure (HF), but limited real-world data exist on them. We aimed to compare outcomes between these two strategies across the left ventricular ejection fraction (LVEF) spectrum. MATERIALS AND METHODS: This retrospective cohort study used data from the randomized MISOAC-AF trial, including from patients with AF and coexistent HF who were hospitalized and followed up after discharge. At baseline, the patients were classified into pharmaceutical (or electrical cardioversion) rhythm control strategy or rate control treatment (b-blocker, digoxin, calcium channel blockers) groups. The primary outcome was all-cause mortality. Kaplan-Meier curves and multivariable-adjusted Cox regression were utilized to compare the two strategies. Spline curve models were used to demonstrate the results across the LVEF stratified spectrum. RESULTS: In total, 199 AF patients with HF were studied (mean age, 77 years). At discharge, 73 (36.7%) patients received rhythm control and 126 (63.3%) rate control treatment. After a median follow-up period of 31 months, 26 (35.6%) patients in the rhythm-control group died, as compared to 43 (33.3%) in the rate-control group (aHR: 1.29; 95% CI: 0.78-2.14; p = 0.31). The spline curves also revealed no difference in all-cause mortality favoring either strategy in any HF subtype across the nominally classified LVEF. CONCLUSION: The use of a pharmacological rhythm-control strategy was not associated with a survival advantage compared to the rate control strategy in recently hospitalized patients with AF and comorbid HF. More randomized trials and large studies are needed in the future to explore these results in each subgroup of HF patients.

Potent P2Y12 inhibitors versus clopidogrel to predict adherence to antiplatelet therapy after an acute coronary syndrome: insights from IDEAL-LDL.

BACKGROUND: Superiority of potent P2Y12 inhibitors over clopidogrel after an acute coronary syndrome (ACS) has been well established, however potent P2Y12 inhibition is responsible for more adverse events, which may influence patient adherence to treatment. Aim of the present study is to investigate the adherence to the prescribed P2Y12 inhibitor (P2Y12i) in patients on dual antiplatelet therapy (DAPT) after an ACS. METHODS: In an IDEAL-LDL trial substudy, we included 344 patients after ACS discharged on DAPT. The primary outcome was the difference between potent P2Y12i and clopidogrel in terms of adherence, as well as other predictors of adherence to the antiplatelet regimen. Secondary outcomes included the prevalence of DAPT continuation and its predictors and the antiplatelet regimen selection after DAPT. RESULTS: Adherence to the potent P2Y12i and to clopidogrel was observed in 140/178 (78.7%) and 111/166 (66.9%) patients (p = 0.016), respectively. In the multivariate model, after adjustment for P2Y12i switching during the first year of therapy, there was no difference observed in adherence between potent P2Y12i and clopidogrel (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.55-1.74). Significant predictors included history of cardiovascular disease (CVD) (OR = 0.51, 95% CI = 0.31-0.86) and percutaneous coronary intervention (PCI) index event treatment (OR = 2.58, 95% CI = 1.38-4.82). Of patients, 72% continued DAPT >12 months and female gender was a negative predictor of DAPT prolongation (adjusted OR = 0.43, 95% CI = 0.21-0.90). DAPT was continued until the end of follow-up in 42.7%, while 54.6% resumed with single antiplatelet regimen. CONCLUSIONS: Adherence to DAPT was not affected by the P2Y12i potency, whereas history of CVD and PCI treatment were associated with reduced and increased adherence, respectively. CLINICAL TRIAL REGISTRATION: NCT02927808, https://clinicaltrials.gov/ct2/show/NCT02927808.