Clinical features and outcomes of patients in different age groups with non-valvular atrial fibrillation receiving oral anticoagulants.

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Patient with a PRKAG2 mutation who developed Immunoglobulin A nephropathy: a case report.

BACKGROUND: PRKAG2 syndrome (PS) is a rare, early-onset autosomal dominant inherited disease caused by mutations in PRKAG2, the gene encoding the regulatory γ2 subunit of adenosine monophosphate-activated protein kinase. PRKAG2 syndrome is associated with many cardiac manifestations, including pre-excitation, arrhythmias, left ventricular hypertrophy, and chronotropic incompetence frequently leading to early pacemaker placement. A meta-analysis of genome-wide association data in subjects with chronic kidney disease (CKD) identified a susceptibility locus in an intron of PRKAG2, which has been replicated in other studies. However, CKD has not been reported in patients with PS or mutations in PRKAG2. CASE SUMMARY: We report a case of a woman diagnosed at age 27 with PS when she presented with atrial fibrillation and pre-excitation on electrocardiogram. By age 35, she had developed mild renal insufficiency and a biopsy demonstrated IgA nephropathy (IGAN). DISCUSSION: This is the first reported case of IGAN in a patient with PS. We discuss both PS and IGAN and the potential mechanisms by which they could be related.

Role of diabetes and insulin use in the risk of stroke and acute myocardial infarction in patients with atrial fibrillation: A Medicare analysis.

BACKGROUND: 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. METHODS: 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. RESULTS: 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)]. CONCLUSION: 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.

Procedural Outcomes of Patients With Heart Failure Undergoing Catheter Ablation of Atrial Fibrillation.

BACKGROUND: 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. STUDY QUESTION: This study aims at identifying the characteristics and procedural outcomes of patients with HF undergoing catheter ablation of AF. STUDY DESIGN: 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. MEASURES AND OUTCOMES: We compared procedural outcomes between patients who had known HF with those who did not. RESULTS: 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. CONCLUSION: 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.

Outcomes of hospitalizations with atrial fibrillation-flutter on a weekday versus weekend: an analysis from a 2014 nationwide inpatient sample.

BACKGROUND: Patients with atrial fibrillation-flutter (AF) admitted on the weekends were initially reported to have poor outcomes. The primary purpose of this study is to re-evaluate the outcomes for weekend versus weekday AF hospitalization using the 2014 Nationwide Inpatient Sample (NIS). METHODS: Included hospitalizations were aged above 18 years. The hospitalizations with AF were identified using the international classification of diseases 9 (ICD-9) codes (427.31, 427.32). In-hospital mortality, length of stay (LOS), other co-morbidities, cardioversion procedures, and time to cardioversion were recorded. All analysis was performed using SAS 9.4 statistical software (Cary, North Carolina). RESULTS: A total of 453,505 hospitalizations with atrial fibrillation and flutter as primary discharge diagnosis were identified. Among the total hospitalizations with a primary diagnosis of AF, 20.3% were admitted on the weekend. Among the weekend hospitalizations, 0.19% died in hospital compared to 0.74% among those admitted during the week. After adjusting for patient characteristics, hospital characteristics and disease severity, the adjusted odds for in-hospital mortality were not significantly different for weekend vs. weekday hospitalizations (OR = 0.91, 95% CI [0.77-1.11]; p = 0.33). The weekend admissions were associated with significantly lower odds of cardioversion procedures (OR = 0.72, 95% CI [0.69-0.76], P < 0.0001), lower cost of hospitalization (USD 8265.8 on weekends vs. USD 8966.5 on the weekdays, P < 0.001), slightly lower rate of anticoagulation (17.09% on the weekends vs. 18.73% on the weekdays. P < 0.0001), and slightly increased time to cardioversion (1.94 days on the weekend vs. 1.73 days on weekdays, P < 0.0005). The mean length of hospital stay (LOS) was statistically not different in both groups: (3.49 days ± 3.70 (SD) in the weekend group vs. 3.47 days ± 3.50 (SD) in the weekday group, P = 0.42). DISCUSSION: The weekend AF hospitalizations did not have a clinically significant difference in mortality and LOS compared to those admitted on a weekday. However, the use of cardioversion procedures and cost of hospitalization was significantly lower on the weekends.

Right ventricular lead location, right-left ventricular lead interaction, and long-term outcomes in cardiac resynchronization therapy patients.

BACKGROUND: The effects of right ventricular (RV) lead location and the combination of RV and left ventricular (LV) lead locations on long-term outcomes in patients receiving cardiac resynchronization therapy with defibrillator (CRT-D) are not well understood. METHODS: Our cohort consisted of 743 CRT-D patients from MADIT-CRT. We evaluated long-term death and combined heart failure or death (HF/death) in patients with non-apical RV vs. apical RV leads. We further assessed these long-term outcomes based on the combination of RV and LV leads, termed "RV-LV lead interaction." Patients with non-apical RV and apical LV leads and those with apical RV and non-apical LV leads were described to have "discordant RV and LV leads." Patients with RV and LV leads that were both non-apical or both apical were defined to have "concordant RV and LV leads." RESULTS: There were no differences in death and HF/death between patients with non-apical RV vs. apical RV leads. However, patients with non-apical RV and apical LV leads had higher mortality risk, relative to those with apical RV and non-apical LV leads (HR = 4.06, 95% CI 1.73-9.53, p = 0.001) as well as those with both leads in the non-apical (HR = 3.82, 95% CI 1.33-10.98, p = 0.013) or apical (HR = 3.40, 95% CI 1.24-9.37, p = 0.018) positions. There was no difference in HF/death by RV-LV lead sub-groups. CONCLUSION: Among CRT-D patients, long-term outcomes were similar for non-apical RV and apical RV leads. However, mortality risk was increased with discordant RV and LV leads, when a non-apical RV lead was combined with an apical LV lead.

Left Atrial Appendage Closure Device in Atrial Fibrillation.

The relationship of stroke and atrial fibrillation seems to become more complex as we gain more knowledge of the issue. Recent studies have questioned the temporal relationship between the two, which also questions causation. Left atrial appendage closure is an attractive, but unproven technology when compared with the 50-year experience with warfarin. In a patient who is on warfarin and having no issues with bleeding, medication intolerance, or lack of efficacy, it is difficult to justify stopping the drug and placing a closure device as sole therapy to prevent a stroke.

Carotid Dissection Complicated by Polymorphic Ventricular Tachycardia.

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.

Left atrial appendage closure device in atrial fibrillation.

The relationship of stroke and atrial fibrillation seems to become more complex as we gain more knowledge of the issue. Recent studies have questioned the temporal relationship between the two, which also questions causation. Left atrial appendage closure is an attractive, but unproven technology when compared with the 50-year experience with warfarin. In a patient who is on warfarin and having no issues with bleeding, medication intolerance, or lack of efficacy, it is difficult to justify stopping the drug and placing a closure device as sole therapy to prevent a stroke.

Venous Stenosis After Transvenous Lead Placement: A Study of Outcomes and Risk Factors in 212 Consecutive Patients.

BACKGROUND: 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. METHODS AND RESULTS: 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. CONCLUSIONS: 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.

Right ventricular septal pacing in patients with right bundle branch block.

BACKGROUND: Cardiac resynchronization therapy (CRT) has been shown to improve left ventricular (LV) function and exercise performance in patients with left bundle branch block. Patients with right bundle branch block (RBBB) do not have a similar positive response to standard CRT. We hypothesized that single site pacing of the right ventricular septum (RVS) near the proximal right bundle could restore more normal activation of the LV in RBBB patients. METHODS: 78 consecutive patients (56 M, 22 F) with baseline RBBB underwent pacemaker or ICD implantation. Leads were placed in the right atrium and RVS. RESULTS: Baseline QRS duration was 120-220 ms (mean QRSd = 147 ms). At the optimal AV delay, the fused QRSd was 56-160 ms (mean QRSd = 112 ms). The mean decrease in QRSd was 34 ± 20.4 ms (p<0.001). CONCLUSION: RVS pacing in patients with RBBB resulted in a marked decrease in QRS duration and often normalized the ECG.

A safe, simple technique for transseptal catheterization.

Transseptal catheterization is required for atrial fibrillation ablation and many ablations for atrial tachycardias, left atrial flutters, and accessory pathways. Using a Brockenbrough needle or other specialized device adds time, expense, and risk of potential complications such as atrial or aortic perforation, pericardial effusion, and tamponade to these procedures. We present a simple, low-risk technique for transseptal catheterization.

The EKG in hypothermia and hyperthermia.

Hypothermia and hyperthermia are relatively common clinical conditions that are associated with significant morbidity and mortality, especially if not promptly recognized and treated. Both of these conditions associated with extreme alterations in core body temperatures can be accompanied by alteration in cardiac function, often with manifest EKG changes. However, some of the EKG changes associated with hypothermia and heat stroke are non-specific and lead to diagnostic dilemmas. We here present 2 clinical cases, one each for hypothermia and hyperthermia to describe the EKG changes associated with these clinical conditions. We also present a review of available literature on these subjects.

Predictors of long-term maintenance of normal sinus rhythm after successful electrical cardioversion.

Electrical cardioversion (EC) for atrial fibrillation (AF) is a common procedure performed in an attempt to restore normal sinus rhythm (NSR). Many factors predict long-term maintenance of NSR and the risk of AF recurrence. The duration of AF, cardiac size and function, rheumatic heart disease, significant mitral valve disease, left atrial enlargement, and older age are among the most common recognized factors. A number of interventions can potentially decrease the AF recurrence rate. Identifying and treating reversible causes and the use of antiarrhythmic medications in certain situations can help decrease the risk of AF recurrence. The role of the newer anticoagulants is expanding, and wider application is expected in the near future. We hope that this summary will serve as a guide to physicians and healthcare providers to address the question of who should undergo cardioversion, as there are patients who are most likely to benefit from this procedure and others that will revert back into AF within a short period. To identify who would benefit most from EC and have a reasonable chance of long-term maintenance of NSR, a thorough evaluation of each individual patient should be performed to tailor the best therapy to each individual.