Incidence and prognostic significance of chronic atrial fibrillation among 5,839 consecutive patients with acute myocardial infarction. The SPRINT Study Group. Secondary Prevention Reinfarction Israeli Nifedipine Trial

New-onset atrial fibrillation after acute myocardial infarction and its relation to admission biomarkers (from the TRIUMPH registry)

Atrial fibrillation (AF) is an independent predictor of mortality after acute myocardial infarction (AMI). We analyzed the relation between biomarkers linked to myocardial stretch (NT-pro-brain natriuretic peptide [NT-proBNP]), myocardial damage (Troponin-T [TnT]), and inflammation (high-sensitivity C-reactive protein [hs-CRP]) and new-onset AF during AMI to identify patients at high risk for AF. In a prospective multicenter registry of AMI patients (from the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status registry), we measured NT-proBNP, TnT, and hs-CRP in patients without a history of AF (n = 2,370). New-onset AF was defined as AF that occurred during the index hospitalization. Hierarchical multivariate logistic regression models were used to determine the association of biomarkers with new-onset AF, after adjusting for other covariates. New-onset AF was documented in 114 patients with AMI (4.8%; mean age 58 years; 32% women). For each twofold increase in NT-proBNP, there was an 18% increase in the rate of AF (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03 to 1.35; p <0.02). Similarly, for every twofold increase in hs-CRP, there was a 15% increase in the rate of AF (OR 1.15, 95% CI 1.02 to 1.30; p = 0.02). TnT was not independently associated with new-onset AF (OR 0.96, 95% CI 0.85 to 1.07; p = 0.3). NT-proBNP and hs-CRP were independently associated with new in-hospital AF after MI, in both men and women, irrespective of race. Our study suggests that markers of myocardial stretch and inflammation, but not the amount of myocardial necrosis, are important determinants of AF in the setting of AMI.

Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis

OBJECTIVE

Chronic cerebrospinal venous insufficiency (CCSVI) is a recently discovered syndrome mainly due to stenoses of internal jugular (IJV) and/or azygos (AZ) veins. The present study retrospectively evaluates the feasibility and safety of endovascular treatment for CCSVI in a cohort of patients with multiple sclerosis (MS).

METHODS

From September 2010 to October 2012, 1202 consecutive patients were admitted to undergo phlebograpy ± endovascular treatment for CCSVI. All the patients had previously been found positive at color Doppler sonography (CDS) for at least two Zamboni criteria for CCSVI and had a neurologist-confirmed diagnosis of MS. Only symptomatic MS were considered for treatment. Percutaneous transluminal angioplasty was carried out as an outpatient procedure at two different institutes. Primary procedures, regarded as the first balloon angioplasty ever performed for CCSVI, and secondary (reintervention) procedures, regarded as interventions performed after venous disease recurrence, were carried out in 86.5% (1037 of 1199) and 13.5% (162 of 1199) of patients, respectively. Procedural success and complications within 30 days were recorded.

RESULTS

Phlebography followed by endovascular recanalization was carried out in 1999 patients consisting of 1219 interventions. Balloon angioplasty alone was performed in 1205 out of 1219 (98.9%) procedures, whereas additional stent placement was required in the remaining 14 procedures (1.1%) following unsuccessful attempts at AZ dilatation. No stents were ever implanted in the IJV. The feasibility rate was as high as 99.2% (1209 interventions). Major complications included one (0.1%) AZ rupture occurring during balloon dilatation and requiring blood transfusion, one (0.1%) severe bleeding in the groin requiring open surgery, two (0.2%) surgical openings of the common femoral vein to remove balloon fragments, and three (0.2%) left IJV thromboses. The overall major and minor complication rates at 30 days were 0.6% and 2.5%, respectively.

CONCLUSIONS

Endovascular treatment for CCSVI appears feasible and safe. However, a proper learning curve can dramatically lower the rate of adverse events. In our experience, the vast majority of complications occurred in the first 400 cases performed.

Atrial fibrillation and mortality in patients with acute myocardial infarction: a systematic overview and meta-analysis

Atrial fibrillation (AF) confers an increased risk of mortality in patients hospitalized for acute myocardial infarction (AMI). However, it is unclear whether new-onset and preexisting AF portend a different risk. We extracted data from studies that evaluated in-hospital mortality in patients with AMI and included information on cardiac rhythm. Overall, the risk of mortality was higher in patients with AF than in those in sinus rhythm (OR 2.00, 95 % CI: 1.93-2.08; P < 0.0001). Compared with patients who remained in sinus rhythm, the risk of death was increased in patients with new AF certain (sinus rhythm on admission, new AF during hospitalization, and history of no evidence of prior AF; OR 3.38, 95 % CI: 2.98-3.83; P < 0.0001), new AF uncertain (sinus rhythm on admission, AF during hospitalization, but no clear information about previous history of AF; OR 1.90, 95 % CI:1.83-1.98; P < 0.0001), and permanent AF (AF before and during hospitalization; OR 2.01, 95 % CI:1.70-2.38;P < 0.0001). In a meta-regression analysis, the risk of death was 87 % higher in patients with new AF certain than in those with permanent AF (P = 0.013) or AF uncertain (P = 0.003), and not dissimilar in patients with new AF uncertain and permanent AF (P = 0.706).

[Is atrial fibrillation an independent marker of cardiovascular risk?]

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia and its prevalence rises with age. AF may cause stroke and heart failure but the relationship between AF and mortality is less clear. It is difficult to determine if cardiovascular events in patients with AF are attributable to the arrhythmia itself or if they are merely related to the comorbidities frequently associated with AF. Review of the literature suggests that lone AF (without structural heart disease), a rare clinical entity except in young patients, is not an independent risk factor for mortality. On the other hand, if illnesses usually associated with AF are present (hypertension, heart failure...), AF has a negative impact on outcome in terms of survival and morbidity. Current antiarrhythmic medications have not shown reduction in mortality of AF patients, but new agents and catheter ablation are promising paths to explore in order to decrease AF burden.

The patient with atrial fibrillation

Atrial fibrillation is a frequently encountered arrhythmia, particularly affecting the elderly. Patients at significant risk for stroke should be considered for anticoagulation with warfarin. Management of atrial fibrillation revolves around either controlling the ventricular rate response or trying to maintain sinus rhythm with either pharmacologic or nonpharmacologic therapies. There are many treatment options to consider, based upon the patient's expectations, symptoms, and comorbid conditions. Therefore, the treatment of atrial fibrillation must be individualized.

Effectiveness of atrial fibrillation as an independent predictor of death and coronary events in patients having coronary angiography

The impact of atrial fibrillation (AF) on future coronary events is uncertain. In particular, the prognostic impact of AF in the clinically important population of coronary patients who undergo angiography is unknown. The aim of this study was to investigate (1) the prevalence of AF, (2) its association with coronary atherosclerosis, and (3) its impact on future coronary events in patients who undergo angiography. Electrocardiograms were evaluated in a consecutive series of 613 patients who underwent coronary angiography. Prospectively, death and cardiovascular events were recorded over 4.0 +/- 0.6 years. Among these patients, 37 (6%) at baseline had AF, and 576 (94%) were in sinus rhythm. The presence of AF was associated with a lower prevalence of coronary artery disease and of coronary diameter narrowing >or=50% on baseline angiography. However, prospectively, patients with AF were at a strongly increased risk for all-cause mortality (adjusted hazard ratio 5.15, 95% confidence interval 2.36 to 11.26, p <0.001), coronary death (hazard ratio 8.16, 95% confidence interval 2.89 to 23.09, p <0.001), and major coronary events (hazard ratio 3.80, 95% confidence interval 1.45 to 9.94, p = 0.007). In conclusion, although inversely associated with the presence of angiographically determined coronary atherosclerosis, AF is a strong predictor of death and future coronary events in patients with coronary artery disease who undergo coronary angiography.

Prognostic value of short-deceleration time of mitral inflow E velocity: implications in patients with atrial fibrillation and left-ventricular systolic dysfunction

OBJECTIVE

The aim of this prospective study was to evaluate the contribution of an initially shortened deceleration time of mitral inflow E velocity (E-wave DT) to predict survival in patients with left-ventricular (LV) systolic dysfunction in atrial fibrillation (AF) and in sinus rhythm (SR).

BACKGROUND

To date, few data are available concerning the prognostic value of Doppler mitral profile in patients with AF, particularly in the presence of LV systolic dysfunction.

METHODS

We studied the outcome of 140 consecutive patients with LV ejection fraction less than 40%. Complete history, physical examination and echocardiography were performed.

RESULTS

Chronic AF was present in 40 (29%) patients. Over a mean follow-up of 25+/-11 months, 54 (39%) patients died, 18 in the AF group and 36 in the SR group. Ejection fraction was similar in the two groups (31% versus 32%, respectively). Survival curves indicated a significantly poorer prognosis for shortened E-wave DT less than 150 ms in the AF group and in the SR group (both p<or=0.01). Using multivariable Cox analysis, shortened E-wave DT was identified as an independent predictor of mortality in the AF group (exponential of coefficient: 0.97; chi-square: 5.82; p=0.01) and in the SR group (exponential of coefficient: 0.98; chi-square: 5.82; p=0.001).

CONCLUSION

In patients with LV systolic dysfunction, a shortened deceleration time E-wave on Doppler examination appears to predict a similar poor prognosis in patients with AF as with SR.

Cardiovascular death in patients with atrial fibrillation is better predicted by left atrial thrombus and spontaneous echocardiographic contrast as compared with clinical parameters

We hypothesized that altered intra-atrial thrombogenicity, as reflected by the presence of left atrial (LA) thrombus or spontaneous echocardiographic contrast (SEC), would predict cardiovascular death in patients with atrial fibrillation (AF). In 175 patients with AF and no more than mild mitral regurgitation as detected by transesophageal echocardiography (TEE), 13 cardiovascular deaths occurred during a mean follow-up of 31 +/- 20 months. Multivariate logistic regression analysis using clinical variables identified the presence of congestive heart failure (relative risk [RR] = 4.22; P = .02) as the only positive predictor of cardiovascular death. However, when the TEE variables were added to the model, LA thrombus (RR = 5.52; P = .024) and LA SEC (RR = 7.96; P = .013) emerged as the only positive predictors of cardiovascular death. Kaplan-Meier analysis demonstrated a lower event-free survival from cardiovascular death in patients with LA thrombus and/or SEC ( P = .0013). These findings support AF as a contributing cause of cardiovascular death independent of clinically associated risk factors, such as hypertension, diabetes mellitus, smoking, congestive heart failure, and prior myocardial infarction.

Epidemiology and significance of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting an estimated 2.2 million adults in the United States. The median age of people with AF is 75, and it affects 8.8% of the US population > 80 years of age. Prevalence data from other countries are presented. Direct comparisons are limited by study design, but rough comparisons suggest that the prevalence of AF in Europe is similar to the prevalence in the United States, whereas the prevalence in Asia may be lower. The limited comparative data underscore our lack of understanding of AF risk factors and complications in racial subgroups and in developing countries. AF increases stroke risk 5-fold. The clinical features that predict higher risk of stroke in AF are prior stroke, hypertension, advancing age, diabetes, and congestive heart failure. Predicting which patients with atrial fibrillation are at the highest risk of stroke remains a challenge. Echocardiographic findings have been investigated to assist in the risk stratification of patients with AF. Despite evidence from clinical trials that anticoagulation with warfarin reduces stroke incidence and even mortality, anticoagulation remains underutilized, especially in the elderly. Improvement in the rate of anticoagulation in patients with AF at risk of stroke can be expected to decrease the complications and mortality of AF.

Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates

Atrial fibrillation (AF) is the most common of the serious cardiac rhythm disturbances and is responsible for substantial morbidity and mortality in the general population. Its prevalence doubles with each advancing decade of age, from 0.5% at age 50-59 years to almost 9% at age 80-89 years. It is also becoming more prevalent, increasing in men aged 65-84 years from 3.2% in 1968-1970 to 9.1% in 1987-1989. This statistically significant increase in men was not explained by an increase in age, valve disease, or myocardial infarctions in the cohort. The incidence of new onset of AF also doubled with each decade of age, independent of the increasing prevalence of known predisposing conditions. Based on 38-year follow-up data from the Framingham Study, men had a 1.5-fold greater risk of developing AF than women after adjustment for age and predisposing conditions. Of the cardiovascular risk factors, only hypertension and diabetes were significant independent predictors of AF, adjusting for age and other predisposing conditions. Cigarette smoking was a significant risk factor in women adjusting only for age (OR = 1.4), but was just short of significance on adjustment for other risk factors. Neither obesity nor alcohol intake was associated with AF incidence in either sex. For men and women, respectively, diabetes conferred a 1.4- and 1.6-fold risk, and hypertension a 1.5- and 1.4-fold risk, after adjusting for other associated conditions. Because of its high prevalence in the population, hypertension was responsible for more AF in the population (14%) than any other risk factor. Intrinsic overt cardiac conditions imposed a substantially higher risk. Adjusting for other relevant conditions, heart failure was associated with a 4.5- and 5.9-fold risk, and valvular heart disease a 1.8- and 3.4-fold risk for AF in men and women, respectively. Myocardial infarction significantly increased the risk factor-adjusted likelihood of AF by 40% in men only. Echocardiographic predictors of nonrheumatic AF include left atrial enlargement (39%/ increase in risk per 5-mm increment), left ventricular fractional shortening (34% per 5% decrement), and left ventricular wall thickness (28% per 4-mm increment). These echocardiographic features offer prognostic information for AF beyond the traditional clinical risk factors. Electrocardiographic left ventricular hypertrophy increased risk of AF 3-4-fold after adjusting only for age, but this risk ratio is decreased to 1.4 after adjustment for the other associated conditions. The chief hazard of AF is stroke, the risk of which is increased 4-5-fold. Because of its high prevalence in advanced age, AF assumes great importance as a risk factor for stroke and by the ninth decade becomes a dominant factor. The attributable risk for stroke associated with AF increases steeply from 1.5% at age 50-59 years to 23.5% at age 80-89 years. AF is associated with a doubling of mortality in both sexes, which is decreased to 1.5-1.9-fold after adjusting for associated cardiovascular conditions. Decreased survival associated with AF occurs across a wide range of ages.

Impact of atrial fibrillation on the risk of death: the Framingham Heart Study

BACKGROUND

Atrial fibrillation (AF) causes substantial morbidity. It is uncertain whether AF is associated with excess mortality independent of associated cardiac conditions and risk factors.

METHODS AND RESULTS

We examined the mortality of subjects 55 to 94 years of age who developed AF during 40 years of follow-up of the original Framingham Heart Study cohort. Of the original 5209 subjects, 296 men and 325 women (mean ages, 74 and 76 years, respectively) developed AF and met eligibility criteria. By pooled logistic regression, after adjustment for age, hypertension, smoking, diabetes, left ventricular hypertrophy, myocardial infarction, congestive heart failure, valvular heart disease, and stroke or transient ischemic attack, AF was associated with an OR for death of 1.5 (95% CI, 1.2 to 1.8) in men and 1.9 (95% CI, 1.5 to 2.2) in women. The risk of mortality conferred by AF did not significantly vary by age. However, there was a significant AF-sex interaction: AF diminished the female advantage in survival. In secondary multivariate analyses, in subjects free of valvular heart disease and preexisting cardiovascular disease, AF remained significantly associated with excess mortality, with about a doubling of mortality in both sexes.

CONCLUSIONS

In subjects from the original cohort of the Framingham Heart Study, AF was associated with a 1.5- to 1.9-fold mortality risk after adjustment for the preexisting cardiovascular conditions with which AF was related. The decreased survival seen with AF was present in men and women and across a wide range of ages.

The medical management of atrial fibrillation

Atrial fibrillation is an extremely common arrhythmia that is associated with significant sequelae. Certain aspects of therapy, such as anticoagulation, are studied in well-constructed randomized trials. Other therapy, such as the maintenance of sinus rhythm with antiarrhythmic agents, is supported by limited evidence. This article reviews the epidemiology and medical treatment of this arrhythmia, addressing anticoagulation, ventricular rate control, and restoration and maintenance of sinus rhythm. Randomized trials in progress that attempt to answer important questions in the management of atrial fibrillation are also discussed.

Frequency and prognosis of stroke/TIA among 4808 survivors of acute myocardial infarction. The SPRINT Study Group

BACKGROUND AND PURPOSE

Stroke complicating acute myocardial infarction is associated with substantial morbidity and mortality. The purpose of this study was to assess the incidence, predictors, and impact on mortality of stroke/transient ischemic attacks occurring after hospital discharge in a large unselected population of acute myocardial infarction survivors.

METHODS

During a secondary prevention study with nifedipine (SPRINT), demographic, anamnestic, and clinical data were collected for 5839 consecutive acute myocardial infarction patients admitted to 13 coronary care units in Israel. Hospital survivors (n = 4808) were followed for a year after their discharge. Mortality was assessed for a mean follow-up of 5.5 years (range, 4.5 to 7 years).

RESULTS

One percent (48/4808) of hospital survivors from acute myocardial infarction experienced a stroke/transient ischemic attack in the year after acute myocardial infarction. Thirty-one percent (15 of 48) of events occurred in the first month after hospital discharge. Incidence was higher among older patients (> 70 years; 1.9%), those with anterior site of myocardial infarction (1.35%), a previous history of myocardial infarction (1.8%), hypertension (1.4%), stroke in the past (4.1%), and chronic atrial fibrillation (9%). Multivariate analysis identified the following as independent predictors of stroke/transient ischemic attacks occurring in the year after hospital discharge: chronic atrial fibrillation, older age, history of previous myocardial infarction, anterior myocardial infarction site, serum glutamic oxaloacetic transaminase levels more than four times above upper normal limits, and stroke in the past. The age-adjusted 1-year and long-term mortality rates (4.5 to 7 years; mean, 5.5 years) were significantly higher in patients with (31% and 62%) than in those without stroke/transient ischemic attacks (9% and 31%, respectively; P < .01).

CONCLUSIONS

Stroke/transient ischemic attack is a relatively rare (1%) complication in the year after hospital discharge from acute myocardial infarction, though more frequent in the first month. Chronic atrial fibrillation, older age, anterior myocardial infarction site, serum glutamic oxaloacetic transaminase levels more than four times above upper normal limits, past myocardial infarction, and stroke identify high-risk patients. Patients suffering from subsequent stroke/transient ischemic attacks experienced higher mortality than counterparts who remained free from this complication.