Clinical and echocardiographic markers of mortality risk in patients with atrial fibrillation

Predictive indicators in peripheral blood and left atrium blood for left atrial spontaneous echo contrast in atrial fibrillation patients

OBJECTIVES

The purpose of this study was to demonstrate the discriminating predictive indicators in peripheral blood and left atrium blood for predicting the risk of left atrial spontaneous echo contrast (LASEC) in atrial fibrillation patients underwent catheter ablation.

METHODS

A total of 108 consecutive AF patients treated with radiofrequency ablation between July 2022 and July 2023 were enrolled and divided into two groups based on preprocedural transesophageal echocardiography: the non LASEC group (n = 71) and the LASEC group (n = 37). Circulating platelet and endothelial- derived MPs (PMPs and EMPs) in peripheral blood and left atrial blood were detected. Plasma soluble P-selectin (sP-selectin) and von Willebrand factor (vWF) were observed. Diagnostic efficiency was measured using receiver operating characteristic (ROC) curve.

RESULTS

Peripheral sP-selectin, vWF and EMPs expressions elevated in all subjects when compared to those in left atrium blood. Levels of sP-selectin and vWF were significantly higher in peripheral blood of LASEC group than those of non LASEC group (p = 0.0018,p = 0.0271). Significant accumulations of peripheral PMPs and EMPs were documented in LASEC group by comparison with non LASEC group (p = 0.0395,p = 0.018). The area under curve(AUC) of combined PMPs and sP-selectin in predicting LASEC was 0.769 (95%CI: 0.678-0.845, sensitivity: 86.49%, specificity: 59.15%), significantly larger than PMPs or sP-selectin alone.

CONCLUSIONS

Expressions of PMPs, sP-selectin, EMPs and vWF Increased in NVAF patients with LASEC and that might be potential biomarkers for LASEC prediction.

The CHA2DS2-VASC Score Predicts Mortality in Patients Undergoing Coronary Angiography

BACKGROUND

The CHA2DS2-VASC score is used to predict the risk of thromboembolic complications in patients with atrial fibrillation (AF). We hypothesized that the CHA2DS2-VASC score can be used to predict mortality in patients undergoing coronary angiography.

METHODS AND RESULTS

This was a prospective study of 990 patients undergoing coronary angiography. The median follow-up was 2294 days. The patients were categorized into two groups according to their CHA2DS2-VASC score: group I had scores <4 and group II had scores ≥4 (527 (53.2%) and 463 (46.8%), respectively). A Kaplan-Meier analysis demonstrated a significant association between the CHA2DS2-VASC score and mortality (69/527 (13.1%) vs. 179/463 (38.7%) for group I vs. group II, respectively, p < 0.0001). The association remained significant in patients with and without AF, reduced and preserved LVEF, normal and reduced kidney function, and with and without ACS (p < 0.009 to p < 0.0001 for all). In the Cox regression model, which combined the CHA2DS2-VASC score, the presence of AF, LVEF, anemia, and renal insufficiency, an elevated CHA2DS2-VASC score of ≥4 was independently associated with higher mortality (HR 2.12, CI 1.29-3.25, p = 0.001).

CONCLUSIONS

The CHA2DS2VASC score is a simple and reliable mortality predictor in patients undergoing coronary angiography and should be used for the initial screening for such patients.

CHA2DS2-VASc score, P-wave indexes, and echocardiographic parameters in sinus rhythm patients without valvular heart disease

OBJECTIVE

The aim of this study was to evaluate the correlation between P-wave indexes, echocardiographic parameters, and CHA2DS2-VASc score in patients without atrial fibrillation and valvular disease.

METHODS

This retrospective cross-sectional study included patients of a tertiary hospital with no history of atrial fibrillation, atrial flutter, or valve disease and collected data from June 2021 to May 2022. The exclusion criteria were as follows: unavailable medical records, pacemaker carriers, absence of echocardiogram report, or uninterpretable ECG. Clinical, electrocardiographic [i.e., P-wave duration, amplitude, dispersion, variability, maximum, minimum, and P-wave voltage in lead I, Morris index, PR interval, P/PR ratio, and P-wave peak time], and echocardiographic data [i.e., left atrium and left ventricle size, left ventricle ejection fraction, left ventricle mass, and left ventricle indexed mass] from 272 patients were analyzed.

RESULTS

PR interval (RHO=0.13, p=0.032), left atrium (RHO=0.301, p<0.001) and left ventricle diameter (RHO=0.197, p=0.001), left ventricle mass (RHO=0.261, p<0.001), and left ventricle indexed mass (RHO=0.340, p<0.001) were positively associated with CHA2DS2-VASc score, whereas P-wave amplitude (RHO=-0.141, p=0.02), P-wave voltage in lead I (RHO=-0.191, p=0.002), and left ventricle ejection fraction (RHO=-0.344, p<0.001) were negatively associated with the same score. The presence of the Morris index was associated with high CHA2DS2-VASc (p=0.022).

CONCLUSION

Prolonged PR interval, Morris index, increased left atrium diameter, left ventricle diameter, left ventricle mass, and left ventricle indexed mass values as well as lower P-wave amplitude, P-wave voltage in lead I, and left ventricle ejection fraction values were correlated with higher CHA2DS2-VASc scores.

Angiographic profile and outcomes in persistent non-valvular atrial fibrillation: A study from tertiary care center in North India

Background

The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients.

Methods

The study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded.

Results

A total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005).

Conclusions

Majority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.

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Coexistent coronary artery disease is common in symptomatic non-valvular atrial fibrillation (AF).

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Revascularization was needed in 35.7% of patients.

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Lower ejection fraction, haemoglobin and serum albumin levels correlated with worse outcomes.

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Coronary slow-flow is highly prevalent in AF patients (42%) and has a bearing of future events.

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Hospitalizations for fast ventricular rate were significantly increased in those having slow flow.

Glomerular filtration rate: A prognostic marker in atrial fibrillation-A subanalysis of the AntiThrombotic Agents Atrial Fibrillation

OBJECTIVE

An increased cardiovascular mortality and morbidity has been widely reported in patients with atrial fibrillation (AF). In this study, a subanalysis of the AntiThrombotic Agents Atrial Fibrillation (ATA-AF) is performed with the aim to evaluate estimated glomerular filtration rate (eGFR) as an independent prognostic marker of cardiovascular mortality and morbidity in patients with AF.

METHODS AND RESULTS

The ATA-AF study enrolled 7148 patients with AF, in 360 Italian centers. The eGFR was calculated from data reported in patient notes or hospital database. This post-hoc analysis included 1097 AF patients with eGFR data available and 1-year clinical follow-up. The endpoint was assessed as cardiovascular mortality and/or hospital admission for cardiovascular causes at follow-up. Patients were also divided in two groups according to the eGFR (<60 and ≥60 mL/min/1.73 m² ). The Kaplan-Meyer curve for the mentioned endpoint showed a higher endpoint incidence in the group of patient with eGFR below 60 mL/min/1.73 m² (P < 0.001). Using multivariate analysis (Cox regression), a trend toward a higher rate of occurrence of the primary endpoint was observed for eGFR below 60 mL/min/1.73 m² without reaching the conventional level of statistical significance (hazard ratio [HR] 1.40; 95% confidence interval [CI] 0.99-1.99; P = 0.0572). When eGFR was included in the analysis as continuous variable a significant correlation was observed with the combined endpoint at the Cox regression (HR 0.99, 95% CI 0.98-0.99, P = 0.04).

CONCLUSION

The result of this post-hoc analysis indicates that an impaired eGFR is independently associated with worse prognosis among patients with AF.

Ischaemic cardiovascular mortality in patients with non-valvular atrial fibrillation according to CHADS2 score

The CHADS2 score predicts the risk of ischaemic stroke in patients with non-valvular atrial fibrillation (NVAF). Most components of the CHADS2 score are also risk factors of atherosclerosis, and clustering of these risk factors is associated with increased risk of cardiovascular disease, including ischaemic heart disease. The aim of this study was to investigate whether the CHADS2 score and CHA2DS2-VASc score are predictive of fatal ischaemic heart disease as well as fatal ischaemic stroke. Among 5,268 stroke patients admitted between August 1994 and December 2008, 770 stroke patients with NVAF were enroled in this study. The relationship between CHADS2 score or CHA2DS2-VASc score and the fatal ischaemic events was examined using a Cox regression model. During the follow-up period of 1156.0 ± 1205.0 days (median 729.5, in-terquartile range 179.0 – 1751.0), 321 patients died (41.7%). The CHADS2 score or CHA2DS2-VASc score was positively correlated with fatal ischaemic heart disease as well as with fatal ischaemic stroke. After adjustment for all potential confounders, the occurrence of fatal ischaemic heart disease was independently associated with CHADS2 score or CHA2DS2-VASc score, and previous history of ischaemic heart disease. The CHADS2 and CHA2DS2-VASc scores provide valuable information for identifying high-risk individuals for fatal ischaemic heart and brain diseases among stroke patients with NVAF.

The Prognostic Significance of Cardiac Structure and Function in Atrial Fibrillation: The ENGAGE AF-TIMI 48 Echocardiographic Substudy

BACKGROUND

Atrial fibrillation (AF) is associated with increased risk for thromboembolism and death; however, the relationships between cardiac structure and function and adverse outcomes among individuals with AF are incompletely understood.

METHODS

The Effective Anticoagulation with Factor Xa Next Generation in AF-Thrombolysis in Myocardial Infarction 48 study tested the once-daily oral factor Xa inhibitor edoxaban in comparison with warfarin for the prevention of stroke (ischemic or hemorrhagic) or systemic embolism in 21,105 subjects with nonvalvular AF and increased risk for thromboembolic events (CHADS2 score ≥ 2). In a prospective substudy of 971 subjects who underwent transthoracic echocardiography at baseline, Cox proportional hazards models were used to evaluate associations between cardiac structure and function and the risks for death and thromboembolism (ischemic stroke, transient ischemic attack, or systemic embolism).

RESULTS

Over a median follow-up period of 2.5 years, 89 deaths (9.2%) and 48 incident thromboembolic events (4.9%) occurred in 971 subjects. In models adjusted for CHADS2 score, aspirin use, and randomized treatment, larger left ventricular (LV) end-diastolic volume index (hazard ratio per 1 SD [12.9 mL/m(2)], 1.49; 95% CI, 1.16-1.91) and higher LV filling pressures measured by E/e' ratio (hazard ratio per 1 SD [4.6], 1.32; 95% CI, 1.08-1.61) were independently associated with increased risks for death. E/e' ratio > 13 significantly improved the prediction of death beyond clinical factors alone. No features of cardiac structure and function were independently associated with thromboembolism in this population. Findings were similar when adjusted for CHA2DS2-VASc score in place of CHADS2 score.

CONCLUSIONS

In a contemporary population of patients with AF at increased risk for thromboembolic events, larger LV size and higher filling pressures were significantly associated with increased risk for death, but neither left atrial nor LV measures were associated with thromboembolic risk. LV size and filling pressures may help identify patients with AF at increased risk for death.

How does Chronic Atrial Fibrillation Influence Mortality in the Modern Treatment Era?

Atrial fibrillation (AF) continues to impose a significant burden upon healthcare resources. A sustained increase in the ageing population and better survival from conditions such as ischaemic heart disease have ensured that both the incidence and prevalence of AF continue to increase significantly. AF can lead to complications such as embolism and heart failure and these acting in concert with its associated co-morbidities portend increased mortality risk. Whilst some studies suggest that the mortality risk from AF is due to the "bad company it keeps" i.e. the associated co-morbidities rather than AF itself; undoubtedly some of the mortality is also due to the side-effects of various therapeutic strategies (anti-arrhythmic drugs, bleeding side-effects due to anti-coagulants or invasive procedures). Despite several treatment advances including newer anti-arrhythmic drugs and developments in catheter ablation, anti-coagulation remains the only effective means to reduce the mortality due to AF. Warfarin has been used as the oral anticoagulant in the treatment of AF for many years but suffers from disadvantages such as unpredictable INR levels, bleeding risks and need for haematological monitoring. This has therefore spurred a renewed interest in research and clinical studies directed towards developing safer and more efficacious anti-coagulants. We shall review in this article the epidemiological features of AF-related mortality from several studies as well as the cardiovascular and non-cardiac mortality mechanisms. We shall also elucidate why a rhythm control strategy has appeared to be counter-productive and attempt to predict the likely future impact of novel anti-coagulants upon mortality reduction in AF.

Usefulness of a low CHADS2 or CHA2DS2-VASc score to predict normal diagnostic testing in emergency department patients with an acute exacerbation of previously diagnosed atrial fibrillation

International guidelines do not specify what testing should be performed during emergency department (ED) evaluations for patients presenting with an exacerbation of previously diagnosed atrial fibrillation (AF). We hypothesized that low CHADS2 and CHA2DS2-VASc scores predict normal routine diagnostic testing in these patients. We conducted an analysis within a prospective observational cohort study at a university-affiliated hospital. We included patients with previously diagnosed AF and who presented to the ED primarily for an AF-related complaint. Logistic regression was used to analyze the association between CHADS2 and CHA2DS2-VASc scores and abnormal results for blood counts, electrolytes, cardiac markers, thyroid function, and chest x-rays. We included 216 patients in this analysis. The odds ratios (95% confidence interval) for each point increase in CHADS2 for abnormal blood counts, electrolytes, troponin I, brain natriuretic peptide, thyroid function, and chest x-ray were 1.28 (0.99 to 1.65), 1.48 (1.19 to 1.84), 1.42 (1.10 to 1.82), 1.66 (1.15 to 2.41), 0.95 (0.70 to 1.29), and 1.17 (0.94 to 1.44), respectively. The corresponding odds ratios (95% confidence interval) for each point increase in CHA2DS2-VASc were 1.17 (0.96 to 1.42), 1.27 (1.09 to 1.49), 1.30 (1.07 to 1.57), 1.57 (1.18 to 2.10), 0.98 (0.79 to 1.22), and 1.14 (0.97 to 1.33), respectively. Among ED patients with established AF who underwent evaluation for acutely symptomatic AF, nearly 3/4 of routine diagnostic tests return to normal. In conclusion, patients with CHADS2 or CHA2DS2-VASc score of 0 have the lowest likelihood of abnormal studies and may represent an easily identifiable group of patients who need fewer ED tests.

The association between asymptomatic coronary artery disease and CHADS2 and CHA2 DS2 -VASc scores in patients with stroke

BACKGROUND AND PURPOSE

CHADS2 and CHA2 DS2 -VASc scores are measurement tools that stratify thromboembolic risk in patients with non-valvular atrial fibrillation, and are predictive of cerebral atherosclerosis, fatal stroke and ischaemic heart disease. Patients with higher CHADS2 and CHA2 DS2 -VASc scores are more likely to have had an akinetic/hypokinetic left ventricular segment or a recent myocardial infarction, all of which are associated with coronary artery disease (CAD). Most of the CHADS2 score components are also risk factors for atherosclerosis. Thus, CHADS2 and CHA2 DS2 -VASc scores may be predictive of CAD.

METHODS

In all, 1733 consecutive patients with acute ischaemic stroke who underwent multi-slice computed tomography coronary angiography were enrolled. The association of CHADS2 and CHA2 DS2 -VASc scores with the presence and severity of CAD was investigated.

RESULTS

Of the 1733 patients, 1220 patients (70.4%) had any degree of CAD and 576 (33.3%) had significant CAD (≥ 50% stenosis in at least one coronary artery). As the CHADS2 and CHA2 DS2 -VASc scores increased, the presence of CAD also increased (P < 0.001). The severity of CAD was correlated with CHADS2 score (Spearman coefficient 0.229, P < 0.001) and CHA2 DS2 -VASc score (Spearman coefficient 0.261, P < 0.001). In multivariate analysis, after adjusting for confounding factors, CHADS2 and CHA2 DS2 -VASc scores ≥2 were independently associated with CAD. The CHA2 DS2 -VASc score was a better predictor of the presence of CAD than the CHADS2 score on area under the curve analysis.

CONCLUSION

CHADS2 and CHA2 DS2 -VASc scores were predictive of the presence and severity of CAD in patients with stroke. When a patient has high CHADS2 or CHA2 DS2 -VASc scores, physicians should consider coronary artery evaluation.

Evaluation of the CHADS2 risk score on short- and long-term all-cause and cardiovascular mortality after syncope

BACKGROUND

Syncope risk stratification is difficult and has not been implemented clinically.

HYPOTHESIS

The CHADS2 score can be applied as a risk stratification tool for predicting mortality after an episode of syncope.

METHODS

All patients discharged from emergency departments with a first-time diagnosis of syncope from 2001 to 2009 where identified from nationwide registers in Denmark and matched on sex and age with a control population. Risk of all-cause or cardiovascular death was analyzed by multivariable Cox models.

RESULTS

A total of 37,705 patients were included. There were a total of 7761 deaths (21%), of which 52% were cardiovascular vs 27 862 (15%) deaths in the control population. The risk of cardiovascular death was significantly increased with increasing CHADS2 score (CHADS2 score: 1-2, hazard ratio [HR]: 9.11, 95% confidence interval [CI]: 8.25-10.07; CHADS2 score: 3-4, HR: 17.32, 95% CI: 15.42-19.47; CHADS2 score: 5-6, HR: 26.66, 95% CI: 21.40-33.21) relative to CHADS2 score of 0. A CHADS2 score of 0 was associated overall with very low event rates (15.1 deaths per 1000 person-years) but was associated with increased relative risk in the syncope population compared to controls. Syncope predicted 1-week, 1-year, and long-term mortality across CHADS2 scores compared to controls but did not reach significance in CHADS2 scores of 5 to 6.

CONCLUSIONS

Increasing CHADS2 score significantly predicts mortality in patients discharged with a diagnosis of syncope, and a CHADS2 score of 0 was associated with a very low absolute mortality. Compared to controls, syncope was associated with increased short- and long-term mortality, particularly in the lower CHADS2 scores.

Role of CHADS2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy)

The CHADS(2) (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke or transient ischemic attack [2 points]) scoring scheme has been found to be a good predictor of stroke risk in patients with nonvalvular atrial fibrillation (AF). However, the value of the CHADS(2) scoring system in the risk stratification of patients with AF who undergo direct-current cardioversion has not yet been specifically investigated. In this study, a subgroup of 541 patients from the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) study who had AF for >48 hours and planned to undergo transesophageal echocardiography before direct-current cardioversion were enrolled. Each patient had a CHADS(2) score calculated. Of the patients with CHADS(2) scores of 0, 14 (10%) were found to have left atrial appendage thrombi on transesophageal echocardiography. After 6 months of follow up, patients with CHADS(2) scores of 3 to 6 showed a significantly higher mortality rate in comparison with patients with lower CHADS(2) scores (4.3% vs 0.5%, p = 0.004), despite their similar prevalence of left atrial appendage thrombus and stroke (thrombus: 13.4% vs 11.6%, p = 0.60; stroke: 0% vs 0.3%, p = 0.70). In conclusion, the CHADS(2) scoring system may be useful for predicting short-term mortality risk in patients with AF receiving elective direct-current cardioversion. However, in the preprocedural risk assessment of these patients, the CHADS(2) scoring system is not reliable in predicting risk for left atrial appendage thrombus formation, especially in patients with low CHADS(2) scores.

Usefulness of high-sensitivity C-reactive protein to predict mortality in patients with atrial fibrillation (from the Atherosclerosis Risk In Communities [ARIC] Study)

High-sensitivity C-reactive protein (hs-CRP) is a marker for the risk of cardiovascular and overall mortality. However, information about the association between hs-CRP and mortality in patients with atrial fibrillation is scarce. A total of 293 participants of the Atherosclerosis Risk In Communities study with a history of AF and hs-CRP levels available were studied. During a median follow-up of 9.4 years, 134 participants died (46%). The hazard ratio of all-cause mortality associated with the highest versus the lowest tertile of hs-CRP was 2.52 (95% confidence interval 1.49 to 4.25) after adjusting for age, gender, history of cardiovascular diseases, and cardiovascular risk factors. A similar trend was observed for cardiovascular mortality (57 events; hazard ratio 1.90, 95% confidence interval 0.81 to 4.45). The Congestive heart failure, Hypertension, Age >75 years, Diabetes, and previous Stroke or transient ischemic attack (CHADS2) score was also associated with all-cause and cardiovascular mortality, with an adjusted hazard ratio of 3.39 (95% confidence interval 1.91 to 6.01) and 8.71 (95% confidence interval 2.98 to 25.47), respectively, comparing those with a CHADS2 score >2 versus a CHADS2 score of 0. Adding hs-CRP to a predictive model including the CHADS2 score was associated with an improvement of the C-statistic for total mortality (from 0.627 to 0.677) and for cardiovascular mortality (from 0.700 to 0.718). In conclusion, high levels of hs-CRP constitute an independent marker for the risk of mortality in patients with atrial fibrillation.

Outcomes and safety of antithrombotic treatment in patients aged 80 years or older with nonvalvular atrial fibrillation

Our aim was to evaluate the effectiveness of oral anticoagulation (OAC) in patients aged ≥80 years with nonvalvular atrial fibrillation in daily clinical practice. From February 1, 2000 to June 30, 2009, we enrolled all patients aged ≥80 years with nonvalvular atrial fibrillation attended at 2 outpatient cardiology clinics of a tertiary care university hospital. The patients received antithrombotic treatment according to the recommendations from scientific societies and were prospectively followed, with major events (i.e., all-cause death, stroke, transient ischemic attack, peripheral embolism, severe bleeding) analyzed according to the treatment group (OAC vs no OAC). Of 269 patients included in the present study (87 men, mean age 83 ± 3 years), 164 received OAC (61%). After 2.8 ± 1.9 years of follow-up, the raw rates (per 100 patient-years) of embolic events (1.52% vs 8.30%, p <0.0001) and mortality (6.67% vs 10.94%, p = 0.04) were lower for patients receiving OAC, with a nonsignificant greater rate of severe bleeding (3.03% vs 1.25%, p = 0.14). The probability of survival free of major embolic or hemorrhagic events at the mean follow-up was greater for patients receiving OAC (82.27% vs 66.10%, p = 0.004). After adjustment for age, gender, coronary heart disease, and embolic risk, evaluated using the CHADS(2) score (congestive heart failure, 1 point; hypertension [blood pressure consistently >140/90 mm Hg or hypertension medication], 1 point; age ≥75 years, 1 point; diabetes mellitus, 1 point; previous stroke or transient ischemic attack, 2 points), only OAC was an independent predictor of embolic events (hazard ratio 0.17, 95% confidence interval 0.07 to 0.41, p <0.001). The CHADS(2) score (hazard ratio 1.32, 95% confidence interval 1.01 to 1.73, p = 0.04) and OAC (hazard ratio 0.52, 95% confidence interval 0.31 to 0.88, p = 0.01) were independent predictors of mortality. In conclusion, OAC according to the scientific societies' recommendations is effective and safe in daily clinical practice, even in patients aged ≥80 years.

Global left atrial strain correlates with CHADS2 risk score in patients with atrial fibrillation

BACKGROUND

The aim of this cross-sectional study was to explore the association between echocardiographic parameters and CHADS2 score in patients with nonvalvular atrial fibrillation (AF).

METHODS

Seventy-seven subjects (36 patients with AF, 41 control subjects) underwent standard two-dimensional, Doppler, and speckle-tracking echocardiography to compute regional and global left atrial (LA) strain.

RESULTS

Global longitudinal LA strain was reduced in patients with AF compared with controls (P < .001) and was a predictor of high risk for thromboembolism (CHADS2 score ≥ 2; odds ratio, 0.86; P = .02). LA strain indexes showed good interobserver and intraobserver variability. In sequential Cox models, the prediction of hospitalization and/or death was improved by addition of global LA strain and indexed LA volume to CHADS2 score (P = .003).

CONCLUSIONS

LA strain is a reproducible marker of dynamic LA function and a predictor of stroke risk and cardiovascular outcomes in patients with AF.

Chronic kidney disease and CHADS(2) score independently predict cardiovascular events and mortality in patients with nonvalvular atrial fibrillation

Chronic kidney disease is a risk factor for cardiovascular events, but how it relates to the prognosis associated with clinical risk factors for thromboembolism in patients with nonvalvular atrial fibrillation (AF) is not well known. Estimated glomerular filtration rate (eGFR), score for congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke/transient ischemic attack (CHADS(2)), and clinical outcomes of cardiovascular events were determined in 387 patients with nonvalvular AF (mean age 66 years, 289 men, mean follow-up 5.6 ± 3.2 years). Decreased eGFR (<60 ml/min/1.73 m(2)) combined with CHADS(2) score ≥2 was associated with higher all-cause (12.9% vs 1.4% per year, hazard ratio [HR] 6.9, p <0.001) and cardiovascular (6.5% vs 0.2% per year, HR 29.7, p <0.001) mortalities compared to preserved eGFR (≥60 ml/min/1.73 m(2)) combined with CHADS(2) score <2. This was also true for rates of cardiac events (cardiac death, nonfatal myocardial infarction, or hospitalization for worsening of heart failure, 10.4% vs 1.3% per year, HR 8.9, p <0.001), ischemic stroke (3.6% vs 0.2% per year, HR 11.0, p <0.001), and cardiovascular events (cardiac events and ischemic stroke, 13.6% vs 1.5% per year, HR 8.3, p <0.001). On multivariate analysis, CHADS(2) score ≥2, decreased eGFR, and male gender independently predicted all-cause mortality. In conclusion, combined eGFR and CHADS(2) score could be an independent powerful predictor of cardiovascular events and mortality in patients with nonvalvular AF. Long-term mortality, cardiac events, and stroke risk were >8 times higher when decreased eGFR (<60 ml/min/1.73 m(2)) was present with higher CHADS(2) score (≥2).

Association of warfarin use with CHADS(2) score in 441 patients with nonvalvular atrial fibrillation and no contraindications to warfarin

The authors investigated the use of warfarin at hospital discharge in 557 consecutive patients, mean age 76 years, with nonvalvular atrial fibrillation (AF) at a university hospital. Of 557 patients with AF, 116 (21%) had contraindications to warfarin. Of patients eligible for warfarin, warfarin was used in 8 of 30 patients (27%) with a CHADS(2) score of 0, in 82 of 132 patients (62%) with a CHADS(2) score of 1, in 121 of 175 patients (70%) with a CHADS(2) score of 2, in 72 of 77 patients (94%) with a CHADS(2) score of 3, and in 27 of 27 patients (100%) with a CHADS(2) score of 4 to 6. Warfarin was used in 123 of 168 patients (73%) older than 75 years, in 74 of 79 patients (94%) aged 65 to 75 years, and in 23 of 32 patients (72%) younger than 65 years. Warfarin was used in 80 of 116 patients (69%) with a glomerular filtration rate < 60 mL/min/1.73 m(2) and in 140 of 163 patients (86%) with a glomerular filtration rate ≥ 60 mL/min/1.73 m(2) . There was no significant difference in use of warfarin between men and women and between whites and nonwhites.

A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation

STUDY OBJECTIVE

Atrial fibrillation affects more than 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic atrial fibrillation and admit more than 65%. Our aim is to assess whether data available in the ED management of symptomatic atrial fibrillation can estimate a patient's risk of experiencing a 30-day adverse event.

METHODS

We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic atrial fibrillation between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication, or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated with 300 bootstrap replications.

RESULTS

During the 3-year study period, 914 patients accounted for 1,228 ED visits. Eighty patients were excluded for non-atrial-fibrillation-related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least 1 of the 30-day adverse events. Increasing age (odds ratio [OR] 1.20 per decade; 95% confidence interval [CI] 1.06 to 1.36 per decade), complaint of dyspnea (OR 1.57; 95% CI 1.12 to 2.20), smokers (OR 2.35; 95% CI 1.47 to 3.76), inadequate ventricular rate control (OR 1.58; 95% CI 1.13 to 2.21), and patients receiving β-blockers (OR 1.44; 95% CI 1.02 to 2.04) were independently associated with higher risk for adverse events. C-index was 0.67.

CONCLUSION

In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and β-blocker treatment were associated with an increased risk of a 30-day adverse event.

Body mass index and risk of left atrial thrombus in patients with atrial fibrillation

This study sought to assess the impact of body mass index (BMI) on the risk of left atrial (LA)/left atrial appendage (LAA) thrombus in patients with atrial fibrillation (AF) before catheter ablation. From January 2007 to March 2008, 433 consecutive patients with nonvalvular AF were enrolled. Patients with valvular heart disease, deep vein thrombosis, or pulmonary embolism were excluded. All patients underwent transesophageal echocardiography. Twenty-six of 433 patients (6.0%) had LA/LAA thrombus and the patients with thrombus had a significantly higher BMI (27.9 +/- 3.1 vs 26.0 +/- 3.3 kg/m(2), p = 0.005). The area under the receiver operating characteristic curve of BMI predicting thrombus was 0.662. With a cut-off point of 27.0 kg/m(2), the sensitivity and specificity of BMI for the diagnosis of thrombus were 69.2% and 83.1%, respectively. The incidence of LA/LAA thrombus was 10.6% in patients with BMI > or =27.0 kg/m(2) versus only 3.0% for patients with BMI <27.0 kg/m(2) (p = 0.001). In multivariable analysis, BMI > or =27.0 kg/m(2) (odds ratio 4.02, 95% confidence interval 1.19 to 13.55, p = 0.025), Cardiac Failure, Hypertension, Age, Diabetes, Stroke Doubled score > or =2, and nonparoxysmal AF were independent risk factors of LA/LAA thrombus. In conclusion, BMI > or =27.0 kg/m(2) is an independent risk factor of LA/LAA thrombus in patients with AF.

Atrial Fibrillation: The New Epidemic of the Ageing World

The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases. AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily.

Etiology, pathophysiology, and treatment of atrial fibrillation: part 1

Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, verapamil, or diltiazem may be given to immediately slow a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nonpharmacologic therapies should be used in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. This is part 1 of a 2-part review of the etiology, pathophysiology, and treatment of atrial fibrillation. The second part will be published in the subsequent issue of Cardiology in Review.