Impact of left ventricular function and transaortic gradient on outcomes from transcatheter aortic valve implantation: data from the UK TAVI Registry.

AIMS: Aortic valve surgery in the presence of reduced ejection fraction (EF) or low transaortic gradient is associated with adverse outcome. Low gradient (LG) may be associated with reduced EF, known as low EF-low gradient (LEF-LG), or "paradoxically" low with normal EF (P-LG). Our aim was to investigate the impact of EF and transaortic gradient on outcome following transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: We retrospectively analysed the UK TAVI Registry from 2007 to 2011 (n=2,535 consecutive patients, mean age 81.3±7.5, logistic EuroSCORE 21.8±14). Thirty-day mortality was 7.8%, low EF (<50%) was present in 39%, low gradient (<64 mmHg) was present in 27%, LEF-LG in 15% and P-LG in 12% of patients, respectively. LEF-LG patients had the highest risk profile vs. the other groups (EuroSCORE 30±16 vs. 20±12, p<0.001). Neither EF nor gradient impacted on procedural outcome or 30-day mortality. Mortality at two years was significantly higher in LEF-LG patients (34.7%), whereas, in patients with low EF/high gradient (27.8%) or normal EF/low gradient (23%), mortality was not significantly different from that of normal EF/high gradient (23%) patients. LEF-LG independently predicted reduced survival, HR 1.7 (1.4-2.1). CONCLUSIONS: Neither low EF nor low gradient affected procedural success or 30-day mortality. Long-term survival was reduced in LEF-LG patients but not in those with low EF and high gradient or P-LG with normal EF.

The impact of posttraumatic stress disorder on cannabis quit success.

BACKGROUND: Though a growing number of US Veterans are being diagnosed with cannabis use disorders, with posttraumatic stress disorder (PTSD) observed as the most frequently co-occurring psychiatric disorder among this population, no research has investigated the impact of PTSD diagnosis on cannabis quit success. OBJECTIVES: The present study sought to determine the impact of PTSD on cannabis use following a self-guided quit attempt. METHODS: Participants included 104, primarily male, cannabis-dependent US Veterans (Mage = 50.90 years, SDage = 9.90). The study design was prospective and included an assessment immediately prior to the quit attempt, and assessments weekly for the first 4 weeks post-quit, and then monthly through 6 months post-quit. RESULTS: Results indicated that PTSD diagnosis was not associated with time to first lapse or relapse. However, individuals with PTSD used more cannabis at baseline and evidenced a slower initial decline in cannabis use immediately following the quit attempt. All findings were significant after accounting for alcohol and tobacco use across the cessation period, as well as co-occurring mood and anxiety disorder diagnoses. CONCLUSION: Findings highlight the potential utility of interventions for individuals with cannabis use disorder and co-occurring PTSD, particularly early in a cessation attempt.

The effects of cannabis use expectancies on self-initiated cannabis cessation.

AIMS: To prospectively investigate the relation between cannabis use expectancies and cannabis use prior to and during a self-initiated cannabis cessation attempt. DESIGN: Cohort design that followed participants for 4 weeks following a self-initiated cessation attempt. SETTING: United States Department of Veterans Affairs medical center. PARTICIPANTS: One hundred cannabis dependent military veterans. MEASUREMENTS: The Marijuana Effects Expectancy Questionnaire at baseline; the timeline follow-back procedure at baseline and during the cessation attempt. FINDINGS: Cannabis use at baseline was associated with positive (P = 0.01), but not negative (P = 0.25), expectancies. Cannabis lapse was associated with positive (P = 0.03) and negative expectancies (P = 0.01), and relapse was associated with positive (P = 0.04), but not negative (P = 0.21), expectancies. The trajectory of average cannabis use during the cessation period was associated with positive (P = 0.03), but not negative (P = 0.96), expectancies. Results were similar in effect and statistical significance when adjusting for demographic factors, motivation to quit cannabis, mental disorder diagnoses, and alcohol and tobacco use, and when analyzing complete data sets obtained through multiple imputation. CONCLUSIONS: In the USA, cannabis use expectancies, especially those regarding the positive effects of cannabis use, appear to be strongly and consistently linked to cannabis use and quit failure.

The use of anticoagulants in the management of atrial fibrillation among general practices in England.

OBJECTIVES: To investigate the use of oral anticoagulants (AC) and antiplatelet agents (AP) in the management of atrial fibrillation (AF) among patients in primary care in England. DESIGN: Epidemiological study. SETTING: 1857 general practices in England representing a practice population of 13.1 million registered patients. PATIENTS: 231,833 patients with a history of AF. MAIN OUTCOME MEASURES: The primary outcome was AC and AP use by CHADS2 score and age groups <30 years, 30-49 years, 50-64 years, 65-79 years and >79 years. RESULTS: 231,833 patients with a history of AF were identified, giving a prevalence among uploading practices of 1.76%. Prevalence of AF varied markedly between practices, related to differing practice age profiles. The total number of patients with AF in a practice was strongly predicted by the number of patients aged 65 years and over in the practice. 57.0% of the AF population had a CHADS2 score ≥2 and 83.7%≥1. 114,212 (49.3%) patients received AC therapy. AC uptake increased with increasing CHADS2 score up to a score of 3, but thereafter reached a plateau. Among 132 099 patients with a CHADS2 score ≥2, 72,211 (54.7%) received an AC, 14 987(11.3%) were recorded as having a contraindication or having declined AC therapy, leaving 44,901 (34.0%) not on AC therapy and without a recorded contraindication or recorded refusal. Among patients not prescribed an AC, 79.9% were prescribed an AP. The use of AC declined in the elderly (for CHADS2 ≥ 2, 47.4% of patients ≥80 years, compared with 64.5% for patients aged <80 years, p<0.001). By contrast, AP uptake was more prevalent among elderly patients. CONCLUSIONS: Over one-third of patients with AF and known risk factors who are eligible for AC do not receive them. There is a high use of AP among patients not receiving AC. Uptake of AC is particularly poor among patients aged 80 years and over.