Current Use of Oral Anticoagulation Therapy in Elderly Patients with Atrial Fibrillation: Results from an Italian Multicenter Prospective Study-The ISNEP Study.

Background: Atrial fibrillation (AF) is the most common heart arrhythmia, and its prevalence increases with age. Oral Anticoagulant Therapy (OAT) with non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K antagonists (VKAs) is essential to avoid thromboembolic events in AF. However, this treatment is associated with a high risk of bleeding and low adherence in elderly patients. Aim: The aim was to evaluate the real-world use of OAT in a population of patients aged ≥80 years in twenty-three Italian centers and to investigate the tolerance of and patient satisfaction with this therapy. Methods: The ISNEP Study is a multicenter cross-sectional study enrolling patients with AF and aged ≥80 years and treated with either NOACs or VKAs. A written questionnaire was administered to each patient to evaluate the adherence to and patient satisfaction with this therapy. Results: The study included 641 patients with a mean age of 85 (82−87) years. The use of NOACs was reported in 93.0% of cases, with the remaining 7.0% treated with VKAs. A history of stroke events was reported in five (11.1%) and one (0.2%) patients in the VKA and NOAC groups, respectively. The rate of referred ecchymosis/epistaxis was significantly higher in the VKA group compared to the NOAC group (p < 0.001). Patients receiving NOACs reported a substantial improvement in their quality of life compared to the VKA group. Conclusions: A small, but not negligible, proportion of elderly AF patients is still treated with VKAs. Patients treated with NOAC have a higher level of satisfaction with the therapy and complete adherence.

Abnormal QT interval variability in patients with hypertrophic cardiomyopathy: can syncope be predicted?

We sought to determine QT variability pattern in patients with hypertrophic cardiomyopathy (HCM) and its relationship with the risk of syncope. QT interval variability was assessed from 24-hour Holter monitoring in 10 HCM patients with history of syncope, 10 HCM patients without history of syncope, and 10 healthy subjects. QT variability was higher in patients with HCM, in particular in those with history of syncope, than in healthy controls. Time domain QT variability did not vary between waking and sleeping hours in HCM patients, whereas it was significantly shorter while asleep in the control group. Increased QT SDANN identified HCM patients with history of syncope with an accuracy of 75%. Our data show that QT variability is abnormal in HCM patients and indirectly support the concept that arrhythmia-related syncope in these patients may be, at least in part, related to an altered control of repolarization.

Hemodynamic effects of isometric exercise in hypertrophic cardiomyopathy: comparison with normal subjects.

BACKGROUND: We assessed the hemodynamic effects of isometric exercise by an ambulatory radionuclide monitoring device (VEST) that measured left ventricular function in patients who had hypertrophic cardiomyopathy (HCM), with and without significant left ventricular outflow-tract obstruction at rest, compared with control subjects. METHODS AND RESULTS: We studied 10 patients with obstructive HCM, 25 patients with nonobstructive HCM, and 11 control subjects. During VEST monitoring, all patients gripped a dynamometer at 75% of maximal strength for up to 5 minutes. End-diastolic, end-systolic, and stroke volumes; cardiac output; and systemic vascular resistance were expressed as a percentage of baseline. The mean exercise duration was similar among the 3 groups. During handgrip, heart rate, systolic blood pressure, and cardiac output increased significantly and similarly in the 3 groups. There was a significant difference in the lung activity between obstructive and nonobstructive HCM patients and control subjects (P <.001), with a fall in control subjects and no change in HCM patients, irrespective of obstruction. Control subjects showed a decrease in end-systolic volume (P =.02) and an increase in ejection fraction (P =.003) and stroke volume (P =.009), whereas these parameters did not change in HCM patients, irrespective of obstruction. Systemic vascular resistance increased in obstructive (P =.02) and nonobstructive (P <.01) HCM patients but did not change in control subjects. CONCLUSIONS: Isometric exercise causes an abnormal and similar adaptation to load changes in obstructive and nonobstructive HCM patients, as compared with control subjects.

Hemodynamic determinants of exercise-induced abnormal blood pressure response in hypertrophic cardiomyopathy.

OBJECTIVES: We sought to assess the hemodynamics of exercise in patients with hypertrophic cardiomyopathy (HCM), with and without an exercise-induced abnormal blood pressure (BP) response, by ambulatory radionuclide monitoring of left ventricular (LV) function with the VEST device (Capintec Inc., Ramsey, New Jersey). BACKGROUND: Blood pressure fails to increase >20 mm Hg during exercise in about one-third of patients with HCM. This carries a high risk of sudden death. METHODS: Forty-three patients with HCM and 14 control subjects underwent maximal symptom-limited exercise on a treadmill during VEST. The VEST data were averaged for 1 min and analyzed at baseline, 3 min and peak exercise. The LV end-diastolic, end-systolic and stroke volumes, cardiac output and systemic vascular resistance were expressed as the percentage of baseline. RESULTS: Ejection fraction and stroke volume fell in patients with HCM, although they increased in control subjects (p < 0.001 and p = 0.002, respectively). Cardiac output increased significantly more in control subjects than in patients with HCM (p = 0.001). In 17 patients with HCM (39%) with an abnormal BP response, ejection fraction and stroke volume fell more (p = 0.032 and p = 0.009, respectively) and cardiac output increased less (p = 0.001) than they did in patients with HCM with a normal BP response. Systemic vascular resistance decreased similarly in patients with HCM, irrespective of the BP response. CONCLUSIONS: In patients with HCM with and without an abnormal BP response, abnormal hemodynamic adaptation to exercise was qualitatively similar but quantitatively different. An abnormal BP response was associated with exercise-induced LV systolic dysfunction. This causes hemodynamic instability, associated with a high risk of sudden cardiac death.