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Cabulong AP, Tang JJ, Teraoka JT, Dewland TA, Marcus GM. Systemic infarcts among patients with atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00245-5. [PMID: 38461923 DOI: 10.1016/j.hrthm.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The epidemiology of atrial fibrillation (AF)-associated thromboembolic complications outside of ischemic strokes has not been thoroughly elucidated. OBJECTIVE The aim of this study was to describe the epidemiology of AF-associated systemic infarcts and relevant interactions by sex and race/ethnicity. METHODS Using the Office of Statewide Health Planning and Development, we performed a longitudinal analysis of patients aged ≥18 years who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2015. We determined the distribution of infarct locations and risks of systemic infarcts for patients with AF. Interaction analyses by sex and race/ethnicity were conducted. RESULTS Of 1,321,694 patients with AF, the average annual rate of systemic infarct was 2.1% ± 0.18% compared with 0.56% ± 0.06% in the 22,944,488 patients without AF. The increased frequency of these infarcts was observed for every body area investigated. After adjustment for potential confounders and mediators, patients with AF experienced a 45% increased risk of a systemic infarct (hazard ratio, 1.45; 95% confidence interval, 1.44-1.47; P < .001). Women, Asians, Blacks, and Hispanics each exhibited a statistically significant heightened relative risk of systemic infarcts in the presence of AF. CONCLUSION AF increases the risk of infarcts throughout the body. Susceptibility to these systemic infarcts varies by sex and race/ethnicity in patterns similar to differential risks for stroke. The presence of a systemic infarct in the absence of a clear cause should raise suspicion for AF, and the potential benefits of AF prevention and anticoagulation should be considered beyond only infarcts to the brain.
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Affiliation(s)
- Alexander P Cabulong
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California
| | - Janet J Tang
- Division of Cardiology, University of California, San Francisco, California
| | - Justin T Teraoka
- Division of Cardiology, University of California, San Francisco, California
| | - Thomas A Dewland
- Division of Cardiology, University of California, San Francisco, California
| | - Gregory M Marcus
- Division of Cardiology, University of California, San Francisco, California.
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Li XL, Adi D, Wu Y, Aizezi A, Li YP, Kerem M, Wei X, Liu F, Ma X, Ma YT. A nomogram to predict ventricular thrombus in dilated cardiomyopathy patients. J Thromb Thrombolysis 2024; 57:29-38. [PMID: 37351822 PMCID: PMC10830674 DOI: 10.1007/s11239-023-02846-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND VT (Ventricular Thrombus) is a serious complication of dilated cardiomyopathy (DCM). Our goal is to develop a nomogram for personalized prediction of incident VT in DCM patients. METHODS 1267 patients (52.87 ± 11.75 years old, 73.8% male) were analyzed retrospectively from January 01, 2015, to December 31, 2020. A nomogram model for VT risk assessment was established using minimum absolute contraction and selection operator (LASSO) and multivariate logistic regression analysis, and its effectiveness was validated by internal guidance. The model was evaluated by the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA). We compared the performance in predicting VT between nomogram and CHA2DS2, CHA2DS2- VASc or ATRIA by AUC, akaike information criterion (AIC), bayesian information criterion (BIC), net reclassification index (NRI), and integrated discrimination index (IDI). RESULTS 89 patients (7.02%) experienced VT. Multivariate logistic regression analysis revealed that age, left ventricular ejection fraction (LVEF), uric acid (UA), N-terminal precursor B-type diuretic peptide (NT-proBNP), and D-dimer (DD) were important independent predictors of VT. The nomogram model correctly separates patients with and without VT, with an optimistic C score of 0.92 (95%CI: 0.90-0.94) and good calibration (Hosmer-Lemeshow χ2 = 11.51, P = 0.12). Our model showed improved prediction of VT compared to CHA2DS2, CHA2DS2-VASc or ATRIA (all P < 0.05). CONCLUSIONS The novel nomogram demonstrated better than presenting scores and showed an improvement in predicting VT in DCM patients.
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Affiliation(s)
- Xiao-Lei Li
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Dilare Adi
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yun Wu
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of General Medicine, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, China
| | - Aibibanmu Aizezi
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yan-Peng Li
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Munawar Kerem
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xian Wei
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Fen Liu
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xiang Ma
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
| | - Yi-Tong Ma
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
- Xinjiang Key Laboratory of Cardiovascular Disease, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
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Coşkun G, Ozde C, Kayapinar O, Aktore G, Ekşi E, Afşin H, Sayın AE. The Relationship of Coronary Thrombus Burden and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Score in Patients With ST-Segment Elevation Myocardial Infarction. Clin Appl Thromb Hemost 2024; 30:10760296241237232. [PMID: 38644774 PMCID: PMC11036931 DOI: 10.1177/10760296241237232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND The anticoagulation and risk factors in atrial fibrillation (ATRIA) score is associated with adverse cardiovascular events. However, its relationship with coronary thrombus burden is unclear. Therefore, we aimed to investigate the relationship between the ATRIA score and thrombus burden in patients with ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI). MATERIALS AND METHODS The study was designed as a prospective cross-sectional observational study. Our study included 319 patients who were prospectively admitted with STEMI between January 2021 and April 2022. Patients were divided into 2 groups with low thrombus burden (LTB) (grade <3) and high thrombus burden (HTB) (grade ≥3). ATRIA score was calculated and recorded for all patients. ATRIA scores of both groups were compared. RESULTS In our study, 58.9% (n = 188) of patients in the LTB group and 41% (n = 131) of patients in the HTB group. The ATRIA risk score (p < .001) was significantly higher in the HTB group. In multivariate logistic regression analysis, ATRIA score, glomerular filtration rate, hypertensıon, abciximab usage, and no-reflow were found to be independent predictors of HTB in STEMI patients undergoing primary PCI. In receiver operating characteristic analysis, ATRIA score >4 had a sensitivity of 66.2% and specificity of 95.2%, and ATRIA score >8 sensitivity of 98% and specificity of 100% predicted HTB. CONCLUSION In this study, we found that thrombus burden may be associated with ATRIA risk score in patients presenting with STEMI.
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Affiliation(s)
| | - Cem Ozde
- Düzce Üniversitesi Tip Fakültesi, Duzce, Turkey
| | | | | | - Ensar Ekşi
- Düzce Üniversitesi Tip Fakültesi, Duzce, Turkey
| | - Hamdi Afşin
- Düzce Üniversitesi Tip Fakültesi, Duzce, Turkey
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Aarnink E, Zabern M, Boersma L, Glikson M. Mechanisms and Prediction of Ischemic Stroke in Atrial Fibrillation Patients. J Clin Med 2023; 12:6491. [PMID: 37892626 PMCID: PMC10607686 DOI: 10.3390/jcm12206491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in adults worldwide and represents an important burden for patients, physicians, and healthcare systems. AF is associated with substantial mortality and morbidity, due to the disease itself and its specific complications, such as the increased risk of stroke and thromboembolic events associated with AF. The temporal relation between AF episodes and stroke is nonetheless incompletely understood. The factors associated with an increased thromboembolic risk remain unclear, as well as the stroke risk stratification. Therefore, in this review, we intend to expose the mechanisms and physiopathology leading to intracardiac thrombus formation and stroke in AF patients, together with the evidence supporting the causal hypothesis. We also expose the risk factors associated with increased risk of stroke, the current different risk stratification tools as well as future prospects for improving this risk stratification.
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Affiliation(s)
- Errol Aarnink
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands
| | - Maxime Zabern
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands
- Department of Cardiology, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
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Fiore G, Gaspardone C, Ingallina G, Rizza V, Melillo F, Stella S, Ancona F, Biondi F, Margonato D, Palmisano A, Esposito A, Agricola E. Accuracy and Reliability of Left Atrial Appendage Morphology Assessment by Three-Dimensional Transesophageal Echocardiographic Glass Rendering Modality: A Comparative Study With Computed Tomography. J Am Soc Echocardiogr 2023; 36:1083-1091. [PMID: 37307939 DOI: 10.1016/j.echo.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Contrast-enhanced computed tomography is the reference-standard imaging technique to assess left atrial appendage (LAA) morphology. The aim of this study was to evaluate the accuracy and reliability of two-dimensional and new three-dimensional (3D) transesophageal echocardiographic rendering modalities in assessing LAA morphology. METHODS Seventy consecutive patients who underwent both computed tomography and transesophageal echocardiography (TEE) were retrospectively enrolled. The traditional LAA morphology classification system (LAAcs; chicken wing, cauliflower, cactus, and windsock) and a new simplified LAAcs based on the LAA bend angle were used for the analysis. LAA morphology was independently assessed by two trained readers using three different modalities: two-dimensional TEE, 3D TEE with multiplanar reconstruction, and a new 3D transesophageal echocardiographic rendering modality with improved transparency (Glass). The new LAAcs and traditional LAAcs were compared in terms of intra- and interrater reliability. RESULTS With the new LAAcs, two-dimensional TEE was fairly accurate in identifying LAA morphology (κ = 0.43, P < .05), with moderate interrater (κ = 0.50, P < .05) and substantial intrarater (κ = 0.65, P < .005) agreement. Three-dimensional TEE showed higher accuracy and reliability: 3D TEE with multiplanar reconstruction had almost perfect accuracy (κ = 0.85, P < .001) and substantial (κ = 0.79, P < .001) interrater reliability, while 3D TEE with Glass had substantial accuracy (κ = 0.70, P < .001) and almost perfect (κ = 0.84, P < .001) interrater reliability. Intrarater agreement was almost perfect for both 3D transesophageal echocardiographic modalities (κ = 0.85, P < .001). Accuracy was considerably lower when the traditional LAAcs was used, with 3D TEE with Glass being the most reliable technique (κ = 0.75, P < .05). The new LAAcs showed higher inter- and intrarater reliability compared with the traditional LAAcs (interrater, κ = 0.85 vs κ = 0.49; intrarater, κ = 0.94 vs κ = 0.68; P < .05). CONCLUSIONS Three-dimensional TEE is an accurate, reliable, and feasible alternative to computed tomography in assessing LAA morphology with the new LAAcs. The new LAAcs shows higher reliability rates than the traditional one.
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Affiliation(s)
- Giorgio Fiore
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Gaspardone
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vincenzo Rizza
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Melillo
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Biondi
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Margonato
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Palmisano
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy; Experimental Imaging Center, Radiology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Esposito
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy; Experimental Imaging Center, Radiology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Samaras A, Doundoulakis I, Antza C, Zafeiropoulos S, Farmakis I, Tzikas A. Comparative Analysis of Risk Stratification Scores in Atrial Fibrillation. Curr Pharm Des 2021; 27:1298-1310. [PMID: 33302847 DOI: 10.2174/1381612826666201210113328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/28/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Atrial Fibrillation (AF) has become a major global health concern and is associated with an increased risk of poor outcomes. Identifying risk factors in patients with AF can be challenging, given the high burden of comorbidities in these patients. Risk stratification schemes appear to facilitate accurate prediction of outcomes and assist therapeutic management decisions. OBJECTIVE To summarize current evidence on risk stratification scores for patients with AF. RESULTS Traditional risk models rely heavily on demographics and comorbidities, while newer tools have been gradually focusing on novel biomarkers and diagnostic imaging to facilitate more personalized risk assessment. Several studies have been conducted to compare existing risk schemes and identify specific patient populations in which the prognostic ability of each scheme excels. However, current guidelines do not appear to encourage the implementation of risk models in clinical practice, as they have not incorporated new ones in their recommendations for the management of patients with AF for almost a decade. CONCLUSION Further work is warranted to analyze new reliable risk stratification schemes and optimally implement them into routine clinical life.
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Affiliation(s)
- Athanasios Samaras
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Antza
- Third Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Greece
| | - Stefanos Zafeiropoulos
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Farmakis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Tzikas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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CHA2DS2-VASc and ATRIA Scores and Clinical Outcomes in Patients with Heart Failure with Preserved Ejection Fraction. Cardiovasc Drugs Ther 2021; 34:763-772. [PMID: 32583288 DOI: 10.1007/s10557-020-07011-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Heart failure (HF) patients have high risks of thromboembolic events regardless of the category of left ventricular ejection fraction. We sought to assess whether the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, and female sex) and ATRIA (anticoagulation and risk factors in atrial fibrillation) scores could predict clinical outcomes in HF patients with preserved ejection fraction (HFpEF). METHODS We performed a retrospective analysis in a multicenter, America-based population of 1766 HFpEF patients who were stratified according to their baseline CHA2DS2-VASc or ATRIA scores. The CHA2DS2-VASc and ATRIA scores were analyzed as a continuous or categorical variable. The outcomes were stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization. RESULTS When score was considered as a continuous variable, each point increase in CHA2DS2-VASc was associated with increased risks of stroke (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 1.06-1.41, C-index = 0.62), HF hospitalization (HR 1.08, 95% CI = 1.01-1.17, C-index = 0.59), and any hospitalization (HR 1.06, 95% CI = 1.01-1.11, C-index = 0.57) whereas each point increase in ATRIA was associated with increased risks of stroke (HR 1.11, 95% CI = 1.01-1.21, C-index = 0.62), all-cause death (HR 1.09, 95% CI = 1.05-1.14, C-index = 0.61), cardiovascular death (HR 1.08, 95% CI = 1.02-1.14, C-index = 0.59), HF hospitalization (HR 1.07, 95% CI = 1.03-1.12, C-index = 0.58), and any hospitalization (HR 1.04, 95% CI = 1.01-1.06, C-index = 0.57). When score was regarded as a categorical variable, compared with controls, CHA2DS2-VASc ≥ 4 was associated with increased risks of stroke and hospitalization whereas ATRIA ≥ 8 was associated with increased risks of stroke, death, and hospitalization. CONCLUSIONS The CHA2DS2-VASc and ATRIA scores are associated with risks of adverse outcomes in HFpEF patients. However, the predictive abilities of CHA2DS2-VASc and ATRIA are modest, and their clinical utility in HFpEF remains to be determined. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov . Identifier: NCT00094302.
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Fox KAA, Virdone S, Pieper KS, Bassand JP, Camm AJ, Fitzmaurice DA, Goldhaber SZ, Goto S, Haas S, Kayani G, Oto A, Misselwitz F, Piccini JP, Dalgaard F, Turpie AGG, Verheugt FW, Kakkar AK. GARFIELD-AF risk score for mortality, stroke and bleeding within 2 years in patients with atrial fibrillation. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:214-227. [PMID: 33892489 PMCID: PMC8888127 DOI: 10.1093/ehjqcco/qcab028] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/08/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
Aims To determine whether the Global Anticoagulant Registry in the FIELD–Atrial Fibrillation (GARFIELD-AF) integrated risk tool predicts mortality, non-haemorrhagic stroke/systemic embolism, and major bleeding for up to 2 years after new-onset AF and to assess how this risk tool performs compared with CHA2DS2-VASc and HAS-BLED. Methods and results Potential predictors of events included demographic and clinical characteristics, choice of treatment, and lifestyle factors. A Cox proportional hazards model was identified for each outcome by least absolute shrinkage and selection operator methods. Indices were evaluated in comparison with CHA2DS2-VASc and HAS-BLED risk predictors. Models were validated internally and externally in ORBIT-AF and Danish nationwide registries. Among the 52 080 patients enrolled in GARFIELD-AF, 52 032 had follow-up data. The GARFIELD-AF risk tool outperformed CHA2DS2-VASc for all-cause mortality in all cohorts. The GARFIELD-AF risk score was superior to CHA2DS2-VASc for non-haemorrhagic stroke, and it outperformed HAS-BLED for major bleeding in internal validation and in the Danish AF cohort. In very low- to low-risk patients [CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)], the GARFIELD-AF risk score offered strong discriminatory value for all the endpoints when compared to CHA2DS2-VASc and HAS-BLED. The GARFIELD-AF tool also included the effect of oral anticoagulation (OAC) therapy, thus allowing clinicians to compare the expected outcome of different anticoagulant treatment decisions [i.e. no OAC, non-vitamin K antagonist (VKA) oral anticoagulants, or VKAs]. Conclusions The GARFIELD-AF risk tool outperformed CHA2DS2-VASc at predicting death and non-haemorrhagic stroke, and it outperformed HAS-BLED for major bleeding in overall as well as in very low- to low-risk group patients with AF. Clinical trial registration URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF: NCT01090362, ORBIT-AF I: NCT01165710; ORBIT-AF II: NCT01701817.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | | | - Jean-Pierre Bassand
- Thrombosis Research Institute (TRI), London, UK.,Department of Cardiology, University of Besançon, Besançon, France
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | | | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai School of medicine, Kanagawa, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich, Germany
| | | | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | | | | | - Frederik Dalgaard
- Department of Cardiology, Hertlev & Gentofte Hospital, Hellerup, Copenhagen, Denmark
| | | | - Freek Wa Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Ajay K Kakkar
- Thrombosis Research Institute (TRI), London, UK.,University College London, London, UK
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Best JG, Ambler G, Wilson D, Lee KJ, Lim JS, Shiozawa M, Koga M, Li L, Lovelock C, Chabriat H, Hennerici M, Wong YK, Mak HKF, Prats-Sanchez L, Martínez-Domeño A, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Lemmens R, Eppinger S, Gattringer T, Uysal E, Tanriverdi Z, Bornstein NM, Ben Assayag E, Hallevi H, Molad J, Nishihara M, Tanaka J, Coutts SB, Polymeris A, Wagner B, Seiffge DJ, Lyrer P, Algra A, Kappelle LJ, Al-Shahi Salman R, Jäger HR, Lip GYH, Fischer U, El-Koussy M, Mas JL, Legrand L, Karayiannis C, Phan T, Gunkel S, Christ N, Abrigo J, Leung T, Chu W, Chappell F, Makin S, Hayden D, Williams DJ, Mess WH, Nederkoorn PJ, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Maaijwee N, Guevarra AC, Yatawara C, Mendyk AM, Delmaire C, Köhler S, van Oostenbrugge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, Hendrikse J, Kelly PJ, Wardlaw J, Soo Y, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Engelter ST, Peters N, Smith EE, Hara H, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Mok V, Veltkamp R, Ay H, Imaizumi T, Gomez-Anson B, Lau KK, Jouvent E, Rothwell PM, Toyoda K, Bae HJ, Marti-Fabregas J, Werring DJ. Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies. Lancet Neurol 2021; 20:294-303. [PMID: 33743239 DOI: 10.1016/s1474-4422(21)00024-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING British Heart Foundation and Stroke Association.
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Affiliation(s)
- Jonathan G Best
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - Duncan Wilson
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jae-Sung Lim
- Department of Neurology, Hallym Neurological Institute, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Caroline Lovelock
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Hugues Chabriat
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Federation Hospitalo-Universitaire NeuroVasc, Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Henry Ka Fung Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Luis Prats-Sanchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- A A Martinos Center for Biomedial Imaging, Department of Neurology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Yin Ka Lam
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Adrian Wong
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Robin Lemmens
- Experimental Neurology, Department of Neurosciences, Katholieke Universiteit Leuven, Leuven, Belgium; Vlaams Instituut voor Biotechnologie, Center for Brain & Disease Research; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Ender Uysal
- Department of Radiology, Saglık Bilimleri University, Sisli Etfal Education and Research Hospital, Istanbul, Turkey
| | - Zeynep Tanriverdi
- Department of Neurology, İzmir Katip Çelebi University Atatürk Education and Research Hospital, İzmir Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeremy Molad
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Masashi Nishihara
- Department of Radiology, Saga University Faculty of Medicine, Saga, Japan
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Alexandros Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - David J Seiffge
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands; Department of Neurology and Neurosurgery, Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Utrecht University, Utrecht, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Hans R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK; Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Urs Fischer
- Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- Department of Neurology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | - Laurence Legrand
- Department of Neuroradiology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | | | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Sarah Gunkel
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Nicolas Christ
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Thomas Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, Edinburgh Imaging, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Derek Hayden
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland; Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences Dublin, Ireland; Department of Geriatric and Stroke Medicine, Beaumont Hospital Dublin, Ireland
| | - Werner H Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Netherlands
| | - Carmen Barbato
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Simone Browning
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Noortje Maaijwee
- Department for Neurology and Neurorehabilitation, Neurocenter, Lucerne State Hospital, Lucerne, Switzerland
| | | | | | - Anne-Marie Mendyk
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Christine Delmaire
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France; Department of Radiology, Fondation A de Rothschild, Paris, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, The Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Ying Zhou
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christopher Chen
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Min Lou
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Régis Bordet
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Simister
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter J Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Yannie Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia
| | - David Calvet
- Department of Neurology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | - Simon Jung
- Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan; Department of Neurology, Kansai Medical University, Osaka, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Vincent Mok
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany; Department of Brain Sciences, Imperial College London, London, UK
| | - Hakan Ay
- A A Martinos Center for Biomedial Imaging, Department of Neurology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA; Takeda, Cambridge, MA, USA
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Beatriz Gomez-Anson
- Unit of Neuroradiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric Jouvent
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Federation Hospitalo-Universitaire NeuroVasc, Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Joan Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - David J Werring
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.
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Greenberg SM. Cerebral microbleeds and prediction of intracranial haemorrhage. Lancet Neurol 2021; 20:252-254. [PMID: 33743229 DOI: 10.1016/s1474-4422(21)00065-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Steven M Greenberg
- Stroke Research Center, Massachusetts General Hospital, Boston MA 02114, USA.
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Liu Y, Zhu D, Xiao Y, Zhu Y, Zhou Q, Ren L, Chen L. Risk factors of left atrial appendage thrombus in patients with non-valvular atrial fibrillation. Open Med (Wars) 2021; 16:361-366. [PMID: 33869773 PMCID: PMC8024551 DOI: 10.1515/med-2021-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/16/2020] [Accepted: 09/26/2020] [Indexed: 12/15/2022] Open
Abstract
Objective To investigate the risk factors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF). Methods We collected the clinical data of patients with non-valvular AF who underwent transesophageal echocardiography (TEE) at the Zhongda Hospital of Southeast University between January 2016 and June 2019. The patients were divided into two groups, LAAT and non-LAAT. We performed comparative analysis, receiver operating characteristic (ROC) curve analysis and logistic regression analysis to estimate the risk factors of LAAT. Results A total of 442 patients with non-valvular AF were enrolled in the study. LAAT was detected by TEE in 20 cases (4.7%). Compared with patients without LAAT, patients with LAAT had higher CHA2DS2-VASc scores (3 vs 2, p = 0.001), higher values of D-dimer (180.0 vs 90.0 μg/L, p = 0.003), larger LA anteroposterior diameters (50.5 vs 41.0 mm, p < 0.001) and higher ratios of non-paroxysmal AF (85.0% vs 23.6%, p < 0.001). ROC curve analysis revealed that the cutoff value of LA anteroposterior diameter was 49.5 mm. After adjusting for other confounders, logistic regression analysis showed that enlarged LA (anteroposterior diameter ≥49.5 mm) and non-paroxysmal AF were independently associated with higher risks of LAAT (OR = 7.28, 95% CI: 2.36-22.47; OR = 8.89, 95% CI: 2.33-33.99, respectively). The proportions of LAAT in patients with larger LA (anteroposterior diameter ≥49.5 mm), non-paroxysmal AF and both larger LA and non-paroxysmal AF were 30% (12/40), 15.2% (17/112) and 39.1% (9/23), respectively. Conclusion Enlarged LA (anteroposterior diameter ≥49.5 mm) and non-paroxysmal AF were independent risk factors of LAAT in non-valvular AF patients.
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Affiliation(s)
- Yaowu Liu
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Didi Zhu
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Yunyun Xiao
- Department of Geriatrics, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China
| | - Yeqian Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qianxing Zhou
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Liqun Ren
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Long Chen
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 4873] [Impact Index Per Article: 1624.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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Yu I, Song TJ, Kim BJ, Heo SH, Jung JM, Oh KM, Kim CK, Yu S, Park KY, Kim JM, Park JH, Choi JC, Park MS, Kim JT, Hwang YH, Chung JW, Bang OY, Kim GM, Kim YJ, Kim S, Woo SY, Cho H, Seo WK. CHADS2, CHA2DS2-VASc, ATRIA, and Essen stroke risk scores in stroke with atrial fibrillation: A nationwide multicenter registry study. Medicine (Baltimore) 2021; 100:e24000. [PMID: 33545993 PMCID: PMC7837865 DOI: 10.1097/md.0000000000024000] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/25/2020] [Indexed: 11/27/2022] Open
Abstract
The performance of scoring systems for risk stratification in patients with atrial fibrillation (AF) was not validated well in patients with stroke. The purpose of this study was to evaluate whether the risk scoring systems predict vascular outcomes in stroke patients with AF.Data were obtained from a nationwide multicenter registry for acute stroke with AF from January 1, 2013, to December 31, 2015. We investigated the predictive power of the CHADS2, CHA2DS2-VASc, ATRIA, and Essen stroke scores in stroke patients with AF. The subjects were further stratified into groups according to treatment with or without oral anticoagulants (OACs).A total of 3112 stroke with AF subjects were included. The rate of recurrent ischemic stroke and any stroke were not associated with the CHADS2, CHA2DS2-VASc, ATRIA, and Essen stroke risk scores. The risks of death and major adverse cerebrovascular and cardiovascular events (MACEs) increased sequentially with the increase of each risk score in OAC group. (the range of C-index 0.544-0.558 for recurrent ischemic stroke; 0.523-0.537 for any stroke; 0.580-0.597 for death; 0.564-0.583 for MACEs). However, in the group treated with OACs, all risk scores were significantly associated with the risk of MACEs. The C-statistics of the 4 scoring systems were 0.544 to 0.558, 0.523 to 0.537, 0.580 to 0.597, 0.564 to 0.583, respectively, for recurrent ischemic stroke, any stroke, death, and MACEs.The performance of the CHADS2, CHA2DS2-VASc, ATRIA, and Essen stroke risk scores for the prediction of recurrent stroke was unsatisfactory in stroke patients with AF whereas the performance for the prediction of recurrent stroke was not MACEs or death was good. A new risk stratification scheme that is specific for secondary stroke prevention in the AF population is needed.
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Affiliation(s)
- Inwu Yu
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital Ewha Womans University College of Medicine
| | - Bum Joon Kim
- Department of Neurology, Stroke Center, Asan Medical Center
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Kyungki-Do
| | - Kyung-Mi Oh
- Department of Neurology, Korea University Guro Hospital
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital
| | - Sungwook Yu
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University College of Medicine
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul
| | - Jong-Ho Park
- Department of Neurology, Myongji Hospital, Hanyang University College of Medicine, Goyang
| | - Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju
| | - Yang-Ha Hwang
- Department of Neurology, Cerebrovascular Center, Kyungpook National University School of Medicine and Hospital, Daegu
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Geong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Yong-Jae Kim
- Department of Neurology, Eunpyeong St. Mary's Hospital, the Catholic University of Korea
| | - Seonwoo Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Sook young Woo
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyun Cho
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine
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17
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Abstract
Atrial fibrillation (AF) significantly increases the risk of stroke and, therefore, stroke prevention is an essential component of the management for patients with AF. This requires formal assessment of the individual risk of stroke to determine if the patient is eligible for oral anticoagulation (OAC), and if so, their risk of bleeding on OAC, before a treatment decision regarding stroke prevention is made. Risk of stroke is not homogenous; it depends on the presence or absence of risk factors. A plethora of stroke and bleeding risk factors has been identified, including common and less-well established clinical risk factors, plus imaging, urine, and blood biomarkers. Consequently, there are several stroke and bleeding risk stratification scores available and this article provides an overview of them, the risk factors included and how they are scored, and provides a critical appraisal of them. The review also discusses the debate regarding whether female sex is a risk factor or a risk modifier, and highlights the dynamic nature of both stroke and bleeding risk and the need to re-assess these risks periodically to ensure treatment is optimal to reduce the risk of adverse outcomes. This review also summarizes the recommended stroke and bleeding risk stratification scores from all current major international guidelines.
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Affiliation(s)
- Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, Liverpool L7 8TX, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, Liverpool L7 8TX, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Zeng J, Yu P, Cui W, Wang X, Ma J, Zeng C. Comparison of HAS-BLED with other risk models for predicting the bleeding risk in anticoagulated patients with atrial fibrillation: A PRISMA-compliant article. Medicine (Baltimore) 2020; 99:e20782. [PMID: 32569222 PMCID: PMC7310965 DOI: 10.1097/md.0000000000020782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The HAS-BLED, HEMORR2HAGES, ATRIA, and ORBIT scores are used to predict bleeding risk in anticoagulated patients with atrial fibrillation (AF). Recently, these scores have been validated in various studies. Therefore, we aimed to compare the occurrence of major bleeding across different risk categories between HAS-BLED and any of HEMORR2HAGES, ATRIA, or ORBIT scores. METHODS A systemic literature search of PubMed and Embase databases was conducted to screen the relevant studies. We calculated and pooled the odds ratios (ORs) and 95% confidence intervals (CIs) for a comparative analysis of the occurrence of major bleeding. RESULTS Nine studies fulfilled the inclusion criteria in this meta-analysis. Compared with HEMORR2HAGES, there were 87% and 39% reduced rates of major bleeding in the HAS-BLED "low-risk" and "moderate-risk" groups, respectively. Compared with ATRIA, there was an 89% decreased rate of major bleeding in the HAS-BLED "low-risk" group. Compared with ORBIT, there were 84% and 44% reduced rates of major bleeding in the HAS-BLED "low-risk" and "moderate-risk" groups, respectively. Patients with HAS-BLED scores ≥3 showed an approximately 3-fold greater risk of major bleeding compared with patients with scores <3 (OR=3.00, CI: 1.21-7.43). CONCLUSIONS Compared with any of HEMORR2HAGES, ATRIA, or ORBIT scores, the HAS-BLED score distributed more major bleeding events into the "low" or "moderate" risk categories.
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Affiliation(s)
- Junquan Zeng
- Department of internal medicine, Jinggangshan University, Ji’an
| | - Peng Yu
- Department of endocrinology and metabolism, the Second Affiliated Hospital of Nanchang University
| | - Wenjuan Cui
- Department of Oral Prosthetics, Affiliated Stomatological Hospital of Nanchang University, Nanchang
| | - Xiaoping Wang
- Comprehensive teaching and research office, Ji’an college, Ji’an, Jiangxi
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Changai Zeng
- Department of stomatology,Jinggangshan University, Ji’an, Jiangxi, China
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Su Z, Zhang H, He W, Ma J, Zeng J, Jiang X. Meta-analysis of the efficacy and safety of non-vitamin K antagonist oral anticoagulants with warfarin in Latin American patients with atrial fibrillation. Medicine (Baltimore) 2020; 99:e19542. [PMID: 32358343 PMCID: PMC7440306 DOI: 10.1097/md.0000000000019542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Data of non-vitamin K antagonist oral anticoagulants (NOACs) in current management of atrial fibrillation (AF) are predominantly derived from North American and European regions. However, the effects of NOACs for stroke prevention in Latin America remain unclear. Therefore, we aimed to compare the efficacy and safety of NOACs with warfarin in Latin American patients with AF. METHODS The PubMed and Embase databases were systematically searched until July 12, 2019 for applicable randomized clinical trials. The risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using a random-effects model. RESULTS Four trials involving 8943 Latin American patients were included in this meta-analysis. In anticoagulated patients with AF, Latin American patients had higher rates of stroke or systemic embolism and all-cause death compared with non-Latin American subjects. Compared with warfarin use, the use of NOACs was significantly associated with reduced risks of stroke or systemic embolism, major bleeding, intracranial bleeding, and any bleeding in Latin American patients. There were no significant differences in the risks of ischemic stroke, all-cause death, and gastrointestinal bleeding between Latin and non-Latin American groups. All the interactions between Latin and non-Latin American groups about efficacy and safety outcomes of NOACs compared with warfarin were non-significant (all Pinteraction > .05). CONCLUSIONS Our meta-analysis suggested that the use of NOACs was at least non-inferior to warfarin use for stroke prevention in Latin American patients with AF.
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Affiliation(s)
- Zhiyu Su
- Department of Cardiovascular Medicine, Xiangdong Hospital Hunan Normal University, Liling, Hunan
| | - Hao Zhang
- Department of Cardiovascular Medicine, Xiangdong Hospital Hunan Normal University, Liling, Hunan
| | - Wenfeng He
- Jiangxi Key Laboratory of Molecular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Junquan Zeng
- Department of Internal Medicine, Jinggangshan University, Ji’an, Jiangxi, China
| | - Xinhua Jiang
- Department of Cardiovascular Medicine, Xiangdong Hospital Hunan Normal University, Liling, Hunan
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Comparative performance of AnTicoagulation and Risk factors In Atrial fibrillation and Global Registry of Acute Coronary Events risk scores in predicting long-term adverse events in patients with acute myocardial infarction. Anatol J Cardiol 2019; 20:77-84. [PMID: 30088481 PMCID: PMC6237955 DOI: 10.14744/anatoljcardiol.2018.54815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: This study is designed to evaluate the recently developed AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) risk score (RS), which determines the predisposition to thromboembolic and hemorrhagic events in atrial fibrillation, as a predictor of prognosis in patients having acute myocardial infarction (AMI), and to compare the predictive ability of ATRIA RS with GRACE RS. Methods: We analyzed 1627 patients having AMI who underwent coronary angiography and/or percutaneous coronary intervention (PCI) between January 2011 and February 2015. The primary endpoints included all-cause mortality, non-fatal MI, and cerebrovascular events during follow-up. Results: Multivariate Cox regression analysis showed that the ATRIA RS>3 was an independent predictor of major adverse cardiac events in patients with AMI [hazard ratio, 2.00, 95% confidence interval, 1.54 to 2.60, p<0,001]. The area under the curve (AUC) for ATRIA RS and GRACE RS was 0.66 and 0.67 (p<0.001, and p<0.001), respectively. We performed a pair-wise comparison of receiver operating characteristic curves, and noted the predictive value of ATRIA RS with regard to primary endpoints was similar to that of GRACE RS (By DeLong method, AUCATRIA vs. AUCGRACE z test=0.64, p=0.52). Conclusion: ATRIA RS may be useful in predicting prognosis in patients having AMI during long-term follow-up.
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Pallazola VA, Kapoor RK, Kapoor K, McEvoy JW, Blumenthal RS, Gluckman TJ. Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review. Vasc Med 2019; 24:141-152. [PMID: 30755150 DOI: 10.1177/1358863x18819816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.
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Affiliation(s)
- Vincent A Pallazola
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Rishi K Kapoor
- 2 Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, Essex County, NJ, USA
| | - Karan Kapoor
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - John W McEvoy
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Roger S Blumenthal
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Ty J Gluckman
- 1 Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA.,3 Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, Multnomah County, OR, USA
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22
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Ravera M, Bussalino E, Paoletti E, Bellasi A, Di Lullo L, Fusaro M. Haemorragic and thromboembolic risk in CKD patients with non valvular atrial fibrillation: Do we need a novel risk score calculator? Int J Cardiol 2019; 274:179-185. [DOI: 10.1016/j.ijcard.2018.07.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/08/2018] [Accepted: 07/12/2018] [Indexed: 12/11/2022]
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23
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Gómez-Outes A, Suárez-Gea ML, García-Pinilla JM. When are the cardiovascular and stroke risks too high? Pharmacotherapy for stroke prophylaxis. Expert Opin Pharmacother 2018; 19:1427-1440. [PMID: 30198347 DOI: 10.1080/14656566.2018.1511703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Stroke is a significant source of morbidity and mortality in developed countries. Cardioembolic strokes represent approximately 15-30% of all ischemic strokes. They are frequently related to atrial fibrillation (AF) and have a worse prognosis and high recurrence rates when compared to other causes (e.g. atherosclerosis). AREAS COVERED This review includes a summary of general and specific scores to assess cardiovascular and stroke risks, with a focus on specific scores available in AF. Recommendations for antithrombotic therapy are also reviewed. EXPERT OPINION Several scores are available for the evaluation of stroke risk. They are useful to identify the risk factors that trigger the need for medical interventions. Integrated risk scores with visual interfaces showing the risk of events, with and without the proposed interventions, can aid decision-making. The risk of stroke can definitely be considered too high in those patients with a history of stroke/transient ischemic attack, who need antiplatelet therapy (after a non-cardioembolic stroke) or anticoagulant therapy (after a cardioembolic stroke). For primary prevention of stroke, antiplatelet therapy is not usually recommended, while anticoagulation should be considered if the patient has concomitant AF and at least one additional risk factor unrelated to sex.
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Affiliation(s)
- Antonio Gómez-Outes
- a Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use , Spanish Agency for Medicines and Medical Devices (AEMPS) , Madrid , Spain
| | - Mª Luisa Suárez-Gea
- a Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use , Spanish Agency for Medicines and Medical Devices (AEMPS) , Madrid , Spain
| | - Jose Manuel García-Pinilla
- b UGC de Cardiología y Cirugía Cardiovascular , Instituto de Biomedicina de Málaga (IBIMA), Hospital Universitario Virgen de la Victoria , Málaga , Spain.,c Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV) , Instituto de Salud Carlos III , Madrid , Spain
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Bansal VK, Herzog CA, Sarnak MJ, Choi MJ, Mehta R, Jaar BG, Rocco MV, Kramer H. Oral Anticoagulants to Prevent Stroke in Nonvalvular Atrial Fibrillation in Patients With CKD Stage 5D: An NKF-KDOQI Controversies Report. Am J Kidney Dis 2017; 70:859-868. [DOI: 10.1053/j.ajkd.2017.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
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